HOW could they let it GO THIS FAR?!

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- [Petter] Few things will be more terrifying to a pilot than the prospect of running out of fuel mid-flight. But that is exactly what's about to happen to this Boeing 737 crew after having flown a heart-wrenching six approaches, going on their seventh. How that was possible, and what led up to it is what I'm gonna tell you about today. So stay tuned. The story I'm gonna tell you about today is the story of Jet Airways Flight 555, and it's actually one of the more crazy stories that I've ever come across. It's a story about communication; about, to a certain extent, bad luck and bad timing but also decision-making, and how a single decision can have potentially devastating consequences going forward. The incident took place on the 18th of August, 2015. And the aircraft that is involved is a Boeing 737-800, just like the type that I'm flying. The crew was quite experienced. The captain was 40 years old and had just under 6,700 hours, the majority of which he had flown on the 737. He was assisted by a first officer that was slightly less experienced. He had just under 1,500 hours of total time and about 580 on the type. They had both operated together on the day before, on the 17th of August where they had flown from Cochin in India over towards Doha. And then they had a night stop there. They were fully rested on the 18th of August, which is the day of the incident. The flight that they were about to operate was a night flight. So they met up at 18:30 UTC, that's about midnight, local time, and they started doing their pre-flight preparation. The weather en-route looked absolutely fine. But the weather on their destination, looked like it could be potentially a little bit misty. However, the weather they had available for their planning was quite old. It was issued at 09:00 UTC, so almost 15 hours earlier, but it was still valid. It indicated a visibility at their destination, Cochin, of about 4,000 meters with light winds from a northerly direction, and clouds scattered at 1,500 feet and broken clouds at 9,000 feet. So this is fairly good weather. Their alternate airport, Bangalore, had even better weather with a visibility of 8,000 meters, winds from 290 at 10 knots, and some scattered clouds at 1,200 feet and broken clouds at 8,000 feet. So this was perfectly good weather situation for the time. When we have a weather forecast that indicates that at the time of our arrival, plus one hour before and one hour after, the weather will be good enough for us to land using the approaches available at our destination, well, then we only need one alternate airport. Now, the alternate airport needs to have slightly better weather than our destination just to give us a little bit better margin in case we have to divert. What we do is that we look at the best possible approach aids at our alternate airport, and then we go to the second best approach aid, and we make sure that the weather is still good enough to be able to take that. In this case, the crew looked at the weather and they figured that, yeah, this is good enough, we don't need two alternates, we don't need to look too much into it. So we could potentially take minimum fuel going here. But the captain looked a little bit closer at the weather and saw that even though it was better than the minimum required, it still wasn't great. There was still some mist there. And whenever you have mist, there's always a possibility that that mist might turn into a fog or it might be worse than expected. So he thought, let's take a little bit extra fuel to enable us to hold a little bit when we get overhead Cochin. So that's what they did. They looked at their flight plan and they started calculating how much fuel they were actually going to take, taking this into consideration. Now, here it's quite important for you guys to understand how we actually calculate our minimum fuel before we dispatch. So, in the case of Jet Airways, they started off with adding taxi fuel. Taxi fuel was about 180 kilos and that was calculated on a fuel burn of about 12 kilos per minute, giving them 15 minutes of taxi time which is reasonable. The next thing they added on was the trip fuel, and the trip fuel is calculated from brakes release for takeoff, climb, the standard instrument departure, then climb-up to cruise level, the whole flight to top of descent, the descent into, and including the standard arrival route. And then 240 kilos for the approach phase, down to landing. In this case, the trip fuel was 11,112 kilos or four hours and seven minutes. On top of this, we also add something called contingency fuel, and it is exactly what it sounds like. It's for contingency. So maybe there's a thunderstorm en-route that we need to divert around or something like that. This tends to be a minimum of 5% of the trip fuel. In this case, there was 556 kilos or 14 minutes. And then we add on the alternate fuel which includes the missed approach at our destination, the climb to 1,500 feet initially, then the standard instrument departure, the climb, cruise and then descent into our alternate and a further approach. In this case, the fuel was to Bangalore and they needed 2,178 kilos for that. That was about 44 minutes of flying time. Now, the last amount of fuel that we need to add in order to find our minimum legal dispatch fuel is our final reserve fuel. And the final reserve fuel needed to enable us to fly at an altitude of 1,500 feet over our alternate for a minimum of 30 minutes, in this case, this was 1,128 kilos. Jet Airways had then also added one hour of APU burn which is 105 kilos, and in total, this led to an absolute minimum fuel, according to Jet Airways of 15,295 kilos for this flight. Like I mentioned before, the captain then decided to add another 750 kilos of fuel, about 19 minutes extra flight time, and then he rounded the total fuel up to the closest 100, ending up at 16,100 kilos of fuel, which was well above the minimum required for this flight. Once the crew had decided on the fuel they were going to take, they now started looking into all of the other preparation material as well. And the first officer took quite a keen interest into the NOTAMs. These are documents that indicate if something is working or not working at the destination, and the alternate airport and also the airports en-route. And his attention to detail is going to become important in this story. Once the pilots were happy with their pre-flight preparation, they walked over to their six cabin crew members that was gonna fly with them on the day. And then they all together walked out to the aircraft and started preparing it for departure. They boarded their 142 passengers that were scheduled for the flight over towards Cochin, and the captain was gonna be pilot flying for the flight, and the first officer was gonna be pilot monitoring. The aircraft in itself was a three-year-old 737-800, which was fully serviceable, there was nothing wrong with it. The pilots completed their pre-flight preparation, they received pushback and start clearance, and then started taxiing out for departure. At time 19:37 UTC, that's just about 10 minutes past one o'clock local time, the aircraft departed from Doha and started flying towards Cochin in India. The climb-out and the cruise phase of this flight was completely uneventful. And at time 23:00 UTC, that's about 04:30 in the morning in Cochin, the flight crew got into contact with Cochin ATC to get the latest weather. ATC responded and reported that the weather was quite nice in Cochin. It was 3,500 meters in mist, some few clouds at 1,500 feet and light winds. So this was more or less exactly what the pilots had expected. So the captain started setting up for a standard ILS approach into Runway 27 in Cochin. And that approach is something we call a full procedure approach. This means that instead of getting radar vector on to the final approach before landing, the crew would have to fly in over a VOR NAVAID that was situated close to the airfield, and then they would have to fly out to a specific distance before they could turn in and join the ILS procedures. About 48 minutes later, at time 23:48, the aircraft arrived above Cochin VOR and started flying outbound for the approach. At this point, they had about 4,844 kilos of fuel available, which was much more than their minimum diversion fuel towards Bangalore. The crew started to slow the aircraft down according to procedure, they started to extend their flaps and completing their landing checklists. The minimum visibility for this approach was 650 meters and the minima, the lowest point that they could fly down to before they had to do a missed approach was 320 feet. And the crew was not expecting any problems with this, given the weather they just received. But as they were descending down the glide slope, it became more and more obvious that the weather was actually much worse than expected. And when the captain reached the minima, 320 feet, he couldn't see anything. So, he executed the first go-around. After the go-around, the crew entered a holding pattern over Cochin VOR and they now started discussing how to proceed. They had 4,699 kilos of fuel on board, and the minimum diversion fuel towards Bangalore was 3,306, so they still had a lot of fuel. They knew that the weather in Bangalore was good and that they had a working ILS approach there, but they now started looking into the other alternates that were a little bit closer to see if they maybe could change their alternate to one of them, in order to give them even more fuel margin to do possibly one or two more approaches into Cochin. The two alternates they were now looking into was Coimbatore which was the closest one, and Thiruvananthapuram which was a little bit further away. But when they were discussing this, the first officer told the captain that actually in Thiruvananthapuram, we have to be a bit careful because even though it normally has an ILS approach there, the ILS approach was down for maintenance for about a week. So they only have non-precision approaches, a VOR approach available, in Thiruvananthapuram. The captain acknowledged this and they checked what the weather was like in Thiruvananthapuram, and it was given as 3,000 meters, which was well above the minimum requirement for a VOR approach into there. So the captain felt quite confident about it. As they were discussing this and setting up for their second approach into Runway 272, Air India Express Boeing 737s were ahead of them on final. The first one managed to land and reported that he could see the runway at about 1,400 feet, but that there were low clouds moving around the airport. The second Air India Express had to go around. So when Jet Airways Flight 555 started their second approach, Cochin ATC came in and told them that the visibility was now 2,500 meters, and that there were low clouds at about 600 feet. The second approach proceeded exactly like the first one, with the pilots reaching the minima without having any sign of the runway in front of them. They now executed their second go-around and once again, entered a holding pattern over Cochin. The fuel was now 3,919 kilos, which was still more than the minimum of 3,306 kilos they needed to divert to Bangalore. But the captain now wanted to redesignate their alternate to Thiruvananthapuram instead, because if he did so, that would give him approximately 20 minutes longer, which he could use to do a third approach in towards Cochin. The first officer was not very happy with this. He pointed out to the captain that the weather was actually getting worse, not better, and that the sun was about to rise, and that would make it even harder to see through the haze. The captain countered that argument with the fact that they had Coimbatore as an alternate airport that was even closer than Thiruvananthapuram if they will need it. But they never took any weather for Coimbatore. At time 00:20:06, the crew of Jet Airways Flight 555 informed air traffic control that they were now redesignating Thiruvananthapuram as their primary alternate. And this is where you guys need to pay particular attention as to decision-making, because up until this point, the decision-making that these two pilots have made is just like any other flight crew. They decided to take some extra fuel because they saw that the weather was a little bit iffy at Cochin, they then flew the flight, they executed a go-around on their first approach attempt, they went into holding, they discussed their fuel state, they did a second approach that also led to a go-around. And now they're in the holding pattern discussing what to do further. And you can see how the Captain is reasoning, right? He has talked, listened to air traffic control, they've given him good weather, he has also listened to some pilot reports both from aircraft that has been on approach but also on the runway, saying that the visibility is generally around 3,000 meters, but there's some few clouds moving around. So it's likely that he thinks that they were just unlucky on their first two attempts, okay? They just managed to hit those few clouds, and on the third attempt, they are going to get this aircraft down on the ground. But while he is thinking like this, he's also painting himself into a corner. He's getting fewer and fewer options available to him. And that is going to lead to some quite crazy things coming up next, so after this short message from my sponsor, I'm gonna tell you all about it. Did you know that every time that you access a public WiFi, hackers could potentially access your data and steal your identity? Scary, right? 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The crew now started to prepare for their third approach into Runway 27, and as they did so, another flight, a Kuwait Flight 329, went around ahead of them. That prompted air traffic control to update the weather to a visibility of 2,000 meters and scattered clouds at 400 feet. Air traffic control now asked the Jet Airways crew what their intentions were, and the captain informed them that in case of a missed approach, they would request a diversion straight down towards Thiruvananthapuram. ATC then told them that the latest weather they had for Thiruvananthapuram was a visibility of 3,000 meters and overcast clouds at 1,500 feet. Still perfectly okay for the VOR approach. So, the crew initiated their third approach with exactly the same result. They came down to their minima, saw nothing, and executed their now third missed approach for the day. When they started flying their missed approach procedure, air traffic control told them to climb straight ahead to 4,000 feet, and then turn left to join the Cochin radial 180 and proceed down towards Thiruvananthapuram. The crew acknowledged this, and started flying according to their cleared route. And at this point, they had a fuel of about 2,644 kilos, and the minimum diversion fuel down towards Thiruvananthapuram was 2,614 kilos. So they're basically bang on their minimum diversion fuel. They requested to climb to 21,000 feet, flight level 210. And as they were cleared to climb, they received an updated weather report from Thiruvananthapuram, where the visibility had now started to go down to 2,500 meters. At time 01:02 UTC, that's 06:30 local time, the Jet Airways crew got into contact with Thiruvananthapuram ATC. Thiruvananthapuram ATC told them that they could expect Runway 14 for the VOR approach, and that the visibility has now gone down to 1,500 meters. And that's a problem because the minimum visibility to start the VOR approach for that runway was 2,100 meters. When the captain heard this, he asked if there was high intensity approach lights and runway lights available to him, because he wanted to use something called converted met visibility in order to start the approach. Now, converted met visibility is basically a tool that we pilots have when we're flying and we don't have access to proper RVR, we only have reported met visibility. And that was the case here. Because if you, for example, can see 500 meters normal visibility, but you're looking at a very strong light, it's very likely that you'll be able to see that light at a much further distance. So, especially during hours of darkness, we can actually use a table to convert reported visibility into converted met visibility and thus get a higher visibility number to enable us to start an approach. And that was what the captain was trying to do here. Unfortunately, at this runway, that wasn't available. So air traffic control told him that no, we only have a simple approach light system with high intensity. But anyway, the captain did the conversion anyway, which enabled him to start the approach, and this is where things are starting to get a little bit sketchy. The crew now starts descending down towards Thiruvananthapuram but when they're about 25 miles away from the airport, the captain realizes that he's way too high to start this approach. That might be because he was expected to do a full procedure arrival and he actually started getting radar vectors in for the approach. But in any case, he had to do a 360-degree turn in order to lose a little bit of altitude which, of course, used up a little bit of fuel as well. After this, the crew declares minimum fuel to air traffic control. Minimum fuel is the first step in a multi-step process indicating that they have a fuel problem, and minimum fuel is not an emergency call but it tells air traffic control that this aircraft has reduced its available airport down to one, and that any change to their current clearance might lead to this aircraft landing with less than final reserve fuel. And any time that an air crew sees that they're gonna land with less than final reserve, they have to declare an emergency which is the next step in that process. Air Traffic Control acknowledged the message and cleared the crew for a VOR approach, Runway 14, and they also cleared them to land Runway 14, with a visibility of 2,000 meters. At time 01:19 UTC, Jet Airways Flight 555 reaches its minimum descent altitude on the VOR approach without being able to see the runway. This now means that they have to execute their fourth go-around of the day, and when they hit the TOGA buttons, they're down to a fuel of 1,324 kilos. And remember that the final reserve fuel is only about 1,300 kilos. And that means that 40 seconds after they initiate the go-around, they now call, "Mayday, mayday, mayday, fuel, Jet Airways Flight 555." Whenever a fuel emergency is announced, this opens up all available runways, airports and approaches for the aircraft that has declared the emergency. This includes military airports as well. So after having declared the emergency, the captain now ask air traffic control if he can do a visual approach in for Runway 14 instead. And this is where things are starting to get really, really crazy, because remember, they've just done a VOR approach down to Runway 14, they didn't see enough to land from that approach. So, to be able to do a visual approach, as the name suggests, you're doing that visually, you need to see the whole runway and the runway environment clearly, in order to safely do a visual approach, which is not backed up by any NAVAIDs. Now, a visual approach is something that we would do in order to do a slightly tighter approach in order to save some time and fuel, but you have to have really, really good weather in order to do this, and they do not have this weather. Now, I understand that the captain, at this point is probably starting to panic a little bit. He doesn't think that he has enough fuel to safely fly a full procedure VOR approach in and he just wants to get the aircraft down on the ground. But on the other hand, he doesn't see the runway, so it doesn't make any sense. Anyway, he levels off the aircraft at approximately 1,000 feet above ground level, which is lower than we would normally do during a visual approach. He then flies downwind until he is approximately abeam the threshold for Runway 14, and as they pass the abeam point, they call up air traffic control and tell them that they are now turning base for Runway 14. Air traffic control tells them that, "You're just passing the abeam point. Confirm that you can see the runway," indicating that air traffic control thinks that they're way too close to make the 90-degree turn to start getting themselves on to final. The crew reads this back, they descend down to 500 feet, and then turns towards the airport. But because they cannot see the airport properly, they end up to the right of centerline and way too low. And once they realize this, when they finally see the runway, the captain turns abruptly to the left, causing a bank angle warning, and when he hears the bank angle, he now goes around for the fifth time. They now have only 898 kilos on board, and the captain once again asks if he can do another visual approach for Runway 14. Because he's in an emergency, air traffic control approves this. Once again, he levels off at 1,000 feet, and he gets an updated visibility report from the Thiruvananthapuram ATC saying that they now have 2,000 meters visibility, which is way too low for what he is doing. He continues down once again, initiates his base turn way too early, descending to 500 feet on base and once again, ends up in a position where he's not aligned with the runway, and he's too high, prompting an incredible sixth go-around for the day. The fuel is now 662 kilos, and things are starting to get really, really critical. Unless they can manage to get this aircraft down on the ground within the next 10 to 12 minutes, they will run out of fuel and the captain is well aware of this. Because of this, he now tells air traffic control and his colleague that he intends to, instead of doing another circuit for Runway 14, he wants to do a 180-degree turn to land on the opposite runway, Runway 32, which would be slightly quicker. The problem is, of course, that he still is in cloud; he doesn't see anything. So, he takes control of the aircraft, turns slightly to the left in order to widen the turn slightly and then starts turning right to join with the final approach. As he's doing this, the first EGPWS warning goes on, saying, "Terrain! Terrain!" followed by a second saying, "Terrain! Terrain! Pull up!" The pilots responds to both of these warnings with saying out loud that they are visual with the terrain below them and the first officer reaches over and inhibits the Ground Proximity Warning System. At time 01:38:06, the first officer looks over to the captain and ask, "Do you know where it is?" And the captain just responds, "Just flying blindly." They then continue to descend down towards the runway. The bank angle warning comes on several times, the latest one is at 50 feet above the runway. And at time 01:39, they manage to touch down safely on Runway 32. The aircraft is okay, passengers and crew are okay, and they taxi into the airport. The final total fuel recorded on board after the engines were shut down at the gate was 349 kilos. Just to give you some perspective, the aircraft normally burns about 40 to 50 kilos per minute and about twice as much if it's on climb thrust. Because the pilots had declared an emergency, the cockpit voice recording was preserved and sent in to the investigation team. And that, together with the safety report that the crew filed, laid foundation to the incident report that I've just told you about. But after the cockpit voice recorder had been removed and replaced, the crew of this flight simply refuelled the aircraft and flew back to Cochin on the very same day. And that's just something that I personally cannot understand because what they've just been through is basically a near-death experience, all right? Their adrenaline levels must have been through the roof. And to think that they will be fit to fly on a second flight on the same day after something like this is just unfathomable. The findings of the investigation showed that the weather was obviously a factor that led the pilots into this situation. But it also showed that there was insufficient guidance from the company, from Jet Airways, on how the pilot should be thinking about doing multiple approaches into an airport where the weather was marginal. And just to give you an example, the airline that I work for myself, we have a rule saying that you can do two approaches into the same airport with the same weather. But in order to do a third approach, you need the weather to have doubled. If that's not the case, so if you're hovering around the same kind of marginal weather as you did during the first two approaches, well, then you have to divert. And obviously, you wanna divert to an airport where you are reasonably sure that you can get down. Specifically, you wanna fly to an airport, where you have, if possible, a precision approach to fly to. To go to an alternate airport where the weather is equally marginal as the airport that you just left behind you but where the approach aids are worse, is setting you up for a potentially very, very bad situation, which this crew definitely experienced. Now, the final report also stated that the pilots broke several rules and regulations during this flight, which ultimately endangered the safety of the crew, the passengers and the aircraft. But I don't know what happened to them. I don't know if they lost their jobs or if they continue to fly, and I don't really care because these videos are not about assigning blame. It's about learning something. It's about knowing what has happened and how the industry has learned from it and become safer. That's all I want to do. One thing I can say, though, is that this final report was very poorly written. It left out a lot of details. I would have loved to know what kind of discussions, communications there was between the flight crew and the cabin crew and also the passengers, because I can't even begin to imagine the amount of discomfort and, potentially, fear that the passengers would have felt during this flight, having to go through six go-arounds on one single flight. And if you were a passenger on this flight out there, feel free to reach out to me with an email. I would love to hear from you about this experience. Now, if you wanna see a video that I think you're really gonna enjoy, check this one out, or maybe this one. If you wanna support the work that I do here on the channel, then consider becoming part of my lovely Patreon crew and join my next weekly hangout. I'd love to see you there. And you can also buy yourself some merch. Have an absolutely fantastic day, and I'll see you next time. Bye-bye.
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Channel: Mentour Pilot
Views: 2,064,920
Rating: undefined out of 5
Keywords: true crime, crime stoires, storytelling, captain, mentour pilot, mentor pilot, crash investigation, full epsiodes, aviation, pilot, crash, air crash investigation, final report, boeing, airbus, piper, cessna, disaster, fatal crash, air incident, air disasters 2022, fuel, fumes, india, boeing 737, Thiruvananthapuram, bangalore, cochin, Kempegowda, doha, empty
Id: o-IuOnDBoGA
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Length: 27min 47sec (1667 seconds)
Published: Sat Aug 13 2022
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