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B752, Mumbai India, 2010

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Summary
On 9 June 2010, a Boeing B757-200 being operated by Chennai-based Blue Dart Aviation on a scheduled cargo flight from Mumbai to Bangalore lined up and commenced a night take off in normal ground visibility aligned with the right hand runway edge lights of 45 metre wide runway 27. ATC were not advised of the error and corrective action and once airborne, the aircraft completed the intended flight without further event. A ground engineer at Bangalore then discovered damage to the right hand landing gear assembly including one of the brake units. After being alerted, the Mumbai Airport Authorities discovered a number of broken runway edge lights.
Event Details
When June 2010
Actual or Potential
Event Type
Human Factors, Runway Excursion
Day/Night Night
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft BOEING 757-200
Operator Blue Dart Aviation
Domicile India
Type of Flight Public Transport (Cargo)
Origin Chhatrapati Shivaji International Airport
Intended Destination HAL Bangalore International Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Take Off
TOF
Location - Airport
Airport Chhatrapati Shivaji International Airport
General
Tag(s) Event reporting non compliant,
Inadequate Aircraft Operator Procedures
HF
Tag(s) Ineffective Monitoring,
Procedural non compliance,
Spatial Disorientation
RE
Tag(s) Directional Control,
Misalignment on runway"Misalignment on runway" is not in the list (Overrun on Take Off, Overrun on Landing, Directional Control, Excessive Airspeed, RTO decision after V1, High Speed RTO (V above 80 but not above V1), Unable to rotate at VR, Collision Avoidance Action, Parallel Approach Operations, Late Touchdown, ...) of allowed values for the "RE" property.
Outcome
Damage or injury Yes
Aircraft damage Minor
Non-aircraft damage Yes
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Air Traffic Management
Investigation Type
Type Independent

Description

On 9 June 2010, a Boeing B757-200 being operated by Chennai-based Blue Dart Aviation on a scheduled cargo flight from Mumbai to Bangalore lined up and commenced a night take off in normal ground visibility aligned with the right hand runway edge lights of 45 metre wide runway 27. ATC were not advised of the error and corrective action and once airborne, the aircraft completed the intended flight without further event. A ground engineer at Bangalore then discovered damage to the right hand landing gear assembly including one of the brake units. After being alerted, the Mumbai Airport Authorities discovered a number of broken runway edge lights.

Investigation

An Investigation was carried out by the Indian DGCA. Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) data was available to the investigation. It was found that the aircraft commander, a Check Captain for the Operator, had been PF for the take off and that the First Officer had been aware of his line up error and had alerted him to a position ‘on the right’ of the runway 27 centreline. In response, the standing-start, full runway length take off had been commenced with an intention to re-align. However, when the take off roll was commenced, a further deviation to the right initially occurred during which the FO called out twice accordingly in quick succession prior to the standard ‘80 knots’ , ‘V1’ and ‘rotate’ calls.

It was noted that the runway 27 centreline lights had been inoperative for the six weeks prior to the event and this had been so advised by an appropriate Notice To Airmen.

FDR data showed that as the aircraft started to accelerate, it drifted further to the right for approximately 300 metres before a sharp correction was made to the left at a speed of 77 KCAS and then back to the right at 91 KCAS by which time the aircraft had travelled approximately 850 metres since the start of the take off roll. It became airborne at a distance of approximately 1380 metres from start of roll.

It could not be confirmed that all the edge light damage discovered by the subsequent inspection had been the result of the excursion.

The Investigation concluded that the Probable Cause of the event was “incorrect lineup by the Captain on the right side of the RW instead of the Center even after being informed by the FO”.

It also concluded that Contributory Factors to the event were:

  • an error in judgment / assessment in determining the extent of displacement to the right of centerline while lining up.
  • Inadequate Crew Resource Management practices both by the Captain and FO. Displacement of the aircraft (by) the Captain (and) inadequate attention on the part of the Captain towards inputs from the FO.

The Final Report of the Investigation was completed by the DGCA Investigator on 12 July 2010. It contained three Safety Recommendations as follows:

  • Appropriate action may be taken in view of lapses on the part of the flight crew.
  • Incident may be brought to all concerned highlighting the consequences of distraction in cockpit during critical phase of flight.
  • MIAL/AAI (ATC) should review the procedure of runway inspection and ensure that same is followed meticulously.

Further Reading