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Report: Poor CRM factor in cargo plane takeoff incident (India)
28 February 2011

Indian investigators concluded that inadequate CRM and a lack of assertion on the part of the first officer were factors in a takeoff incident at Mumbai Airport in June 2010. A Boeing 757 was lined up right of the centreline and k knocked down 15 runway edge lights during the takeoff before the captain was able to steer to the runway centreline.

Blue Dart Aviation Flight No BD-201, a Boeing 757-200F, operated on a cargo flight from Kolkata to Delhi, Mumbai and Bangalore. The flight departed on schedule from Kolkata at 22:25 hrs and was uneventful till Mumbai.

At Mumbai, the aircraft taxied out from Bay No G-4 via Papa, Echo, and was cleared to proceed to holding point N1 for runway 27. The flight was cleared to line up after an arrival of Kuwait Airways Boeing 777 aircraft.

The Captain was PF and the FO was Pilot Monitoring for the departure. While lining up, the Captain lined up on the right of centerline of the runway. The FO promptly drew the attention of the Captain by stating that the centerline was on the left. This was acknowledged by the Captain. On being cleared for take off the thrust levers were opened by the Captain and the aircraft commenced its roll. The FO at this stage called out to the Captain that he was on the right, twice in quick succession. The Captain carried out a correction to the left to return to the centerline. The take off was continued with and the aircraft took off at 05:15 hours at the correct speed and carried out a standard departure. The flight to Bangalore i.e climb, cruise, decent and approach were normal. The aircraft carried out an uneventful landing with FO as PF. The aircraft taxied to the bay at 06:45 hours.

On arrival at the bay, the Engineer observed that there were damages to the right hand wheels. No. 3 main wheel tyre was deflated. There were deep incisions on No.3, 4 & 8 main wheel tyres and reverted rubber on No. 7 tyre. No. 3 brake assembly had signs of FOD and grease nipple was deformed.

At 08:30 hours information was received from Mumbai that a runway inspection was carried out and runway edge lights were damaged. A subsequent report indicated that a total of 15 runway edge lights of runway 27/09 were damaged, nine towards the north side between N1 and N4 and six on the southern side between taxiway E1 and intersection.

The investigators concluded:

The cause for the incident is incorrect lineup by the Captain on the right side of the RW instead of the Center even after being informed by the FO.

Contributory factors: An error in judgement / assessment in determining the extent of displacement to the right of centerline while lining up. Inadequate CRM practices both by the Captain and FO. Lack of assertion on the part of the FO in emphasizing the displacement of the aircraft to the Captain. Inadequate attention on the part of the Captain towards inputs from the FO.

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