DH8D, Belagavi India, 2021

DH8D, Belagavi India, 2021

Summary

On 24 October 2021, a Bombardier DHC8-400 inbound to Belagavi initially advised to expect a non-precision procedural approach to runway 08 was subsequently instructed and acknowledged clearance for an equivalent procedural approach to runway 26. An approach to runway 08 was then flown without ATC intervention or pilot error recognition but with no actual consequences. The error was attributed to pilot expectation bias and distraction and controller failure to order a go-around after eventually realising what was happening. The context which had facilitated the errors was considered to be procedure and performance inadequacy at both the aircraft operator and ATC.

Event Details
When
24/10/2021
Event Type
AGC, HF, RI
Day/Night
Day
Flight Conditions
VMC
Flight Details
Operator
Type of Flight
Public Transport (Passenger)
Take-off Commenced
Yes
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Landing
General
Tag(s)
Inadequate Aircraft Operator Procedures, Inadequate ATC Procedures, Non Precision Approach, CVR overwritten
AGC
Tag(s)
Incorrect Readback missed, Phraseology, Read Back Clearance not followed
HF
Tag(s)
Distraction, Ineffective Monitoring, Plan Continuation Bias, Procedural non compliance, Ineffective Monitoring - SIC as PF
RI
Tag(s)
Accepted ATC Clearance not followed, Phraseology, Wrong Active Runway
Outcome
Damage or injury
No
Non-aircraft damage
No
Non-occupant Casualties
No
Off Airport Landing
No
Ditching
No
Causal Factor Group(s)
Group(s)
Aircraft Operation
Air Traffic Management
Safety Recommendation(s)
Group(s)
Aircraft Operation
Air Traffic Management
Investigation Type
Type
Independent

Description

On 24 October 2021, a Bombardier DHC8-400 (VT-SQC) being operated by SpiceJet on a scheduled domestic passenger flight from Hyderabad to Belagavi as SEJ3734 was initially advised by Belagavi ATC to expect a procedural VOR approach to runway 08 at destination but the clearance subsequently given was for a procedural VOR approach to runway 26. This change was not noticed by the crew and their further readbacks of ATC instructions which mentioned runway 26 were similarly incomplete - all omitted mention of the runway. The Controller only became aware that the approach was being made to the wrong runway when he saw the aircraft on short final and decided that in the absence of any conflicting traffic, it was not necessary to require a go around or inform the crew of their error by means of a radio transmission. Required ATC and airline procedures subsequent to the runway incursion were not followed.

Investigation

A Serious Incident Investigation was carried out by the Aircraft Accident Investigation Bureau India (AAIB). Relevant data were successfully available from the FDR but corresponding data from the CVR was not because it was not downloaded prior to continued use of the aircraft. Recorded ATC and related (commercially-sourced) flight tracking data were available.

It was noted that the 43 year-old Captain had a total of 8,104 hours flying experience of which 7,711 hours were on type and the 28 year-old First Officer had a total of 2,302 hours flying experience, all but 200 hours of which were on type.

What Happened

With the First Officer acting as PF, the flight crew were on their third sector of a four sector duty. Whilst still on their en-route frequency, the Captain contacted destination ATC to obtain the latest weather and was advised that the surface wind was from 070° at 5 knots and the visibility was 6 km with runway 08 in use. The flight was advised that it was No.1 for approach and to expect a (procedural) VOR approach to runway 08 with no delay (see the VOR 08 procedure chart reproduced below). After being transferred to Belagavi, the flight reported maintaining FL 110 and being on the 070° radial from the VOR at 15 nm and requested further descent. Clearance was given to 4,600 feet QNH on the 070° radial with a surface wind of 340° at 4 knots - in effect the wind remained ‘light and variable’ throughout the approach. This transmission was then followed almost immediately with ATC clearing the flight for the VOR runway 26 approach via the overhead with a request to call outbound (This chart is also reproduced below). 

Four minutes later, the flight reported entering the overhead hold as requested and was again instructed to report leaving the ‘BBM’ VOR (the overhead). When it did so, TWR responded with “report established for the approach to runway 26”, which the flight crew explicitly acknowledged. On calling “base turn”, the Controller acknowledged and repeated the previous instruction to “report established for the approach to runway 26” which was again explicitly acknowledged. One minute later, the flight reported “established final approach track” and the Controller replied “runway 26 cleared to land” which was explicitly acknowledged and followed three minutes later by a request to set the PAPI lights to maximum intensity. 

One minute after making the PAPI request, the controller acknowledged that the aircraft had in fact landed on runway 26 and cleared it to backtrack, vacate and taxi to Stand No.1. Once on stand, airline ground staff informed the Captain that he should call ATC on his phone. When he did so, the controller advised that the flight “had probably landed on the wrong runway, to which the Captain said that they had landed on the correct runway”. The controller then said that they would confirm this by listening to the ATC tape. The Captain was aware of a requirement to have the CVR removed from the aircraft before further flight in the event of such an error but this was not done as he was “not formally informed about the occurrence by the controller”. It was also not removed after the aircraft subsequently arrived at Hyderabad on its return flight there.

Why It Happened 

It was found that whilst the flight crew appeared to have been unaware of their error, the controller had seen the aircraft on the 08 approach at around 300-400 feet aal but had then made no attempt to prevent it landing in the wrong direction. The controller justified their inaction on the basis that it was safe for the flight to land on it as there was no other traffic. The Investigation team took the view that the only acceptable deviations from an instruction to go around in such circumstances were if an emergency has been declared or “the flight crew has clearly expressed the requirement to land immediately”. However, the failure of ATC to properly notify the change of runway was expressly contrary to the MATS and clearly contributory. 

The crew admitted during interview that their failure to appreciate the change of runway after programming the FMS for runway 08 was at least partly due to non-pertinent conversation and the fact that the First Officer had the AP engaged and had permitted the aircraft automation to follow the programmed FMS without cross-checking the revised ATC clearance.

A range of significant deficiencies were identified in respect of the aircraft operator’s focus on maintaining acceptable standards of operational safety including but not limited to the configuration and use of the OFDM system, the way in which pilots’ recurrent training is delivered and the standard of radio communications as conducted by the Captain during the approach, in particular his multiple failures to include the runway designator mentioned in clearances in his readbacks.

It was found that the operator did not carry out internal investigations into occurrences with a bearing on operational safety but instead “waits for the formal report to be published by AAIB before any mitigation action is taken, thereby losing crucial time to bring in ‘interim mitigation actions’ to avoid such serious occurrences”

Finally, it was noted that one of the aircraft operator’s Boeing 737s had landed on the wrong runway at Hyderabad the previous year and one of the actions taken had been to issue an ‘Operations Circular’ to all DHC8-400 pilots on ‘Mitigation of Landing on the Wrong Runway’ which is on page 53 of the Investigation Final Report to which a link is provided at the end of this summary of its contents. However, this detailed Circular was only valid for 2½ months from the date of issue and none of its content was then transferred to the OM. It was also specifically observed that all of the contributory factors identified in the Hyderabad event were also present in the Belagavi event and concluded that “two unassigned runway landings by the same operator in less than two years is a matter of concern”.

DH8D-Belagavi-2021-VOR-1

DH8D-Belagavi-2021-VOR-2

The two available VOR procedures at Belagavi. [Reproduced from the Official Report]

The Probable Causes of the event were determined as:

  1. The flight crew commencing an instrument approach for the unassigned runway (08) due to expectation bias and distraction leading to remaining fixated on carrying out a VOR approach for runway 08.                   
  2. The controller not advising the flight crew to go-around when he observed the aircraft at 300-400 feet agl (1-2 nm) on final approach of runway 08 and thereby knowingly permitting the aircraft to land on runway 08.

Four Contributory Factors were also identified as follows;

  1. Non-Adherence to ICAO Radio Telephony Phraseology by the Captain (Pilot Monitoring) while communicating with Belagavi ATC.
  2. Controller 1 not informing the flight crew regarding change of runway as per the Manual of Air Traffic Services Chapter 6.
  3. The First Officer (PF) not monitoring the ATC clearance and permitting the aircraft automation to fly programmed FMS approach for runway 08 which was not in conformity with the ATC clearance received. 
  4. The First Officer not cross-checking the FMS and ensuring the FMS met the ATC Clearance.

A total of 17 Safety Recommendations were made as a result of the Investigation as follows:

  • that SpiceJet advise all their flight crew to follow proper ICAO Phraseology while communicating with ATC and other aircraft.
  • that SpiceJet advise all flight crew to strictly follow the “Sterile Flight Deck” requirements as laid down in the company Operations Manual.
  • that SpiceJet consider incorporating the information which is made available to flight crew in form of a Circular into the Company Operations Manual in a stipulated time period instead of leaving it in the form of Circular which has an expiry date. Example: The Flight Operations Circular regarding “Mitigation of Wrong Runway Landing”.
  • that SpiceJet consider consolidating flight operations-related information to improve ease of access for flight crew.
  • that SpiceJet seek the approval of the DGCA office for their Q-400 Line and Training Guide (QLTG) as SOP or follow the manufacturer’s SOP as stipulated in the Aircraft Operating Manual (AOM).
  • that SpiceJet review their SOP given in the QLTG to ensure that the Pilot Flying as well as the Pilot Monitoring cross-check that the approach briefing is in accordance with the ATC clearance and that the FMS programming matches the ATC clearance at all phases of flight including the planned instrument approach.
  • that SpiceJet formulate a process for all flight crew to undergo a psychometric assessment at the time of joining the company and for flight crew already employed to undergo a similar assessment if upgraded to Captain or Training Captain.
  • that SpiceJet ensure that an aircraft CVR is downloaded and made available as per relevant DGCA regulations.
  • that the Airports Authority of India (AAI) advise all ATCOs that if they observe any unauthorised aircraft operations such as an approach to land on an unassigned runway, the aircraft concerned must be instructed to Go-Around or Discontinue Approach by the ATCO unless the aircraft has declared an emergency. 
  • that the AAI advise all ATCO’s to notify the flight crew involved in any violation of ATC instructions on R/T at an appropriate time, for example either before the said flight leaves their airspace or after landing but before parking. 
  • that the AAI advise all ATCO’s that all conversation with the flight crew must be carried out on a recorded landline especially after an occurrence for the purpose of investigations and the corresponding timelines recorded in the ATC log-book. 
  • that the AAI advise all ATCOs that once a violation occurs and the flight crew have been notified, the ATCO must complete their occurrence report filing as per the SOP given in Manual of Air Traffic Services.
  • that the Directorate of Civil Aviation (DGCA) ensure that all operators follow the requirement of downloading the CVR for the purpose of investigation as per DGCA CAR Section 5, Series C, Part I.
  • that the DGCA ensure that SpiceJet uses only DGCA or manufacturer-approved documents for flight operations.
  • that the DGCA ensure SpiceJet promptly carries out an internal investigation and implements “Interim Mitigation Actions” rather than continue to wait for the Final Investigation report.
  • that the DGCA re-examine the number of prescribed exercises being carried out in the Instrument Rating/Pilot Proficiency Check within the stipulated period of two hours and carry out a realistic assessment whether all required exercises can be carried out within two hours. International best practices (EASA, FAA etc.) in this regard should also be reviewed .
  • that the DGAC consider carrying out a study on the underlying causes of the repeated number of cases of Accidents/ Serious Incidents involving SpiceJet within a stipulated time period. 

The Final Report was completed on 20 February 2022 and subsequently published.

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