Automation vs. Instinct: The crash of Indian Airlines Flight 605

Bangalore, India. February 14, 1990. Indian Airlines Flight 605 pierces through scattered clouds, descending towards its destination. In the cockpit, two seasoned pilots man the controls of their cutting-edge Airbus A320. But as they approach the runway, this routine flight is about to take an extraordinary turn.

The aircraft’s descent rate suddenly increases, its altitude dropping faster than normal. Warning systems remain eerily silent as the ground rushes up to meet them. In mere moments, a cascading series of events will unfold, testing both human and machine to their absolute limits.

This is the story of Indian Airlines Flight 605.

Our story begins on a seemingly ordinary day at the main International Airport of Mumbai, formerly Bombay. Ground crews prepare Victor Tango – Echo Papa November (VT-EPN), an Airbus A320-231, barely a year old and representing the pinnacle of aviation technology.

In the airport terminal, passengers make their way through security, bound for Bangalore. None of them know that they’re about to become part of one of India’s most significant aviation incidents.

As the passengers board, two seasoned pilots prepare for departure. 

Captain Fernandez, age 46, settles into the left seat. With 9,307 flight hours under his belt, Fernandez had 68 hours on the A320, all as co-pilot. This flight marks a crucial milestone in his career his first route check for command endorsement on the A320. As such, he’ll be flying as pilot-in-command under supervision.

A route check assesses a pilot’s ability to operate as the captain or pilot-in-command on a specific aircraft type and route. This check typically involves demonstrating proficiency in normal and emergency procedures, decision-making, crew resource management, and adherence to company policies. Passing this check is a significant step towards becoming a captain on that aircraft type.

Beside him sits Captain Gopujkar, age 44, equally experienced with 10,340 total flight hours. Gopujkar had 255 hours on the A320 of which 212 of those hours were as pilot in command. So, while he was a highly experienced pilot, his hours on this type of aircraft were relatively short, which is not at all surprising because the A320 was very new at this time.

For context, 10,000 hours is considered highly experienced, often taking 15-20 years of professional flying to accumulate.

His career with Indian Airlines stretches back to 1969, spanning various aircraft types from the HS 748 to the Boeing 737. Importantly, Gopujkar had recently returned from France, where he received specialized training on the A320. For this flight, he’s serving as a check pilot, evaluating his colleague’s performance but also, technically, as pilot in command.

A check pilot, also known as an examiner, is an experienced pilot authorized to assess the skills and knowledge of other pilots during practical tests or checkrides. Check pilots evaluate a pilot’s ability to operate an aircraft safely and in compliance with regulations, often determining whether a pilot can advance to a new level of certification or aircraft type.

So, both pilots were highly experienced. But, little did they know, their years of experience were about to be put to the ultimate test.

For Fernandez, this flight represents years of hard work culminating in a make-or-break evaluation. For Gopujkar, it’s a test of his judgment as both pilot and examiner. So, with that in mind, both pilots are probably keenly aware of this additional pressure on top of their usual flight responsibilities.

On board were a total of 146 people consisting of 139 passengers, 5 cabin crew and the 2 pilots.

Let’s take a quick moment to understand the aircraft they’re flying. The Airbus A320 represents a quantum leap in aviation technology. Its fly-by-wire system represents a revolutionary shift in aircraft control systems and was very new in 1990. 

Instead of using mechanical linkages to connect the pilot’s controls to the aircraft’s control surfaces, fly-by-wire uses electronic signals. These signals are interpreted by a number of computers that then command the aircraft’s control surfaces. This system allows for more precise control, reduced aircraft weight, and enhanced safety features, but it also requires pilots to adapt to a new way of interacting with their aircraft and this is something that both pilots were still mastering at the time of this particular flight.

Would this cutting-edge technology prove to be a lifesaver or a silent, deadly trap?

One of the Airbus A320’s critical safety features is the alpha floor protection system. Alpha floor protection is an automated feature designed to prevent aerodynamic stalls. It activates when the angle of attack becomes dangerously high, automatically applying full engine thrust and adjusting the aircraft’s pitch to help recover from a potential stall situation, even if it means overriding pilot inputs.

However, this system has a significant limitation: it takes up to eight seconds for the engines to spool up from idle to max power. I want you to remember that because that delay plays an important role in the unfolding events of Flight 605.

It’s worth noting that the A320 had already been involved in a controversial incident. Just two years earlier, in 1988, Air France Flight 296 crashed during an air show, sparking debates about the aircraft’s fly-by-wire system. While the official investigation blamed pilot error, the incident cast a shadow over the A320’s reputation, one that would resurface in the aftermath of Flight 605.

At 11:58 am local time, almost an hour behind schedule, Flight 605 lifts off from Bombay’s runway. The A320 climbs smoothly to its cruising altitude of flight level 330 or 33,000 feet.

All was well. In the cockpit, Gopujkar and Fernandez settle into the routine of a short domestic flight. 

As they cruise towards Bangalore, it’s a likely scenario that neither pilot can shake the weight of the task at hand. For Fernandez, every decision, every radio call, every adjustment of the flight controls carries the added pressure of evaluation. He knows that Gopujkar is probably watching his every move, assessing his readiness for command of the Airbus A320.

And Gopujkar, for his part, must balance his roles as both safety pilot and examiner. He needs to allow Fernandez enough autonomy to demonstrate his skills while remaining vigilant for any signs of trouble. It’s a delicate balance, one that adds an extra layer of complexity to the operation.

As Flight 605 begins its descent towards Bangalore, the workload in the cockpit intensifies. The pilots begin their approach briefing, initially planning for a VOR/DME approach to Runway 09. This type of approach, using ground-based radio beacons, is familiar territory for both men.

However, as they near Bangalore, air traffic control offers them radar vectors for a visual approach instead of the instrument approach they had expected. It’s a common occurrence, often simplifying the landing process. 

But this change introduces a new variable into an already complex equation. The pilots must now mentally shift gears, adapting their carefully laid plans on the fly. This last-minute change would set in motion a chain of events that would push both men and machine to their limits.

Radar vectors involve air traffic controllers using radar to guide aircraft along a particular path or vector. The controller gives the pilot headings to fly, effectively “vectoring” the aircraft to a desired position. This can be used to sequence aircraft for landing, avoid weather or traffic, or guide an aircraft to a point where the pilots can visually see the runway for landing.

At 12:44 local time, Flight 605 is cleared to descend to 11,000 feet. As the aircraft noses down, Gopujkar and Fernandez discuss the approach profile. They plan to cross 11 miles out at 6,000 feet, and 7 miles out at 4,500 feet, aiming for a Minimum Descent Altitude of 3,280 feet. It’s a textbook approach plan, but executing it perfectly will require precise energy management.

Minimum Descent Altitude is a calculated figure that represents the lowest altitude the pilots can descend to while performing their non-precision approach, without having visual confirmation of the runway. If Gopujkar and Fernandez can’t see the runway upon reaching 3,280 feet, they must abort the landing attempt and climb away, preventing the A320 from flying too low in potentially poor visibility over Bangalore’s terrain.

As they continue their descent, a critical moment in the sequence of events unfolds. Captain Fernandez notices they’re 600 feet higher than the normal glide path and initially calls out for a go-around. The check pilot, Captain Gopujkar, responds with “Go around you want? Or, you want vertical speed?” Fernandez replies, “Vertical speed.” In those few seconds, a decision was made that would alter the fate of everyone on board.

The pilots deploy the speed brakes, recognizing that they’re slightly high on the approach profile. This decision, seemingly minor at the time, will later become a crucial point of future discussion.

Speed brakes, also known as spoilers, are devices on the wings that can be raised to increase drag and reduce lift. They’re often used to slow the aircraft or increase its rate of descent without increasing airspeed. While effective for energy management, the use of speed brakes requires careful monitoring as they can significantly affect the aircraft’s performance and handling characteristics.

As the speed brakes extended, neither pilot realized they had just removed a critical safety margin. But, for now, it simply adds another task to the pilots’ growing workload.

At 12:53, Bangalore Radar identifies Flight 605 at 42 nautical miles on the 316-degree radial. The controller provides vectors for the visual approach to Runway 09. In response, the pilots adjust their altimeter setting to the local atmospheric pressure of 1017 hectopascals. A quick cross-check confirms their altitude at 8,500 feet.

As the minutes tick by, the cockpit becomes a hive of activity. At 12:58, Fernandez completes the approach checklist. He activates the approach mode in the flight management system.

The pilots cross-check the managed approach speed, confirming it at 132 knots. This speed, calculated by the aircraft’s computers, should provide the optimal balance of control and efficiency during landing. But as we’ll soon see, the relationship between pilots and automation is about to be tested to its limits.

With the runway now in sight, Gopujkar and Fernandez begin configuring the aircraft for landing. Flaps extend, increasing lift at lower speeds. The distinctive whine of the landing gear fills the cabin as three sets of wheels drop into the slipstream. These actions, practiced countless times in simulators and real flights, are second nature to both pilots. 

Flaps are movable surfaces on the wings that, when extended, increase the wing’s surface area and curvature. This allows the aircraft to generate more lift at slower speeds, which is crucial for takeoff and landing. Different flap settings are used for different phases of flight, with full flap extension typically reserved for final approach and landing.

At 13:00, just seven miles west of the runway, Fernandez disengages the autopilot. From this point on, he’ll be hand-flying the sophisticated A320 a task that demands absolute concentration and skill. The next few minutes would determine whether this was a fatal mistake.

Crucially, while the autopilot is off, the flight directors remain on, continuing to provide guidance cues to the pilots. This partial reliance on automation will play a significant role in the unfolding events. The aircraft, now fully configured for landing, begins its final descent towards Runway 09.

Flight directors are visual cues displayed on the pilots’ primary flight displays. They show the optimal flight path to follow, typically represented by crosshairs or bars. Pilots can manually fly the aircraft to keep these cues centered, effectively following the path calculated by the flight management system. While flight directors can enhance precision, over-reliance on them can sometimes lead to reduced situational awareness.

As Flight 605 descends, it’s likely that none of the passengers or cabin crew on board realize that they’re about to become part of a tragic aviation milestone. In the next few critical minutes, a complex interplay of human psychology and advanced aviation technology will push this routine flight to the brink of disaster.

At 13:02, the cabin crew are instructed to prepare for landing. The seatbelt signs chime and passengers stow their tray tables. As the aircraft continues its descent, a series of subtle but critical deviations from the normal approach profile begin to take shape.

The A320, with its fly-by-wire system, is designed to prevent pilots from making catastrophic errors. But this safety net has its limits, and it’s about to be tested to the extreme. The sophisticated system was now guiding them towards the runway. But was it leading them to a safe landing… or disaster?

As Flight 605 sinks below the ideal approach path, both Gopujkar and Fernandez appear unaware of their worsening situation. Even seasoned pilots can fall prey to cognitive biases in such moments. 

It’s common for aircraft to deviate slightly from the perfect glide slope initially. Typically, pilots can either adjust to realign with the correct path or, if necessary, abort the landing and go around. However, in this case, neither pilot seems to recognize the need for either action.

These cognitive biases are unconscious mental patterns that can skew decision-making, causing even expert pilots to misinterpret or overlook critical information.

Approximately 35 seconds before touchdown, the aircraft enters what’s known as “Open Descent” mode. In this configuration, the engines are at idle power, and the aircraft is essentially gliding. It’s a mode that can be useful for rapid descents at higher altitudes, but near the ground, it’s a recipe for disaster. Pilots must be acutely aware of their energy state when using this mode, especially during approach and landing.

The pilots fail to recognize this mode change in time. Captain Gopujkar does comment that the aircraft is in idle open descent mode but fails to take any action at that moment. Whether due to cognitive tunneling, misunderstanding of the A320’s complex modes, or a combination of factors, this oversight would have far-reaching consequences.

Cognitive tunneling is a psychological phenomenon that narrows a person’s focus, causing them to miss critical details. In the case of Indian Airlines Flight 605, remember that the pilots were under pressure from the check ride, managing complex systems, and likely fixated on visual cues. This combination of stress, task saturation, and divided attention may have caused them to overlook critical indicators of their aircraft’s dangerous state.

As the aircraft descends in this idle/open configuration, it rapidly bleeds off airspeed and altitude.

As the A320 continues its unstable approach, several opportunities to recognize and correct the situation slip by. The aircraft’s Radio Altimeter begins making automatic callouts: “400 feet”… “300 feet”… “200 feet.” These auditory warnings, designed to alert pilots to their proximity to the ground, go unheeded. In high-stress situations, human hearing is often the first sense to deteriorate, a phenomenon known as auditory exclusion. This physiological response, coupled with the intense focus on visual cues, may explain why the pilots failed to process these critical audio warnings. It’s a chilling example of how even experienced pilots in high stress situations can fail to process critical information that’s right in front of them – or in this case, sounding clearly in their ears.

In the next few seconds, the true state of their predicament would become horrifyingly clear.

The rapidly unfolding situation is about to trigger another psychological phenomenon: the startle effect. At approximately 136 feet above ground level, Captain Fernandez suddenly realizes the dire situation. “Hey, we are going down,” he exclaims. This moment of sudden awareness can induce a fight-or-flight response, potentially impairing the crew’s ability to respond effectively in the precious few seconds they have left.

In these final moments, the crew attempts to increase power and pitch up the aircraft. But their actions come too late to prevent the impending impact. Remember, it takes up to 8 seconds for jet engines to spool up to full power and for this crew, they were simply out of time. 

At 13:03:17 local time, the aircraft makes its first contact with the ground at a golf course approximately 700 meters short of the runway threshold at Bangalore Airport.

The landing gear strikes the earth with a sickening crunch, sending shockwaves through the fuselage. Passengers, caught off guard, are jolted violently in their seats. 

The aircraft bounces, momentarily airborne again, before slamming onto the golf course with even greater force. This time, the landing gear collapses under the strain, unable to absorb the massive energy of the impact. 

As the A320 careens towards raised ground, the pilots, now fully aware of their dire situation, fight desperately with the controls. But their efforts are in vain. The aircraft slams into a 12 foot embankment with devastating force at an estimated ground speed of 116 knots. That’s 133 mph or 215 kph. The cockpit crumples, the wings separate from the fuselage, and both massive engines are torn from their mountings in a deafening crescendo of destruction.

In those final, terrifying moments, passengers experience a frenzy of sensations. The deafening roar of impact. The nauseating lurch as the plane breaks apart. The choking dust and smoke that immediately fill the cabin. And then, for many, merciful unconsciousness.

But for those who remain aware, a new horror emerges. As the shattered fuselage comes to rest in a marshy area just beyond the airport boundary, flames erupt from the spilled fuel. 

In this hellish scene, acts of heroism emerge. Despite their own injuries, some passengers help others to escape. Cabin crew members, trained for this nightmare scenario but never truly expecting to face it, guide survivors towards emergency exits. Every second counts as the flames spread, consuming more of the aircraft with each passing moment.

Of the 146 souls on board Flight 605, tragically, 92 will not survive this Valentine’s Day disaster. 

The investigation into Indian Airlines Flight 605 revealed a complex interplay of factors that led to the tragedy. Key findings highlighted issues with pilot training for highly automated aircraft, difficulties in mode awareness and automation management, and breakdowns in crew resource management during critical phases of flight.

One point to note is that I could not find an official air accident investigation report for this incident. Instead, I found a 156 page court enquiry report that details findings from an investigation. I also found a transcript of the cockpit voice recorder.

The report outlined how the sophisticated systems of the A320, while designed to enhance safety, paradoxically contributed to the accident by masking the developing low-energy state from the pilots.

The court document suggests a chilling detail about that moment when Captain Fernandez requested a vertical speed of 700 feet per minute. While the investigation didn’t definitively identify the cause of the accident, it inferred the most probable scenario: in a tragic twist of fate, Gopujkar likely made a simple but catastrophic error. Instead of selecting the vertical speed, he may have inadvertently dialled in an altitude of 700 feet.

The court noted that the A320’s Flight Control Unit, with its closely positioned knobs for vertical speed and altitude selection, could have facilitated this deadly mistake. One theory suggests By unknowingly setting an altitude lower than the aircraft’s current position, Gopujkar may have unwittingly commanded the sophisticated systems to descend rapidly.

The court’s analysis suggests that in response, the A320’s computers engaged the idle/open descent mode – a configuration that would seal the fate of Flight 605. 

Beyond the critical 1.2-second delay between when alpha floor protection conditions are met and when the system activates, there’s also a delay of up to eight seconds for the engines to spool up from idle to max power.

There was much controversy surrounding the official findings. The Indian Commercial Pilots Association (ICPA) disputes some conclusions, suggesting possible design flaws in the A320’s systems. They also stated that there was no proof that Captain Gopujkar turned the wrong knob because the flight data recorder apparently did not record such a mistake.

At this point, we’re unlikely to ever know with 100% certainty exactly what happened.  Was it human error, or a flaw in the A320’s design? 

Flight 605’s impact rippled through global aviation. It became a crucial case study, influencing cockpit design, warning systems, and approach procedures for automated aircraft. 

In response, Airbus made significant improvements to the A320, including changes to vertical mode behavior, enhanced speed displays, and new warning systems. These modifications prevent accidental Open Descent engagement near the ground and improve pilot awareness.

The investigation yielded 62 safety recommendations, highlighting the incident’s broad impact on aviation practices. 

Today, the A320 is one of the most successful commercial aircraft, its safety record strengthened by lessons from incidents like Flight 605. 

Air travel remains statistically the safest mode of transport.

📄 SOURCES Final report: https://finalreports.net/1990/Indian-Airlines-Flt-605.pdf

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