reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2012 B738 Fog undershoot, Mangalore, India

Brief account : 

A B737-800 made an ILS approach shortly after sunrise in variable fog. A high rate of descent built up after passing DH and the aircraft touched down short of the runway followed by a bounce and hard landing. 

Crew-related factors : 

A classic low visibility manual landing event undershoot. It involves many of the factors discussed in detail on this site especially relating to visual transitions in limited visibility. 

The RVR information passed to the crew was such that the approach was "legal" but the actual conditions encountered may have been significantly worse than anticipated.  

The Captain (PF) instructed the F/O to call when the lights were visible; he disconnected the autopilot 4 seconds after the (automated) "minimums" call (DH was 212ft). The RoD increased as the nose pitched slowly down. The F/O called lights visible a further 4 seconds later at 175 ft. with 2 dots Glideslope fly up indications. With inadequate visual reference, the Captain was unable to detect and arrest the touchdown at 750fpm.and 3.25g short of the runway. 

The report noted that:  

"The CVR and FDR analysis shows evidence of both crew carrying out the same task of looking out for the runway approach lights.

There was no evidence about the monitoring the instruments of the aircraft during this phase hence no corrective action by P1 or go around call was given by P2.

The increased ROD during the last few seconds of the approach is indicative of the flight crew attempting to get a visual reference on the runway and during this period both crew did not realize the aircraft pitch attitude, ROD & glide slope deviation."

"First officer (PNF) was distracted from his duties to monitor flight instrument due Captain’s instruction to look out for runway lights." 

"The aircraft was pitched down attitude by the captain in order to gain better visual reference of the runway/runway lights."

"The Captain seemed to be concentrating on gaining visual reference at low altitude and in the process losing focus on high rate of descent, aircraft pitch attitude and flying below glide slope."

If the approach had been conducted using PicMA it is likely that a missed approach would have been initiated at DH.

Type: 
B738
Where: 
India Mangalore
Pilot in charge: 
Capt
Early transition: 
Yes
Go-around : 
No
Damage: 
Minor or none
PicMA potential: 
Major
Year: 
2012
Time: 
Day
Deterioration: 
Unknown
Vert Guidance: 
G/S
Both Head Up: 
Yes
LoC: 
No
Operator: 
AIR INDIA CHARTERS
Fully prepared: 
Yes
Actual Weather: 
Fog
Autopilot : 
Y
CCAG: 
High