Biman Bangladesh Airlines Flight BG035 Approach and Landing to Runway
5 December 2004, 1405LT, DC10-30, S2-ACO, SOB 197
This started as a specific report upon an incident that occurred on approach to the airport detailed above.
It has developed into not only a report on that topic but on several other topics raised and observed by me during my one-year contract with Biman Bangladesh Airlines.
I draw upon the incidents detailed and make a personal conclusion at the end based upon no more than observation, and intuition and a measure of fear for the future given the trends I have observed.
I believe that my background and experience in diverse flight operations and qualification as an instructor in a flight, simulator and ground disciplines allows me to observe and report.
Brian W May
FO X was carrying out the landing under supervision of Captain XX who is a training captain. This was on his line experience training as I am told he must be monitored for the first 200 hours by training staff before he is allowed to land the aircraft without supervision. He is an ex Airbus A310 first officer converting to the DC10 within the Company – this is Biman’s normal career progression. At the time of the incident he had approximately 100 hours time on the DC10.
35º flap landing was briefed.
Radar vectoring to the ILS resulted in us being too close at about 3000 feet plus (cleared to 2000 to establish initially then cleared for the approach) and 7 miles.
On visually sighting the runway, it became immediately obvious due to visual aspect that we were too high and I suggested we should do a Go Around (GA). This was ignored.
FO attempted to acquire the glideslope visually, resulting in coarse pitch changes as the PAPIs were clearly visible. This resulted in an increase in IAS to about 200 knots. At this point the captain had selected 50º flap, some 30 knots above limiting speed (this is an area we disagree on, he said the speed was not that high when he selected flap although he acknowledged selecting it well above Placard speed. I definitely saw the lever in the 50º degree detent and an IAS of 200 knots we were however attacking the glideslope at a considerable ROD at this time). I called this and was ignored again. I then called once more for a GA without effect.
I was attempting to monitor this approach and achieve the Landing Checks (which were never finished). I called again for a GA and was again ignored – after 30+ years as a qualified Flight Engineer it is disturbing to know that one’s professional judgement is so poorly regarded. I was trained to understand that if ANY of the 3-man flight deck felt unhappy enough to call for GA, then it was carried out FIRST, and a wash-up carried out once downwind again.
Below 1000’ agl, the EGPWS warning of ‘Sink Rate’ sounded at least three times, the last being at 200’ Radio with a ROD of 1500’ min. When it sounded the FO shouted ‘Disregard’!
Since no comment or action was made by the captain I can only assume he endorsed the copilot’s behaviour. Company guidance indicates that approximately 300’ ROD was normal for 3º glideslope.
Over the threshold, we had 40º flap as the Flap Relief System had blown back the flap to prevent structural damage. A check of the Flap Load Relief schedule will indicate the threshold speed that 40º flap relates to. The actual touchdown whilst too fast was smooth and the aircraft was turned off the runway safely. The runway at Jeddah is LONG, fortunately.
Considering that this approach was monitored by a Training Captain and author of an ‘enhanced’ SOP, the conduct of this approach and landing was nothing short of criminal. SOP’s and guides to safe approach, checklist and good airmanship were totally ignored in the interests of pride (author’s assessment – later the captain agreed, in his enhanced SOP he describes that ‘courage’ is required to initiate a GA).
A safe GA could have been easily achieved and we had the visibility to carry out a safe visual circuit or another ILS. Fuel state was around 17 tonnes (Riyadh was the diversion reporting good weather – 10k plus and scattered at 4000,).
Even with an experienced DC10 pilot flying this approach was not achievable within existing guidelines and SOP. The aircraft was not safely flown, nor was it in the correct briefed configuration. The pilots then attempted to convince me that their actions were justified which I did NOT accept (nor do I still).
The problem was initiated by ATC and then fully endorsed by the Flight Deck crew who made a poor vectoring infinitely worse. At no time were my comments regarding the safety of continuing the approach sustained – wholly unacceptable for a company who has operated the 3 man flight deck for 20 years.
The CRM and Airmanship displayed on this vital phase of flight was non- existent and totally consistent with the actions that were carried out.
The FO’s attitude afterwards was one of bravado and ‘achievement’, he had ‘pulled it off despite being put in that bad position’. He is currently attempting to acquire a JAA ATPL.
This was without doubt the worst approach I’ve been involved with on the DC10 or L1011 – aircraft with a lot of inertia and certainly not cleared for such RODs this close to the ground. It was most unprofessional, displaying total disregard that required safety margins had been grossly eroded.
As an ex-military Flight Safety Officer and someone who has lectured in flight safety aspects I am appalled by ‘being involved’ in this incident AND my inability to report it to a chain of management who would DO something about it.
My background was as a qualified Flight, Simulator and Ground Instructor with a high Training Category training not only RAF but also Foreign Air Force crews, I also was an instructor for British Aerospace in Engines and Performance ‘A’. I am acutely aware of what a ‘poor performance on the flight deck’ looks like.
I am unable to report this incident via the Company system as it suffers ‘political pressure and filtering’ and this (very) senior captain would almost certainly be ‘protected’.
As an ex-patriot contractor, ranks would close against anything I have to say and nothing constructive would be achieved, except my dismissal. I can report it because my contract expires imminently.
Biman talk safety but do NOT practise it. They should remember that ‘pride comes before an accident’. In my time with them (12 months) they have had one Airbus 310 run off the runway at Dhaka and an F28 overrun at Sylhet. Fortunately neither of these incidents has caused serious injury.
As a post script to this incident I spoke to the captain on the return sector expressing my severe disquiet over this incident.
He then read me a report that he’d been writing in a personal notebook which he keeps. Whilst there were minor pieces of data I disagree with, in essence his and my recollection of the incident are identical.
In his narrative, he acknowledged that it should have been a GA with that being carried out early. He explained his reasoning. It is, in my opinion and within the Bangladesh culture, a brave thing to do as he accepted responsibility for the approach – which is correct. He is the one WITH the authority.
Whilst I respect the captain for being this self-examining, it does not excuse the fact that this approach was UNSAFE from a very early stage. Prevention would have been SO easy.
Not a lot can be achieved after the event when the aircraft is damaged and passengers injured or killed because an approach was continued in direct contravention of SOPs, FCOM and a crewmember calling for a GA, not once but three times. My question is: if THIS approach was not worthy of a GA, what would constitute reason enough?
Biman pilots on the DC10 fleet (the only one I can comment upon from experience) are in severe danger due to the levels of complacency and disbelief that ‘it can happen to them’. The authority gradient across the flight deck is very steep. Also there is a culture of ‘keeping it quiet’ thus incidents of this nature are smothered and nothing is learned, there is no/very little system for publicising errors so that everyone can learn, stimulate discussion, re examine procedures – it just doesn’t happen.
If this incident were a one-off, I would be less disturbed. However I have been involved in two Go Arounds in Biman – both were carried out with Land Flap and Gear Down. The captains were highly experienced. The first incident was (I believe) Captain on 21 Jan 04 S2-ACP, Jeddah. The second was Captain who is a Training captain, it was 28 Sep 04 S2-ACS.
Another incident occurred on a flight to Hong Kong from Dhaka. Date 19 Jul 04, S2-ACR, Captain YYY, FO ZZZ Having pointed out visually and warned the captain, we flew under the anvil (i.e. downwind) of a CB over southern China, TAT+1, SAT-35º C, visible moisture hitting the windscreen (i.e. supercooled water droplets). I immediately selected Continuous Ignition and Engine Inlet Anti Icing. I was then ORDERED by the captain to turn if OFF as it was ‘too cold for icing’.
I argued but in the end had to turn it OFF (by that time we were just about clear of the CuNim. I left the flight deck for 40 minutes as it took that long to calm down in the presence of this VERY ignorant man.
The whole company knows about this man and nothing is done. I am told he was in the ‘Resistance’ in Bangladesh’s struggle for freedom and has very powerful political friends.
I hope that they will all attend his funeral if he finally manages to bring to fruition his ‘affaire with calamity’. He continues to operate in this manner with complete impunity and (apparently) immunity. His ‘piece de resistance’ is non- standard, high speed approaches. One must ask that IF he does get involved in an accident due to his intransigent attitude, how many innocent Biman customers will be involved too, and how seriously? This pre-supposes that non-planned ground contact will miss anything important on the ground.
Now this report is written I frankly do not know what to do with it as I’m not sure there is an organisation in Bangladesh which would take it seriously.
Biman as a company, do NOT wish to hear these observations. They have been flying this aircraft for 20 years and there’s nothing they need to learn about it and its operation. I truly hope that they are correct. If they are wrong, I fear it won’t be long before deaths result.
I will be forwarding a copy of this report to Captain AAA an Ops Inspector with the Bangladesh CAA.
We travelled to UK together as I was returning at the end of the contract. He asked me about my experiences with Biman and I told him.
He has requested a copy of this report, but he already KNEW what I was telling him. What this ‘outside’ view provides him with that he doesn’t already have is unknown.
My only choice as I see it, is to approach the UK CAA through their reporting chain as Biman operates into UK and JAA airspace several times per week.
I question their commitment to and practice of CRM, there is very little sign of it full stop. There are some outstanding crew members both captains and first officers (I am unable to comment on the flight engineers), but they are few, they are already practising CRM, they already listen. Sadly nobody (in authority) listens to them.
19th January 2005.
I have heard nothing from the CAAB so I am now submitting this report. I think it IS relevant because this airline operates into UK and I have little confidence in their ability to handle a problem outside the simulator (GECAT, Gatwick – where they EXPECT problems).
CAA Licence No. FE/327984G Bangladesh Licence No. FE/49 20 December 2004
Approximately 6 months later, the Chief of Flight Safety crashed a DC10 at Chittagong, touching down partly off the runway. It was put down to pilot error. Lack of CRM was a contributory cause.