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- [Petter] Few things will be more terrifying to a pilot than the prospect of running

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out of fuel mid-flight.
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But that is exactly what's about to happen to this Boeing 737 crew
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after having flown a heart-wrenching six approaches, going on their seventh.
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How that was possible, and what led up to it
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is what I'm gonna tell you about today.
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So stay tuned.
Flight Origins
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The story I'm gonna tell you about today is the story of Jet Airways Flight 555,
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and it's actually one of the more crazy stories that I've ever come across.
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It's a story about communication;
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about, to a certain extent, bad luck and bad timing
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but also decision-making, and how a single decision
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can have potentially devastating consequences going forward.
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The incident took place on the 18th of August, 2015.
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And the aircraft that is involved is a Boeing 737-800, just like the type that I'm flying.
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The crew was quite experienced.
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The captain was 40 years old and had just under 6,700 hours,
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the majority of which he had flown on the 737.
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He was assisted by a first officer that was slightly less experienced.
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He had just under 1,500 hours of total time and about 580 on the type.
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They had both operated together on the day before, on the 17th of August
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where they had flown from Cochin in India over towards Doha.
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And then they had a night stop there.
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They were fully rested on the 18th of August, which is the day of the incident.
Weather Conditions
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The flight that they were about to operate was a night flight.
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So they met up at 18:30 UTC,
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that's about midnight, local time, and they started doing their pre-flight preparation.
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The weather en-route looked absolutely fine.
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But the weather on their destination, looked like it could be potentially a little bit misty.
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However, the weather they had available for their planning was quite old.
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It was issued at 09:00 UTC, so almost 15 hours earlier, but it was still valid.
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It indicated a visibility at their destination, Cochin, of about 4,000 meters
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with light winds from a northerly direction,
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and clouds scattered at 1,500 feet and broken clouds at 9,000 feet.
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So this is fairly good weather.
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Their alternate airport, Bangalore, had even better weather
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with a visibility of 8,000 meters, winds from 290 at 10 knots,
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and some scattered clouds at 1,200 feet and broken clouds at 8,000 feet.
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So this was perfectly good weather situation for the time.
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When we have a weather forecast that indicates that at the time of our arrival,
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plus one hour before and one hour after,
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the weather will be good enough for us to land using the approaches available at our destination,
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well, then we only need one alternate airport.
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Now, the alternate airport needs to have slightly better weather than our destination
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just to give us a little bit better margin in case we have to divert.
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What we do is that we look at the best possible approach aids at our alternate airport,
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and then we go to the second best approach aid,
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and we make sure that the weather is still good enough to be able to take that.
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In this case, the crew looked at the weather and they figured that, yeah, this is good enough,
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we don't need two alternates, we don't need to look too much into it.
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So we could potentially take minimum fuel going here.
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But the captain looked a little bit closer at the weather and saw that
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even though it was better than the minimum required, it still wasn't great.
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There was still some mist there.
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And whenever you have mist, there's always a possibility that that mist might turn into a fog
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or it might be worse than expected.
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So he thought, let's take a little bit extra fuel to enable us to hold a little bit
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when we get overhead Cochin.
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So that's what they did.
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They looked at their flight plan and they started calculating how much fuel
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they were actually going to take, taking this into consideration.
Fueling Operations
3:47
Now, here it's quite important for you guys to understand how we actually calculate
3:50
our minimum fuel before we dispatch.
3:53
So, in the case of Jet Airways, they started off with adding taxi fuel.
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Taxi fuel was about 180 kilos and that was calculated on a fuel burn of about 12 kilos per
minute,
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giving them 15 minutes of taxi time which is reasonable.
4:07
The next thing they added on was the trip fuel,
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and the trip fuel is calculated from brakes release for takeoff, climb,
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the standard instrument departure,
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then climb-up to cruise level, the whole flight to top of descent,
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the descent into, and including the standard arrival route.
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And then 240 kilos for the approach phase, down to landing.
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In this case, the trip fuel was 11,112 kilos
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or four hours and seven minutes.
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On top of this, we also add something called contingency fuel,
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and it is exactly what it sounds like.
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It's for contingency.
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So maybe there's a thunderstorm en-route that we need to divert around or something like that.
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This tends to be a minimum of 5% of the trip fuel.
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In this case, there was 556 kilos or 14 minutes.
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And then we add on the alternate fuel which includes the missed approach
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at our destination, the climb to 1,500 feet initially,
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then the standard instrument departure,
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the climb, cruise and then descent into our alternate and a further approach.
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In this case, the fuel was to Bangalore and they needed 2,178 kilos for that.
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That was about 44 minutes of flying time.
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Now, the last amount of fuel that we need to add in order to find
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our minimum legal dispatch fuel is our final reserve fuel.
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And the final reserve fuel needed to enable us to fly at an altitude of 1,500 feet
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over our alternate for a minimum of 30 minutes,
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in this case, this was 1,128 kilos.
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Jet Airways had then also added one hour of APU burn which is 105 kilos,
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and in total, this led to an absolute minimum fuel,
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according to Jet Airways of 15,295 kilos for this flight.
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Like I mentioned before, the captain then decided to add another 750 kilos of fuel,
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about 19 minutes extra flight time, and then he rounded the total fuel up to the closest 100,
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ending up at 16,100 kilos of fuel,
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which was well above the minimum required for this flight.
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Once the crew had decided on the fuel they were going to take,
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they now started looking into all of the other preparation material as well.
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And the first officer took quite a keen interest into the NOTAMs.
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These are documents that indicate if something is working or not working at the destination,
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and the alternate airport and also the airports en-route.
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And his attention to detail is going to become important in this story.
Takeoff
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Once the pilots were happy with their pre-flight preparation,
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they walked over to their six cabin crew members that was gonna fly with them on the day.
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And then they all together walked out to the aircraft and started preparing it for departure.
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They boarded their 142 passengers that were scheduled for the flight over towards Cochin,
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and the captain was gonna be pilot flying for the flight,
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and the first officer was gonna be pilot monitoring.
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The aircraft in itself was a three-year-old 737-800,
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which was fully serviceable, there was nothing wrong with it.
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The pilots completed their pre-flight preparation,
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they received pushback and start clearance, and then started taxiing out for departure.
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At time 19:37 UTC, that's just about 10 minutes past one o'clock local time,
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the aircraft departed from Doha and started flying towards Cochin in India.
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The climb-out and the cruise phase of this flight was completely uneventful.
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And at time 23:00 UTC, that's about 04:30 in the morning in Cochin,
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the flight crew got into contact with Cochin ATC to get the latest weather.
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ATC responded and reported that the weather was quite nice in Cochin.
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It was 3,500 meters in mist, some few clouds at 1,500 feet and light winds.
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So this was more or less exactly what the pilots had expected.
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So the captain started setting up for a standard ILS approach into Runway 27 in Cochin.
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And that approach is something we call a full procedure approach.
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This means that instead of getting radar vector on to the final approach before landing,
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the crew would have to fly in over a VOR NAVAID that was situated close to the airfield,
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and then they would have to fly out to a specific distance before they could turn in
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and join the ILS procedures.
Approaching Cochin
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About 48 minutes later, at time 23:48, the aircraft arrived above Cochin VOR
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and started flying outbound for the approach.
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At this point, they had about 4,844 kilos of fuel available,
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which was much more than their minimum diversion fuel towards Bangalore.
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The crew started to slow the aircraft down according to procedure, they started to extend
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their flaps and completing their landing checklists.
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The minimum visibility for this approach was 650 meters
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and the minima, the lowest point that they could fly down to before they had
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to do a missed approach was 320 feet.
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And the crew was not expecting any problems with this,
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given the weather they just received.
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But as they were descending down the glide slope, it became more and more obvious
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that the weather was actually much worse than expected.
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And when the captain reached the minima, 320 feet, he couldn't see anything.
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So, he executed the first go-around.
Go Around One
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After the go-around, the crew entered a holding pattern over Cochin VOR
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and they now started discussing how to proceed.
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They had 4,699 kilos of fuel on board, and the minimum diversion fuel towards Bangalore
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was 3,306, so they still had a lot of fuel.
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They knew that the weather in Bangalore was good and that they had a working ILS approach
there,
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but they now started looking into the other alternates that were a little bit closer
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to see if they maybe could change their alternate to one of them,
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in order to give them even more fuel margin
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to do possibly one or two more approaches into Cochin.
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The two alternates they were now looking into was Coimbatore which was the closest one,
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and Thiruvananthapuram which was a little bit further away.
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But when they were discussing this,
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the first officer told the captain that actually in Thiruvananthapuram, we have to be a bit careful
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because even though it normally has an ILS approach there,
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the ILS approach was down for maintenance for about a week.
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So they only have non-precision approaches, a VOR approach available, in Thiruvananthapuram.
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The captain acknowledged this and they checked what the weather was like in
Thiruvananthapuram,
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and it was given as 3,000 meters, which was well above the minimum requirement
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for a VOR approach into there.
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So the captain felt quite confident about it.
Neighbouring Aircraft
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As they were discussing this and setting up for their second approach into Runway 272,
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Air India Express Boeing 737s were ahead of them on final.
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The first one managed to land and reported that he could see the runway at about 1,400 feet,
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but that there were low clouds moving around the airport.
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The second Air India Express had to go around.
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So when Jet Airways Flight 555 started their second approach,
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Cochin ATC came in and told them that the visibility was now 2,500 meters,
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and that there were low clouds at about 600 feet.
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The second approach proceeded exactly like the first one,
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with the pilots reaching the minima without having any sign
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of the runway in front of them.
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They now executed their second go-around and once again, entered a holding pattern over
Cochin.
Go Around Two
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The fuel was now 3,919 kilos, which was still more than the minimum of 3,306 kilos
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they needed to divert to Bangalore.
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But the captain now wanted to redesignate their alternate to Thiruvananthapuram instead,
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because if he did so, that would give him approximately 20 minutes longer,
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which he could use to do a third approach in towards Cochin.
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The first officer was not very happy with this.
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He pointed out to the captain that the weather was actually getting worse, not better,
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and that the sun was about to rise,
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and that would make it even harder to see through the haze.
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The captain countered that argument with the fact that they had Coimbatore as an alternate
airport
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that was even closer than Thiruvananthapuram if they will need it.
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But they never took any weather for Coimbatore.
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At time 00:20:06, the crew of Jet Airways Flight 555 informed air traffic control
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that they were now redesignating Thiruvananthapuram as their primary alternate.
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And this is where you guys need to pay particular attention as to decision-making,
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because up until this point, the decision-making
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that these two pilots have made is just like any other flight crew.
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They decided to take some extra fuel because they saw that the weather
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was a little bit iffy at Cochin,
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they then flew the flight, they executed a go-around on their first approach attempt,
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they went into holding, they discussed their fuel state,
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they did a second approach that also led to a go-around.
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And now they're in the holding pattern discussing what to do further.
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And you can see how the Captain is reasoning, right?
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He has talked, listened to air traffic control, they've given him good weather,
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he has also listened to some pilot reports both from aircraft that has been on approach
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but also on the runway, saying that the visibility is generally around 3,000 meters,
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but there's some few clouds moving around.
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So it's likely that he thinks that they were just unlucky on their first two attempts, okay?
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They just managed to hit those few clouds,
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and on the third attempt, they are going to get this aircraft down on the ground.
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But while he is thinking like this, he's also painting himself into a corner.
13:12
He's getting fewer and fewer options available to him.
13:15
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13:20
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Now, back to the video.
Planning For Alternates
14:27
The crew now started to prepare for their third approach into Runway 27,
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and as they did so, another flight, a Kuwait Flight 329, went around ahead of them.
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That prompted air traffic control to update the weather to a visibility of 2,000 meters
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and scattered clouds at 400 feet.
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Air traffic control now asked the Jet Airways crew what their intentions were,
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and the captain informed them that in case of a missed approach,
14:51
they would request a diversion straight down towards Thiruvananthapuram.
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ATC then told them that the latest weather they had for Thiruvananthapuram
14:58
was a visibility of 3,000 meters and overcast clouds at 1,500 feet.
15:02
Still perfectly okay for the VOR approach.
Go Around Three
15:05
So, the crew initiated their third approach with exactly the same result.
15:10
They came down to their minima, saw nothing,
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and executed their now third missed approach for the day.
15:17
When they started flying their missed approach procedure,
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air traffic control told them to climb straight ahead to 4,000 feet,
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and then turn left to join the Cochin radial 180 and proceed down towards Thiruvananthapuram.
15:27
The crew acknowledged this, and started flying according to their cleared route.
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And at this point, they had a fuel of about 2,644 kilos,
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and the minimum diversion fuel down towards Thiruvananthapuram was 2,614 kilos.
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So they're basically bang on their minimum diversion fuel.
15:45
They requested to climb to 21,000 feet, flight level 210.
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And as they were cleared to climb, they received an updated weather report from
Thiruvananthapuram,
15:54
where the visibility had now started to go down to 2,500 meters.
Approaching Thiruvananthapuram
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At time 01:02 UTC, that's 06:30 local time, the Jet Airways crew got into contact
16:05
with Thiruvananthapuram ATC.
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Thiruvananthapuram ATC told them that they could expect Runway 14 for the VOR approach,
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and that the visibility has now gone down to 1,500 meters.
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And that's a problem because the minimum visibility to start the VOR approach
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for that runway was 2,100 meters.
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When the captain heard this, he asked if there was high intensity approach lights
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and runway lights available to him,
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because he wanted to use something called converted met visibility in order to start the approach.
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Now, converted met visibility is basically a tool that we pilots have when we're flying
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and we don't have access to proper RVR, we only have reported met visibility.
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And that was the case here.
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Because if you, for example, can see 500 meters normal visibility,
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but you're looking at a very strong light,
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it's very likely that you'll be able to see that light at a much further distance.
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So, especially during hours of darkness,
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we can actually use a table to convert reported visibility
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into converted met visibility and thus get a higher visibility number
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to enable us to start an approach.
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And that was what the captain was trying to do here.
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Unfortunately, at this runway, that wasn't available.
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So air traffic control told him that no, we only have a simple approach light system
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with high intensity.
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But anyway, the captain did the conversion anyway,
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which enabled him to start the approach,
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and this is where things are starting to get a little bit sketchy.
Minimum Fuel
17:39
The crew now starts descending down towards Thiruvananthapuram
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but when they're about 25 miles away from the airport,
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the captain realizes that he's way too high to start this approach.
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That might be because he was expected to do a full procedure arrival
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and he actually started getting radar vectors in for the approach.
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But in any case, he had to do a 360-degree turn in order to lose a little bit of altitude
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which, of course, used up a little bit of fuel as well.
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After this, the crew declares minimum fuel to air traffic control.
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Minimum fuel is the first step in a multi-step process indicating
18:13
that they have a fuel problem, and minimum fuel is not an emergency call
18:18
but it tells air traffic control that this aircraft has reduced its available airport down to one,
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and that any change to their current clearance might lead to this aircraft landing
18:29
with less than final reserve fuel.
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And any time that an air crew sees that they're gonna land with less than final reserve,
18:36
they have to declare an emergency which is the next step in that process.
Go Around Four
18:41
Air Traffic Control acknowledged the message and cleared the crew for a VOR approach,
18:45
Runway 14, and they also cleared them to land Runway 14, with a visibility of 2,000 meters.
18:52
At time 01:19 UTC, Jet Airways Flight 555 reaches its minimum descent altitude
18:58
on the VOR approach without being able to see the runway.
19:03
This now means that they have to execute their fourth go-around of the day,
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and when they hit the TOGA buttons, they're down to a fuel of 1,324 kilos.
19:14
And remember that the final reserve fuel is only about 1,300 kilos.
19:20
And that means that 40 seconds after they initiate the go-around,
19:23
they now call, "Mayday, mayday, mayday, fuel, Jet Airways Flight 555."
Trying a Visual
19:30
Whenever a fuel emergency is announced, this opens up all available runways, airports
19:35
and approaches for the aircraft that has declared the emergency.
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This includes military airports as well.
19:40
So after having declared the emergency, the captain now ask air traffic control
19:44
if he can do a visual approach in for Runway 14 instead.
19:47
And this is where things are starting to get really, really crazy,
19:51
because remember, they've just done a VOR approach down to Runway 14,
19:55
they didn't see enough to land from that approach.
19:58
So, to be able to do a visual approach, as the name suggests, you're doing that visually,
20:04
you need to see the whole runway and the runway environment clearly,
20:08
in order to safely do a visual approach, which is not backed up by any NAVAIDs.
20:13
Now, a visual approach is something that we would do in order to do
20:15
a slightly tighter approach in order to save some time and fuel,
20:19
but you have to have really, really good weather in order to do this,
20:23
and they do not have this weather.
20:25
Now, I understand that the captain, at this point is probably starting to panic a little bit.
20:29
He doesn't think that he has enough fuel to safely fly a full procedure VOR approach in
20:34
and he just wants to get the aircraft down on the ground.
20:37
But on the other hand, he doesn't see the runway, so it doesn't make any sense.
20:43
Anyway, he levels off the aircraft at approximately 1,000 feet above ground level,
20:47
which is lower than we would normally do during a visual approach.
20:51
He then flies downwind until he is approximately abeam the threshold for Runway 14,
20:57
and as they pass the abeam point,
20:59
they call up air traffic control and tell them that they are now turning base for Runway 14.
21:05
Air traffic control tells them that, "You're just passing the abeam point.
21:09
Confirm that you can see the runway," indicating that air traffic control thinks
21:12
that they're way too close to make the 90-degree turn
21:16
to start getting themselves on to final.
21:20
The crew reads this back, they descend down to 500 feet,
21:23
and then turns towards the airport.
21:25
But because they cannot see the airport properly,
21:28
they end up to the right of centerline and way too low.
21:32
And once they realize this, when they finally see the runway,
21:36
the captain turns abruptly to the left, causing a bank angle warning,
21:41
and when he hears the bank angle, he now goes around for the fifth time.
Go Around Five
21:47
They now have only 898 kilos on board, and the captain once again asks
21:52
if he can do another visual approach for Runway 14.
21:55
Because he's in an emergency, air traffic control approves this.
21:59
Once again, he levels off at 1,000 feet,
22:01
and he gets an updated visibility report from the Thiruvananthapuram ATC saying
22:06
that they now have 2,000 meters visibility, which is way too low for what he is doing.
22:12
He continues down once again, initiates his base turn way too early,
22:17
descending to 500 feet on base and once again,
22:20
ends up in a position where he's not aligned with the runway, and he's too high,
22:25
prompting an incredible sixth go-around for the day.
Go Around Six
22:30
The fuel is now 662 kilos, and things are starting to get really, really critical.
22:35
Unless they can manage to get this aircraft down on the ground within the next 10 to 12 minutes,
22:40
they will run out of fuel and the captain is well aware of this.
22:43
Because of this, he now tells air traffic control and his colleague that he intends to,
22:48
instead of doing another circuit for Runway 14,
22:51
he wants to do a 180-degree turn to land on the opposite runway, Runway 32,
22:56
which would be slightly quicker.
22:59
The problem is, of course, that he still is in cloud; he doesn't see anything.
23:03
So, he takes control of the aircraft, turns slightly to the left
23:07
in order to widen the turn slightly and then starts turning right to join
23:11
with the final approach.
23:13
As he's doing this, the first EGPWS warning goes on, saying, "Terrain! Terrain!"
23:19
followed by a second saying, "Terrain! Terrain! Pull up!"
23:22
The pilots responds to both of these warnings with saying out loud
23:26
that they are visual with the terrain below them and the first officer reaches over
23:30
and inhibits the Ground Proximity Warning System.
349 Kilos Left
23:34
At time 01:38:06, the first officer looks over to the captain and ask,
23:39
"Do you know where it is?"
23:41
And the captain just responds, "Just flying blindly."
23:44
They then continue to descend down towards the runway.
23:47
The bank angle warning comes on several times, the latest one is at 50 feet above the runway.
23:53
And at time 01:39, they manage to touch down safely on Runway 32.
24:01
The aircraft is okay, passengers and crew are okay, and they taxi into the airport.
24:08
The final total fuel recorded on board
24:10
after the engines were shut down at the gate was 349 kilos.
24:15
Just to give you some perspective, the aircraft normally burns about 40 to 50 kilos per minute
24:21
and about twice as much if it's on climb thrust.
The Return Leg
24:25
Because the pilots had declared an emergency, the cockpit voice recording was preserved
24:29
and sent in to the investigation team.
24:31
And that, together with the safety report that the crew filed, laid foundation to the incident report
24:38
that I've just told you about.
24:40
But after the cockpit voice recorder had been removed and replaced,
24:44
the crew of this flight simply refuelled the aircraft and flew back to Cochin
24:49
on the very same day.
24:51
And that's just something that I personally cannot understand
24:54
because what they've just been through is basically a near-death experience, all right?
25:00
Their adrenaline levels must have been through the roof.
25:04
And to think that they will be fit to fly on a second flight on the same day
25:08
after something like this is just unfathomable.
Probable Cause
25:11
The findings of the investigation showed that the weather was obviously a factor
25:14
that led the pilots into this situation.
25:17
But it also showed that there was insufficient guidance from the company, from Jet Airways,
25:22
on how the pilot should be thinking about doing multiple approaches into an airport
25:28
where the weather was marginal.
25:30
And just to give you an example, the airline that I work for myself,
25:34
we have a rule saying that you can do two approaches
25:37
into the same airport with the same weather.
25:39
But in order to do a third approach, you need the weather to have doubled.
25:43
If that's not the case, so if you're hovering around the same kind of marginal weather
25:48
as you did during the first two approaches, well, then you have to divert.
25:52
And obviously, you wanna divert to an airport where you are reasonably sure that you can get
down.
25:57
Specifically, you wanna fly to an airport,
26:01
where you have, if possible, a precision approach to fly to.
26:04
To go to an alternate airport where the weather
26:07
is equally marginal as the airport that you just left behind you
26:10
but where the approach aids are worse,
26:12
is setting you up for a potentially very, very bad situation,
26:16
which this crew definitely experienced.
A Poor Report
26:19
Now, the final report also stated that the pilots broke
26:22
several rules and regulations during this flight,
26:25
which ultimately endangered the safety of the crew, the passengers and the aircraft.
26:30
But I don't know what happened to them.
26:32
I don't know if they lost their jobs or if they continue to fly, and I don't really care
26:37
because these videos are not about assigning blame.
26:39
It's about learning something.
26:41
It's about knowing what has happened and how the industry has learned from it and become
safer.
26:46
That's all I want to do.
26:47
One thing I can say, though, is that this final report was very poorly written.
26:52
It left out a lot of details.
26:54
I would have loved to know what kind of discussions, communications there was between the
flight crew
27:00
and the cabin crew and also the passengers,
27:02
because I can't even begin to imagine the amount of discomfort and, potentially, fear
27:08
that the passengers would have felt during this flight,
27:11
having to go through six go-arounds on one single flight.
27:15
And if you were a passenger on this flight out there, feel free to reach out to me with an email.
27:20
I would love to hear from you about this experience.
27:23
Now, if you wanna see a video that I think you're really gonna enjoy, check this one out,
27:27
or maybe this one.
27:29
If you wanna support the work that I do here on the channel,
27:31
then consider becoming part of my lovely Patreon crew
27:34
and join my next weekly hangout.
27:35
I'd love to see you there.
27:37
And you can also buy yourself some merch.
27:39
Have an absolutely fantastic day, and I'll see you next time.
27:42
Bye-bye.

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