Mangalore air disaster: learning for organizational leadership.
| Author | Biswas, Malay |
| Position | Report - Abstract |
Introduction
Modeling human behavior in crisis is not new and rather it has a long tradition. A few of such examples are Mann Gulch Fire accident (Weick, 1993), Tenerife Air Disaster, Bhopal's Union Carbide Gas Leak (Shrivastava, 1987; Weick, 2010), The Esso Gas Plant Explosion (Hopkins, 2000), Mount Everest Accident (Kayes, 2004), Walkerton Water Contamination Crisis (Mullen, Vladi& Mills, 2006), Columbia Shuttle Disaster (Dunbar & Garud, 2005), Trading Room (Beunza & Stark, 2005), United Flight 232 Catastrophe (McKinney, Barker, Davis, & Smith, 2008) to name a few. Discourse over crisis management provides important perspectives that could be incorporated into our personal behavior and organizational infrastructure for informed management of risk (Birkland, 2009). This study attempts to recover the learning that could have relevance in the management of crisis-ridden organizations.
Brief Description
On May 22, 2010, at about 6 a.m., Air India Express flight IX-812, Boeing 737-800 VT-AXV, while landing at Mangalore Airport, overran the airport runway and crashed into a gorge, killing 2 pilots, 4 cabin crew, and 152 passengers. Only 8 passengers survived with injuries. Both the Captain and the First Officer were highly experienced in their respective crew positions. Captain Glusica from Serbia, 55 years old pilot, had logged 10215 hours as Pilot in Command position out of which 2844 hours on 737-800 and had made a total of 16 landings in the past at the Mangalore airport. He earlier worked in Yugoslavia, Malta, Canada and Australian carriers. After returning from his vacation, this was his first flight duty flying back from Dubai to Mangalore. The First Officer, Harbinder Singh Ahluwalia, 40 years old, who was stationed in Mangalore, had logged 3620 hours, with Boeing 737-800 3319 hours and had operated as a copilot on 66 flights at the Mangalore airport.
While attempting to land, the aircraft overshot the runway including the strip of 60 meters, and continued into Runway End Safety Area (90 meters) and the subsequently right wing impacted the localizer antenna structure (85 meters) and fell into a gorge after hitting the boundary fence. The aircraft was totally destroyed due to the impact and post-crash fire.
It could be argued that the aircraft was flying high while attempting to land. It was almost twice the altitude as compared to standard decent procedure. The First Officer called for 'unstabilized' approach and requested for 'go-around'. The electronic signaling system displayed in the cockpit provided regular warnings for danger associated with the current landing approach. Ignoring the First Officer's assessment and recommendations for go-round, complemented by electronic warnings in the cockpit, the Captain attempted to land. Just before the touchdown, cockpit voice recorder indicated that the First Officer made a call "go round Captain--we don't have runway". After touch-down, the Captain opted for Thrust Reverser, but within 6 seconds, initiated an attempted take-off, in contravention of Standard Operating Procedures, set by the Boeing Commercial Airplane Company, USA.
The cockpit voice recorder, normally capable of recording for last 2 hours 5 minutes indicated that there was no conversation between the two pilots for first 1 hour and forty minutes and the Captain was asleep with intermittent sound of snoring, deep breathing and by the end, sound of clearing throat and coughing could be heard. The First Officer attended all the radio calls, and courtesy calls from the Airhostess. Thus, almost negligible interactions between the two pilots, the apparent discomforting health situation of the Captain, incomplete briefing, improper plan for decent of the aircraft, ignoring the assessment of copilot and cockpit electronic signal system, non-availability of radar support at the airport co-created an ecology, where perhaps accident is the only possible outcome.
Cockpit Authority Gradient & Power Dynamics
We look into power dynamics at the cockpit, and its role in procreating the Mangalore air disaster. We examine cockpit authority gradient and explored its link with relevant literature from aviation, psychology and medicine. We review the general tendency among cockpit crew when interaction is interrupted by hierarchy. We also ask questions of ourselves--does national culture have any role in this case? It could be argued that while flying the aircraft, almost no interaction occurred between the Captain and the First Officer that potentially made a significant contribution to the Mangalore air disaster. The cockpit authority gradient was sharp. We also observe that the flying crew performed status consistent dialogical performance.
6:03:14: First Officer: 'Flap forty'.
6:03:17: First Officer: 'Landing checklist'
6:03:40: First Officer: 'Runway straight down'
6:03:41: The Captain: 'Oh my God'
6:03:53: First Officer: 'Go around?' (Auto pilot disengaged by the Captain)
6:03:56: First Officer: 'Wrong LOC--localizer --glide path'
6:04:02: First Officer: 'Go round Captain'.
6:04:05: First Officer: 'Unstabilized'
6:04:20: Tower : 'Wind calm, runway 24, clear to land'
6:04:55: First Officer: 'Go round captain. We don't have runway left'.
(In the next few seconds, aircraft crash-landed into a gorge, killing pilots, other crews, passengers, including 4 infants, leaving only 8 adults who survived somehow).
Oscillation between hierarchical organizational structures and deference to expertise in emergencies are the two important cornerstones in this case. The First Officer accepted the sanctioned and legitimized expertise of the Captain during emergency; at the same time, the Captain failed to accept the situational interpretation provided by the First Officer. The situation accelerated into a danger zone quite swiftly--it appears that the distance between safe, safety and emergency all coexisted within a few seconds away.
Flying an aircraft involves a high degree of interactive complexity. Observation from medicine-in-action literature shows that day to day operations could not be captured into rules and theoretical principles (Lock, Young & Cambrosio, 2000; Franklin & Roberts, 2006). Fluidity into the unfolding situation makes it difficult for codification. It could be argued that knowledge distilled elsewhere is not waiting for its application in practice, but is constantly produced for its immediate application (Smith-Jentsch, Baker, Salas & Cannon- Bowers, 2001). For example, research indicates that pilot engaged in flying responsibility at the time of the incidents commits more errors that trigger an incident, but non-flying pilot is less likely to lose situational awareness. It was also found that the Captains, legally responsible for the flights lose...
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