Investigation Summary
The flight was operating during the Window of Circadian Low (WOCL), a period where human fatigue is most acute. Cockpit Voice Recorder (CVR) data revealed that Captain Zlatko Glušica was asleep for approximately 110 minutes of the flight, with audible snoring recorded. This prolonged sleep likely resulted in sleep inertia, impairing his judgment upon awakening shortly before the descent. The approach was further complicated by the unserviceability of the Mangalore Area Control Radar, which led to a late descent clearance. The aircraft remained significantly above the standard glide path, intercepting the ILS at nearly twice the recommended altitude. Despite the First Officer's three explicit calls for a go-around and multiple EGPWS 'SINK RATE' and 'PULL UP' warnings, the Captain persisted with the landing. The aircraft crossed the threshold at 200 feet (instead of 50 feet) and touched down at 5,200 feet on the 8,000-foot runway. In a final critical error, the Captain attempted to go around after already deploying the thrust reversers, a maneuver that is prohibited by Boeing standard operating procedures as it prevents the engines from developing sufficient forward thrust in time.
Final Conclusions
The Court of Inquiry, headed by Air Marshal Bhushan Nilkanth Gokhale, concluded that the direct cause was the Captain's failure to discontinue an unstabilized approach and his persistence in landing despite warnings. Contributing factors included the Captain's prolonged sleep leading to sleep inertia, the lack of operational radar at Mangalore, and the First Officer's failure to take physical control of the aircraft to initiate a go-around despite recognizing the danger. The final report was submitted in November 2010.
Photographic Evidence (1)
Video Analysis
LETHAL LANDING! - The Tragedy of Air India Express 812 — A detailed breakdown of the Air India Express 812 disaster, exploring the pilot fatigue, the challenges of Mangalore's tabletop runway, and the ignored warnings that led to the crash.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
British and Serbian national, aged 55. Had over 7,500 hours of command experience. CVR recorded him snoring for 110 minutes during the flight.
First Officer
Indian national, aged 40. Full name: Harbinder Singh Ahluwalia. Previously employed by Jet Airways.
Systems & Failure Modes
EGPWS
The Enhanced Ground Proximity Warning System provided multiple 'SINK RATE' and 'PULL UP' alerts during the final descent, which were ignored by the Captain.
Thrust Reversers
The Captain deployed thrust reversers upon touchdown but then attempted to stow them to initiate a go-around, a sequence that significantly delayed engine spool-up.
ILS
The Instrument Landing System was operational, but the crew failed to intercept the glide path at the correct altitude, leading to a steep and fast approach.
Interesting Facts
- 01The aircraft was a Boeing 737-800 with a Short Field Performance (SFP) package.
- 02Mangalore International Airport features a 'tabletop' runway located on a plateau with steep drops at the ends.
- 03The Captain had logged over 10,000 total flying hours, while the First Officer had 3,620 hours.
- 04Only 8 of the 166 people on board survived the crash.
- 05The CVR recorded approximately 110 minutes of silence or snoring from the Captain's side.
- 06The aircraft impacted a localizer antenna and the boundary fence before falling into the ravine.
Safety Actions & Advisories
Establishment of CAA
The Government of India decided to set up an independent Civil Aviation Authority (CAA) to separate the functions of regulation and accident investigation.
Fatigue Management
The investigation led to a review of Flight Duty Time Limitations (FDTL) and the implementation of stricter fatigue management protocols for Indian carriers.
Location
ACCIDENT SITE · Coordinates taken from the entered by an editor.