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Mangalore Crash: Yet Another New Evidence Surfaces

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Aviation India Demands Reopening of Air India Express Flight 812 Crash Investigation

By Jacob K Philip
It has now become clear that the Court of Inquiry that investigated the crash of Air India Express Flight 812 on May 22, 2010 had never considered a vital evidence that would have altered the very character and course of the investigation.
The  ‘Flying Programme’ of Air India Express for the period of  17/05/2010 to 23/05/2010, a copy of which is now with Aviation India, throws light to the following facts:

  • Capt. Zlatco Glusica, the Serbian Captain of the crashed aircraft was drawn in last minute to command the flight.
  • The flights to and from Dubai (flight No. 811 & 812) were supposed to be training flights for Capt. Ahluwalia, who was due for a hike to Commander level.

In the programme, that was prepared on 13 May 2010, the name of the First Officer of the flight of course can be read as  A. H. Ahluwalia. But in the column where the name of the commander was to be typed in, what appears is just three letters: TRG.
TRG means training. Should be commander training for Ahluwalia. But why the actual name of the Pilot in Command was not printed? Might be because Air India Express people were undecided about the person, when the schedule was prepared. But when it was actually decided to fill that gap with Capt. Glusica? When did Capt. Glusica, who had returned to India only on May 18 after a vacation in his country, was informed of this decision? Answers to these questions are very crucial because, in their eagerness to put all the blame on Capt. Glusica, the Court of Inquiry had repeatedly stated in the report that the Captain had slept , atleast for 100 minutes, in the return flight, inspite of  getting adequate rest prior to the flight. And according to the CoI, the inertia caused by that sleep was the main cause of the accident.

From the Report:

The contributory factors (of the crash) were:
(a) In spite of availability of adequate rest period prior to the flight,the Captain was in prolonged sleep during flight, which could have ledto sleep inertia. As a result of relatively short period of time between hisawakening and the approach, it possibly led to impaired judgment. Thisaspect might have got accentuated while flying in the Window ofCircadian Low (WOCL).
(b) In the absence of Mangalore Area Control Radar (MSSR), due toun-serviceability, the aircraft was given descent at a shorter distance onDME as compared to the normal. However, the flight crew did not planthe descent profile properly, resulting in remaining high on approach.
(c) Probably in view of ambiguity in various instructions empoweringthe ‘co-pilot’ to initiate a ‘go around’, the First Officer gave repeatedcalls to this effect, but did not take over the controls to actuallydiscontinue the ill-fated approach.

What if Capt.Glusica was informed of the flight only some hours before?
What if he had not slept for the previous day being not aware of the sudden change in schedule?What if the Captain was not physically well after the long journey back India?
The scope of investigation of the CoI had never entered these zones exactly because this particular schedule mysteriously had escaped their notice.
The significance of the three letters, ‘TRG’ is in addition to this.
If it indeed was a flight in which the eligibility of Capt. Ahluwalia to get promoted to the post of Commander was to be checked, many of an observations and accusations  the Court of Inquiry had put forward regarding the unhealthy ‘steep gradient of authority’ in flight 812’s cockpit suddenly becoming null and void.
A TRG flight justifies Capt. Glusica’s decision to pay not much heed to the first officers suggestions.
A TRG flight makes it clear why  Ahluwalia never took over controls.
A TRG flight again makes it obvious why the Commander allowed the First Officer to do almost all the R/T communications.
The flying Programme of Air India Express for the period of 17/05/2010 to  23/05/2010 clearly is a new and material evidence on the basis of which a reopening of the investigation of the crash of Flight 812 can be ordered.

Jacob K Philip is Editor of Aviation India. He can be reached at jacob@indianaviationnews.net

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June 15th, 2011 at 9:05 pm

Posted in Air crash,Safety

Reopen Mangalore Crash Investigation

without comments

By Jacob K Philip
Editor, Aviation India

The investigation of the 2011 May 22 crash of Air India Express Flight 812 must be reopened.

The Indian Government should discard the the biased, incomplete and erroneous whitewash of a report submitted on April 26, 2011 by the Court of Inquiry and should immediately order a reinvestigation.

The demand for the urgent reopening of the inquiry of the tragic crash in which as many as 158 lives had perished is perfectly in accordance to the rule of the land.

On 2009 March 13, the Government of India had inserted vide GSR No. 168(E)  a very important rule to ‘The Aircraft Rules 1937’, which govern everything aviation in this country.
Here is the rule:

75A. Reopening of InvestigationWhere it appears to the Central Government that any new and material evidence has become available after completion of the investigation under rule 71, 74 or 75, as the case may be, it may, by order, direct the reopening of the same.

The series of six articles published in Aviation India and Decision Height from  May 15  to June 2011 make it abundantly clear that there are enough new and material evidence that make the reopening of the investigation absolutely necessary.

Here is a list of those new and material evidence:

  1. The fact that a huge portion of the wreckage was taken away from the crash site by locals and was sold as scrap metal. What the Court of Inquiry was inspected and studied (if at all they had done any study) was the remaing wreckage. ( Read the article..)
  2. The reconstruction of the wreckage was never actually done by the CoI. The image of the reconstructed wreckage included in the report was a computer generated one. (Read The Article..)
  3. While testifying before the court of Inquiry at Mangalore airport, Six survivors of the crash were made to answer a totaly biased and misleading question by the CoI. The question was, “Do you think the accident occurred because of the fault of the pilot?”This was in plain violation of Rule 7.2.1 of the Manual of Accident/ incident investigation: ‘ The investigation of aircraft accidents and incidents has to be strictly objective and totally impartial and must also be perceived to be so’. (Read The Article..)
  4. The “ Hard Landing” circular issued by Air India is a major contributor to the accident. The CoI had chosen to ignore this vital fact. (Read The Article..)

All the above four new & material evidence had already been elaboarted in the articles published by us.
But there still are more new evidence & facts the CoI never bothered to find out.
We are publishng that new evidence tomorrow.

(Jacob K Philip can be reached at jacob@indianaviationnews.net)

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June 14th, 2011 at 6:01 pm

Posted in Air crash,Safety

Mangalore Crash Inquiry Report: A Desperate Attempt to Save the Skin of AAI Also

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Airports Authority of India is guilty of both erecting a concrete structure at runway end and providing not enough rest for the ATCs
(Mangalore Crash Report – Hidden Factors: 2)

By Capt. A. Ranganathan
When Air India Express Flight 812 crashed in the early morning of May 22, 2010, 158 lives were consumed by fire caused when the wing of the aircraft broke after it struck the concrete structure on which the ILS Antenna was mounted.

Thanks to the ‘smoke screen’ on Page 36 of the CoI report, the fact that the structure was erected there violating all the safety norms is very well camouflaged.

ICAO Annex 14, governs the Standards for Aerodromes. In Chapter 3, under section 3.5 comes Runway End Safety Area ( RESA). The Annex specifies that “ Runway End Safety Area SHALL be provided at each end of the runway strip.

The Dimensions of the Runway end Safety Area

3.5.2   A Runway End Safety Area shall extend from the end of a runway strip to a distance of at least 90m.

3.5.3  Recommendation – A runway end safety area should, as far as practicable, extend from the end of a runway strip to a distance of at least  –  240m where the Code number is 3 or 4

Objects on runway end safety areas

3.5.6 An object on runway end safety area which may endanger aeroplanes should be regarded as an obstacle and should, as far as practicable, be removed.

ICAO has recommended the higher figure of 240m taking into account that most runway overruns take place within 300m beyond the end of the runway. The term “ as far as practicable” would apply for an obstacle which exists naturally and not a man made structure. Considering that Mangalore runway is on a table-top terrain and with the area beyond the strip difficult for rescue operation, the RESA should have been 240m long. When the fatal accident took place, the arrow of guilt pointed to this structure. An effort has been made to portray that there did exist an area 240m beyond the end of the runway. The different statements on Page 36/175 shows their confused mind:

At the time of accident , there was a Basic strip of 60m followed by RESA of 180m ( now reduced to 175m).  After the end of the 237m within RESA, a concrete structure had been constructed on which ILS Localiser antenna is mounted.

Now see the extract of Page 36 of CoI report:

This is another clumsy attempt to cover-up a dangerous safety infringement. The figures of 180m or 175m do not appear anywhere in the ICAO Annex 14 under the heading Runway end safety area. Someone has attempted to indicate the figure of 240m ( 60 = 180 ) was provided but realised that the concrete structure was at 237m. Hence, the figure was reduced to 235m ( 60 + 175 ). A further precaution to protect a wrong structure is the falling back on the figure of 90m x 90m, which is the mandatory figure as per Annex 14 while 240 is a recommendation.

The report goes on to state : After the accident, the ILS was recalibrated on 16th June 2010. The damaged structure was rebuilt with another rigid structure within three weeks of the fatal accident !

Did they realize that the danger for all operations continue from that date? Was the DGCA right in renewing the license for the airport with this dangerous structure?

There is a DGCA C.A.R for Aerodrommes from which the following are extracts:

SERIES ‘F’ PART I

16th October, 2006 EFFECTIVE: FORTHWITH

SUBJECT: REQUIREMENTS FOR ISSUE OF AN AERODROME LICENCE.

4.6 The applicant for the aerodrome to be licenced for Public Use shall

demonstrate the functional arrangements and their integration for provision of CNS-ATM, RFF, AIS, meteorological and security services.

4.7 Final inspection shall be undertaken for on site verification of data,

checking of the aerodrome facilities, services, equipment and procedures to verify and ensure that they comply with the requirements.

4.8 The aerodrome licence shall be issued by the Aerodrome Standard Dte. after approval of DG under the appropriate category, if the DGCA is satisfied that applicant has complied with all relevant requirements. In case of the non-compliance of the requirement by the applicant, licence may either be refused or granted with limitations/ restrictions / conditions as deemed appropriate by the DGCA, provided that in such cases the overall safety is not compromised.

13. OBSTACLE LIMITATION SURFACES

Enclose obstacle limitation charts including type ‘A’ chart for the aerodrome including the details of obstructions, which are marked and lighted.

13.1 Objects in operational areas and their frangible type

a) Runway Strip

b) Stopway

c) Clearway

d) RESA

13.2 OBSTACLES

POSITION OF OBSTACLE

HAZARD TO FLYING

The license given to Mangalore is suspect and officials who conducted the safety audit have made a sham of the inspection. The concrete structure was definitely a hazard to flying and it is surprising if item 13.2 of the Application form was filled up otherwise.

Licensing done by DGCA in 2007 and Surveillance inspection done two days before the accident. It is pure divine grace which has prevented more fatal accidents in Mangalore.

Extract of Page 39 of CoI report:

The highlighted portions of the extract clearly spells out the danger to all aircrafts operating in and out of Mangalore. The dangerous structure on which the ILS antenna is mounted is present. The Rescue and Fire fighting is not possible outside the airport perimeter. Yet, officials of DGCA and AAI have certified that the airport with the present facilities is safe!

The other important factor is the fatigue factor of the Air Traffic controllers. Their shifts are designed to keep them on a continuous 12 hour duty period during the night. They are also exposed to the Window of Circadian low which would result is erroneous or delayed response. On the day of the crash, the ATCO has stated that the end of the runway was not visible and he has given instructions to the aircraft to back track as was the “ normal” practice ! The ATCO was not even aware that the aircraft had crashed !

The entire report on the crash appears to put the blame on the Captain alone. All the other agencies involved in contributing to the death of 158 persons has been blanked out in the smoke-screen. The danger persists and lessons have not been learnt.

(Captain A. Ranganathan is a member of India’s Safety Advisory Committee of the Aviation. The aviation safety expert and veteran pilot has more than 20,000 hours of flying experience to his credit.

Capt. Ranganathan can be reached at mohlak@gmail.com).

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June 12th, 2011 at 3:18 pm

Posted in Air crash,Safety

Mangalore Crash report- The hidden factors

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The “ Hard Landing” circular issued by Air India is a major contributor to the accident and the COI report has chosen to ignore this vital fact.

By Capt. A. Ranganathan

The Court of Inquiry report on the crash of Air India Express flight 812 on 22nd May 2010 has concluded that only the pilot was responsible. On page 115/175 of the report, the direct causes are given as follows:

“The court of Inquiry determines that the cause of the accident was Captain’s failure to discontinue an “Unstabilised approach” and his persistence to continue with the landing, despite three calls from the First Officer to “go-around” and a number of warnings from the EGPWS”

The report is completely silent on the contributory factors when it comes to the failure of the Airline, the Airport Authority of India and the Regulator. The cover up of a circular on hard landing, issued by the Flight Safety Head of Air India, has been swept aside. On page 90/175 of the report, the following statement clearly indicates the cover-up.

2.2.18   Aspects of Hard Landing and Going Around

Flight Safety counseling on one-off incident of Hard Landing by Captain for 1.9 Vg which was much less than AMM limit of 2.1 Vg cannot be considered as a contributing factor towards the accident. Having been consistently unstabilised on the ILS Approach, even if the Captain had been able to stop the aircraft on the runway, the subsequent FOQA analysis of DFDR and possibily of CVR, would have indicated various violations of SOP by the Captain. This would have, in any case, warranted another reprimand by the authorities. In a high energy and fast approach, resulting in a very late touchdown, no prudent pilot would also aim to make a smooth touchdown to avoid flight safety counseling. The aircraft in this instant had not been able to remain firmly on ground because of higher speed at touchdown and not possibly because of any attempted smooth landing.

The last statement clearly indicates the effort to cover up the fact that the circular is one of the major factors that contributed to the accident. The Captain was definitely at fault in continuing the approach to land , in spite of being extremely high on profile as well as speed. However, the aircraft could have been stopped within the paved surface of the runway, if correct stopping techniques were employed. This was clearly stated by the report of the manufacturer, Boeing, on Page 159/175:

“ since the airplane’s final touchdown point was 5200 feet from Runway 24 threshold, the airplane could have come to a complete stop at 7600 feet from the threshold ( 438 feet of runway remaining )

The following image from the report is a clear indication that the COI has deliberately ignored an important factor:

The kink marked by the bottom arrow clearly indicates that the engine thrust was increased to cushion the landing. The normal landing should have been done with idle thrust but the Flight data recorded clearly indicates that there was more than idle thrust at touchdown. The top arrow indicates the vertical profile of the aircraft.

The Boeing report has also indicated that the aircraft had descent rate of more than 1000 feet per minute up to 60 feet above runway and then it has flattened out to a normal rate. The CVR ( Cockpit Voice Recorder ) readout is another clear indicator for this:

06:04:26
EGPWS    Sink Rate Sink Rate
06:04:29
EGPWS    Forty
06:04:30
EGPWS    Thirty
06:04:31
EGPWS    Twenty
06:04:32
EGPWS    Ten
06:04:40
CAM         [ Sound of 3 clicks  and a squeal.-
( speed Brake handle? / MG TD?)

The COI has taken the sounds at 06;04;40 at the Main Gear touchdown, yet in several portions of the report , they indicate the touchdown as 06:04:41. Apart from this error, their contention that the circular on hard landing issued by air India has no bearing on the accident is faulty.

In Page 140/175, the COI report mentions the following

Timings and Correlation

Timing on the transcript was established by correlating CVR, DFDR and ATC recording. The time indicated in CVR transcript is in Indian Standard Time ( IST ) which is UTC + 5:30 hours

Taking the figures indicated in the COI report from the DFDR readouts, the above image is a graphical representation of what was the final profile of the aircraft. The flight was well above the ILS Glide path that it should have taken. The descent rate up to one mile from the runway threshold is more than 4000 feet per minute and the captain reduces the descent rate to more than 1000 feet per minute up to 60 feet above the runway surface. The COI report mentions that the captain violated the Standard Operating Procedure which requires a descent rate not exceeding 1000 feet per minute. However, they chose to ignore the CVR and DFDR indication which clearly points to the fact that the captain ignores all EGPWS warnings and the copilots call for Go-around, yet continues to land late by flattening out the approach. This is a classic case of what is called “Press-on-It is” in aviation safety parlance.

The COI report also ignores the fact mentioned in Page 79/175:

“As per recordings on the DFDR at 06:04:42 hours IST just before touchdown, Thrust levers were at 26 degrees and corresponding N2 at Left Engine was 76.8% and N2 on Right Engine was 78.1%.”

Apart from indicating that the COI report has not correlated the timings of CVR and DFDR ( the touch down is shown as 06:04:40 in the CVR while DFDR shows touchdown as 06:04:41 and on page 79 they indicate “just before touchdown as 06:04:42), the thrust lever indication of 26 degrees should have indicated to them that it was above “Idle” thrust which is the standard procedure for touchdown. The fact that the captain was using power for the touchdown indicated he is going for a smooth touchdown in spite of the fact that he was touching down very late. The following graphic is a representation of the last forty feet of the aircraft profile ( based on CVR recordings):

The action of the captain in arresting the high descent rate and making a smooth touchdown with power , is a clear indication that the counseling he had for the earlier hard landing was the influential factor. The “ Hard Landing” circular issued by Air India is a major contributor to the accident and the COI report has chosen to ignore this vital fact.

(Captain A. Ranganathan is a member of India’s Safety Advisory Committee of the Aviation. The aviation safety expert and veteran pilot has more than 20,000 hours of flying experience to his credit.

Capt. Ranganathan can be reached at mohlak@gmail.com).

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June 8th, 2011 at 6:29 am

Posted in Air crash,Safety

Mangalore crash report – The “truth blanket”

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Capt.Zlatco Glusica's daughter Merima at his grave in Belgrade, Serbia, on the first anniversary of Mangalore crash

By Captain Mohan Ranganathan

Capt M Ranganathan

After a crash, if the pilot is alive, nail him. If he is dead, blame him’ is a saying among pilots. The Court of Inquiry report on the Air India Express flight AIE 812 has lived up to that. The report which has been released shows that the decision to blame the pilot was their sole mandate and they have covered up the failures of all others involved – The Airport Authority of India, The DGCA and Air India.
The poignant image of Captain Glusica’s daughter in front of his grave , probably with a feeling that he was crucified. Her thoughts will be repeating the famous statement from the Bible: “ Father forgive them for they know not what they are doing”.She has every right to feel that her father has been crucified and double –crossed in the report.
The pointers were very clear from the beginning when the ATC tapes were quietly leaked out to the press. The captain ignored all calls to go around when his copilot had repeatedly called out that he was high and fast.
The incompetence of the COI was evident , right from the beginning when the Preliminary report was released on the ministry website. They could not get the location of the crash right!

When the Court of Inquiry got runway 24 wrong

What was marked as Runway 24 was Runway 27. When this was pointed out in the media, the image was pulled off in a hurry and replace with the following image, which appears in the final report :

When the 'runway error' was corrected by the Court of Inquiry

The indications were clear that the objective was not to find out the truth and come out with procedures to prevent another tragedy. It was a single minded objective to blame the captain and give a fairy tale ending to all the others who are equally responsible for the fatal tragedy.
IN November 2007, the DGCA safety oversight audit on Air India Express, had found several deficiencies and the management was notified to make the corrections. The findings included the fact that the airline did not have a Head of Safety and Chief of Training as per the DGCA regulations. In June 2010, when a fresh audit was carried out on the airline, the same deficiencies were found. Yet, the conclusion in the report does not blame the airline nor the DGCA for permitting the continued operation by an airline which did not conform to basic safety norms.
The Head of safety should have been held responsible for the wrong circular he had issued about hard landings. The captain had been counseled earlier for a “hard landing” which fell into that category but which was well within the manufacturer’s limit. The fatal flight which was descending at a very high rate, was corrected to make a smooth landing. The circular would have been at the back of the captain’s mind. Yet, this was covered up by the Court of Inquiry.
The most serious aspect is the failure of the COI in not indicting the Airports Authority of India. The report covers up the dangerous rigid concrete structure that holds the Instrument Landing System Localiser antenna. This is completely against the ICAO Standards which prohibits anything other than a frangible structure in that area. The report clearly states that the right wing broke when it struck the concrete structure and the post accident fire is evident in the vegetation in the slope beyond the boundary wall. The illegal structure was rebuilt and operations continue with this dangerous structure remaining.

The ILS antenna that caused the wing of the aircraft to broke apart. In this picture taken just after the crash, the broken wing too can be seen

The report has stated that the fire services reached the site within 4 minutes. However, the truth was disclosed by the Chief of Fire services at Mangalore, Mr.H.S.Varadarajan. in a recent newspaper interview. His statement that appeared in the is as follows:

After every fire, people conveniently forget the firemen who rescued them, by risking their own necks. The heroic efforts of firemen in the Air India Express IX 812 crash too have gone unsung. After nearly a year, their efforts were labelled as ‘nothing extraordinary’.
The fireman’s manual on aircraft disasters and fires depicts a burning aircraft as a bomb waiting to explode. The oxygen tubes, the helium-filled gadgets, and the hydraulic systems are full of highly combustible material which gives firemen only 160 seconds to carry out any rescue operation.
“It is called ‘2.5 minute window’. Within this time, the fire will travel through the tubular structure of the plane engulfing the entire passenger area. Attempts to save lives will have to be made within that time,” “The IX 812 crash happened in a valley where approach was difficult but our vehicle reached there in eight to nine minutes of the crash. The first gush of aqua film forming foam was administered within 13 to 15 minutes of the crash. But, by that time, fire had engulfed the entire plane and the broken parts of the belly had strewn around in three different places and had turned into mounds of fire.”
“We were criticised for using the AFFF. But it is the only material that can extinguish high intensity fire ignited by highly volatile material like aviation turbine fuel (ATF). Any water sprayed on the burning plane will just evaporate even before it reaches the target area,” said Varadarajan who had fought fire in the 1999 Bangalore air crash and another in Yelahanka air base.
To carry out effective rescue and recovery operations in an emergency situation, it is necessary to cordon off 500 metres around the crash area. “No unauthorised person should be allowed inside. In the case of Mangalore crash, everybody who was anybody entered the site. Indeed, some of them tried to help us but most of them only added to the confusion. The narrow road between Kenjar and Adyapady was blocked with all kinds of vehicles including private cars and two wheelers, not allowing the emergency vehicles to operate freely,” he said.
“The victims’ bodies were damaged so badly that it was hard to identify them. The disaster management machinery had no clue about a procedure called ‘Triage Area (TA)’ where the fireman on duty will deposit the recovered body. This facility was missing at the crash site.

The concrete structure still remains and so do the narrow roads which makes the area beyond the runway difficult to reach. Another tragedy will result in the same kind of tragedy. Like a fairy tale ending, the officials in AAI and the airline will live happily ever after. More families may join those who lost their lives on the fatal 22nd May 2010. Unless people wake up to the danger, we are not far from another tragedy.

(Captain Mohan Ranganathan is a member of India’s Safety Advisory Committee of the Aviation. The aviation safety expert and veteran pilot has more than 20,000 hours of flying experience to his credit).

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June 2nd, 2011 at 2:21 am

Posted in Uncategorized