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The untold story of Jet Airways Flight 9W555: How an airline and its pilot nearly crashed a passenger plane with 150 people onboard

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By Jacob K Philip

An incident that was hardly noticed by the national media, though it was one of the gravest of the safety incidents ever occurred at any of the Indian airports, is bound to land Jet Airways, the operator airline, in deep trouble in the coming days.
The DGCA is viewing the incident very seriously and by all indications, both airline and the pilot who was hailed by the local newspapers and the social media as a hero who miraculously saved the lives of 142  odd passengers and eight crew, are to face the music.
It was at Kochi airport, Kerala, a southern state of India, that the chain of events that culminated in the near-disaster, started on the early morning hours of Tuesday, August 18, 2015.
When Jet Airways flight 9W 555, a Boeing 737-800, arrived from Doha, the Capital of Qatar, over Kochi at 5.45 in the morning, there were not enough visibility for the aircraft to land because of the haze that followed a heavy rain during the previous night. After holding over Kochi for a almost half an hour, the pilot decided to divert to Trivandrum. When it reached Trivandrum, visibility at Trivandrum also was less than what required for a visual landing. (ILS was not available because of a calibration issue).
The captain of the aircraft informed the Air Traffic Control (ATC) that the fuel levels were running low and he should be permitted to attempt landings even though the visibility was insufficient. The pilot tried to land from the ’14’ end of the runway thrice. By the time fuel level dropped to alarming levels according to the pilot and he made a final attempt at the other end of the runway, almost blindly. In between, he made a May Day call also.
A full emergency was declared (even before the May Day call) at the airport and all the steps were taken as per the SOP. ( Getting ambulances ready, informing city fire services also and the alerting the hospitals in the pre-made panel etc.).
The pilot however could manage to land the aircraft. The landing turned out to be without any hitch.
The whole incident would never have attracted not much of an attention, being one of the numerous diversion incidents during the inclement weather in Kerala airports, but for the grave issue of shortage of fuel involved and for the desperate frantic way the pilot behaved , making even a May Day call.
And it indeed was one of the most serious safety occurrences that could happen at any airport. And the government and the regulation authorities should be taking immediate actions, treating the incident at par with an actual air crash.
Here is why:

The core of the incident is a passenger aircraft using up almost all the fuel in-flight. There could be only three reasons for such a rarest of rare occurrence:

  1. The fuel policy of the airline that is not in line with international safety standards
  2.  Erroneous implementation of the fuel policy (If the policy was perfect)
  3. Wrong judgement and short-sighted en-route planning and erroneous/belated decision making of the pilot.

There are only remote chances for 1 to be true, because the SOPs simply will always be correct, everywhere, for all organizations.

So we can pass on to 2:
Though the fuel planning method vary across airlines, the fuel requirement for Boeing 737-800 aircraft is generally calculated as the sum of the following:

  1. Fuel to reach the destination
  2. Fuel to reach an alternate airport from the destination
  3. Fuel to fly for 45 minutes at cruising altitude from the alternate airport
  4. Fuel for planned hold
  5. Fuel to taxi
  6. 5% contingency.

So for B737-800s that fly from Doha to Kochi covering 1677 nm ( 3106 km), each of these items will work out like this:

  1. Fuel to reach the destination (kochi) = 10167 kgm (Allowing an allownace for a headwind of 50kts).
  2. Fuel to reach Trivandrum, the alternate airport, 191 km(103nm) away from kochi – 1497 kgm
  3. Fuel to fly for 45 minutes at cruising altitude from Trivandrum, the alternate airport: 2701 kgm
  4. Fuel for holding for 30 minutes: 1800 kgm
  5. Taxi fuel: 200kgm

The total of 1 to 5 is 16365 kgm

So 5% for contingency is 818.25 kgm

Therefore, the all-up total fuel required is 17183 kgm or 21478 litres

And the total fuel capacity of the aircraft is 20894 kgm (26118 litres).

Even if the aircraft had only 17183 kgm and not the maximum capacity of 20894 kgm, the 9W555 would have had 7016 kgm of fuel left when it reached Kochi.
Imagine it had spent an entire 30 minutes of holding time at Kochi. So the remaining fuel when it left for Trivandrum was 5216 kgm.
On reaching Trivandrum the fuel level would have become 5216-1497 kgm = 3719 kgm.
And how much time it spent at Trivandrum to do the three missed approaches and go-arounds? On 7.03 am, it had touched down. It reached Kochi by 5.50 AM. If it had spent 30 minutes at Kochi and it left it must have left Kochi by 6.20 AM. So, within 43 minutes, it reached Trivandrum, missed three approaches and did the final landing. Deducting the time taken by these exercises, the flying time turns out to be 15 minutes- that is to reach over Trivandrum.

So when the Captain decided to land blindly on a runway he could not see even from a height of 1500m, endangering the lives of all souls on the plane, there were 1379 kgm or 1723 litrs of fuel in the wing tanks. Enough for him to stay up for 28 minutes.
(But had the aircraft been filled up to maximum quantity, that is 20894 kgm, the quantum of the remaining fuel would have been as much as 3711 kgm).

Then why he went for the deadly gamble?

The reason should be one of the three:

  1. The pilot read the remaining fuel quantity erroneously
  2. The pilot did understand the figure correctly, but failed to calculate correctly the reaming time he could be airborne with that much fuel
  3. The fuel quantity indeed was too low. Much lower than the 1723 kgm. May be a couple of hundreds only.

If the reason was 1 or 2, the pilot is guilty of endangering the lives of a plane full of people including himself and the crew.

And if the reason was three, the pilot again is the one responsible- theoretically, at least. It is the duty of the pilot, and pilot alone, to ensure that he had enough fuel in his plane to reach the destination safely.
But it remains just a theory, for most of the private airlines in India, says an Air India commander based at Chennai who flies Gulf routes regularly.

“Being a public sector airlines and because of the presence of an employee’s union, the commanders, who are the real authority when it comes to the safety of the aircraft they fly, still do assert in Air India. But these young boys in the private airlines won’t dare..” says the Captain with over 15 years of flying experience.
And it is not budget airlines alone try to cut cost at all fronts, even if that is by comprising safety.
But even if the fuel planning policy of the airline was a culprit, the Captain of flight 9W555 has still more to answer.

1. The assessment of  the significance of an early warning received

Just five minutes after it left Kochi, the Trivandrum Area Control had passed on a crucial piece of information to Flight 9W555. They said the the visibility at Trivandrum, which was 3000 m when the aircraft started its flight to the airport, had suddenly dropped to 1500 m.   But the Captain was not to turn back.
He expressed his confidence that he can land on ‘converted minima’. (The minimum practical visibility required to land an aircraft even when the stipulated visibility is not available. The visual range is calculated by converting the meteorological visibility).
He could have made the landing as per this calculation but for just one crucial thing he overlooked. That was clouds. If clouds are there at low altitudes, all the calculations would turn upside down.
And that exactly was what happened a few minutes after at Trivandrum.

2. Briefing the ATC of the available fuel.

On way to Trivandrum from Kochi, the pilot had informed the Trivandrum ATC  that he had enough fuel  to fly for one more hour.  It was when the aircraft was around 12 minutes away from Trivandrum that this information about the fuel quantity was given to the ATC as an answer to a routine query.

So as per his own estimation, he had got only 48 minutes of fuel left when reached above Trivandrum airport. One missed approach will cost 7 minutes, approximately. So the time for three approaches is 21 minutes.

But there was a problem. The fuel consumption for B737-800 aircraft at approach levels (around 3000ft) is almost 1.5 times of the consumption in cruising levels. So at the end of three approaches he would only have fuel for for 18 minutes left instead of 27 minutes. Or roughly 1092 kgm or 1365 litters of fuel.
So when he decided at last to land blindly on Runway 32 after saying a “Good Bye” to the ATC, he actually had got fuel for 18 minutes left, if what he said to Trivandrum ATC before indeed was correct.
Why he went for the do-or-die landing where chances of crash were much so high, with 1365 litters of inflammable fuel in his wings? Perplexing, indeed.

3. The selection of the runway

At Trivandrum, the ILS is installed at the North-West or 32 end of the runway. The other end, the south-east one, is denoted by the shortened bearing, 14.
On the fateful morning, the ILS was not operative as said earlier. So we may think it was natural for the pilot to align to land from 14 end.
But it was not so. At Trivandrum, only wide body aircraft choose runway 14 these days because the width to turn from the other end is less when land on 32 end. For a narrow body aircraft like Boring 737-800, it never was a problem. The obvious choice was 32.
The reasons were two:

  1. When landing from 32 end, the available runway length would be more. It was because, the threshold, the first point on runway for the aircraft to touch on landing, is only 135m from the end for 32, But for 14, it is 406 m away from the runway end. When attempting to land on a runway in low visibility and in an urgency, no pilot would opt for a short runway.
  2. When trying to land on a runway with no ILS, the main navigational equipment the pilot got is his eyes. He has to see the runway and surroundings clearly. But when an aircraft approaches from 14 end, the morning sunlight would be falling right on the pilot’s face, effectively blinding him.

But even as the perplexed ATC people were watching, he tried not just once, but three times to land from that very side- wasting precious time and fuel.

When trying to land on the same end of the runway after an approach was missed, the aircraft will have to do a ‘go around’ to align again to that end again. That means more flying and alas, more loss of fuel.

And in the end, from where he could make the landing?

From the 32 end, of course !

4. The timing of the May Day call

When did the captain actually make the May Day call that simply transformed the very character of the whole incident?
Not before the last attempt, as one would expect.
The call had already been made after the second attempt to land. And at that time, the pilot was having enough fuel to stay in the skies comfortably for 23 more minutes.
After the May Day call he tried another attempt at the same, short, runway 14.  And only after spending fuel for another 7 minutes that he could realize that runway 32 was the better choice.

The Good Bye to the ATC too to be mentioned here. It is highly unusual to end the communication with the ATC with a Good Bye. Usually it is something like “Good Day”. And the situation in which the Good Bye was uttered never lost on the ATC people.

Jet Airways, the airline and its selection of alternate airports

It is only commonsense that, chances are much high for same climatic conditions to prevail at Trivandrum and at Kochi within a span of an hour or less. If the visibility at Kochi is less, that at Trivandrum too would be less, being located only a few hundred kms away on the same western cost of Kerala. So it is sensible to NOT to set Trivandrum as an alternate airport, if the safety of passengers is indeed the main criteria.
That is why for Air India, the alternate airport is either Bangalore or Chennai and for Air Arabia, it is Coimbatore.

But then why it is Trivandrum for Jet Airways?

The answer is obvious. Private airlines are more eager to reduce the flying expenditure by all means and they think they can get away with it. It is only to fulfill a safety requirement that they fix an alternate airport in the first place. And when being compelled to do so, they select the nearest airport. Nearest airport means less flying time and less fuel.

Some other facts

What actually was the available visibility at Trivandrum when 9W555 did the reckless landing?
It was 1500 m.
And what was the actual distance required?
For runway 32, it was 2400m and for runway 14 it was 2100 m.  That was the theory.  But for all practical purposes, a visibility of 1500 m is pretty comfortable to land, says an Air India pilot- that is, if the sky is clear. The problem that morning at Trivandrum was that, in addition to the low visibility, there were clouds hanging around at an elevation 450 m or so. So when coming down to land from 900 m, that indeed would have hidden the runway from the pilot.

The May Day call
Unlike many tend to think, the utterance of a May Day call (it was SOS earlier days- Save Our Souls) by an aircraft on the final approaches at an airport is actually depriving the pilot of all the assistance from the ATC. Once the words are out, the ATC will cease all communications with him and he will be on his own then onward. That is to not to disturb the pilot when he frantically would be trying to manage the landing. He then has full freedom to resort to any action he thinks that would save the flight.  No one will interrupt him. And on Tuesday, the ATC at Trivandrum did exactly follow this dictum. Even when the aircraft’s nose pointed right towards the tower for a while during the final moments before the landing, they never tried to yell at the pilot, even as they really got terrified. With the May Day call, the preparations to handle the emergency did not escalate, though, at the airport during this  period. It was because the airport had declared a full emergency even before the May Day call was made and the SOP for that was already being followed. So there were nothing more to be done on the ground, except staying alert, expecting a crash any moment.

(Jacob K Philip, a Doha based aviation analyst, is the honorary editor of Indian Aviation News Net. He can be reached at jacob@indianaviationnews.net)
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August 21st, 2015 at 12:40 pm

Posted in Air crash,Safety

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

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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

Faridabad Air Ambulance Crash: DGCA, the real culprit

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By Jacob K Philip

VT-ACF, The Pilates PC-12 aircraft that crashed on 25 May. This picture was taken in early January this year when the aircraft was with its previous owner Range Flyers Inc, US.

Directorate General of Civil Aviation (DGCA), India’s aviation regulatory body alone is responsible for the Wednesday night’s small aircraft crash at Faridabad near Delhi that Killed all 7 people on board and 3 on ground.

It was by violating its own regulations that DGCA had granted permission to the single engine Pilatus PC-12/45 to fly as air ambulance in India.

The CAR or Civil Aviation Requirement notification released by DGCA on 1st June, 2010 (SECTION 3, AIR TRANSPORT

SERIES ‘C’, PART III, ISSUE II) prohibits all single engine aircraft ferrying patients.

Captain Mohan Ranganathan , aviation safety expert and veteran pilot who also is a member of Safety Advisory Committee of the Aviation Ministry points out:

” The CAR (Civil Aviation Requirement) is very clear that a Single-engine aircraft cannot be used for ambulance flgihts. The CAR is also very clear that the flight cannot be undertaken at night and in Bad weather conditions..”

Paragraphs 2.2 & 2.3 of the CAR:

Single engine, turbine powered aeroplanes may be operated day/night, VFR/IFR weather conditions as per their certification and operating procedures stipulated in flight manual. Single engine piston airplanes shall not be operated at night or in Instrument Meteorological conditions. However, they may be operated under special VFR subject to the limitations contained in the type certificate.

Operations with single engine aeroplanes shall be conducted only on domestic sectors except for medical evacuation flights and shall be operated along such routes or within such areas for which surfaces are available which permit a safe forced landing to be executed.

” When the flight left Patna, there was a Squall warning for Delhi. The flight should not have been cleared as it was already night and the weather forecast was bad.Whoever gave the permission for the flight from DGCA should be held accountable for all the fatalities..” say Capt. Ranganathan who has more than 20,000 hours of flying experience to his credit.

The Union government has already announced it will appoint a committee of inquiry to probe the crash of the air ambulance in a residential area in neighbouring Faridabad.

But it is really doubtful if the probe would reach anywhere.

Because in this accident the law maker, who also happens to be the agency that implements the law, itself is the real culprit.

And it has already become clear, to where the investigation is heading:

See this news report:

Preliminary probe by aviation regulator DGCA into the Faridabad air crash that claimed ten lives today pointed towards technical malfunction and high velocity winds as possible major reasons for the mishap.

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May 27th, 2011 at 4:25 pm

Posted in Air crash,Safety

Mangalore Crash: An Inquiry That Ends with Photoshopping the Truth

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Air India Express flight 812: An investigation gone hauntingly wrong-V

By Jacob K Philip

Because it was mandatory to reconstruct the shape of the aircraft with remains of the wreckage, the Court of Inquiry (CoI) appointed by the Govt of India to investigate the crash of Air India Express flight-812 too had attempted it with 16 tonnes of the debris that Air India chose to collect from the crash site.

Or did they, actually?

Given below is the photograph of the Re-arranged wreckage, as given in the final investigation report the CoI submitted to the Ministry of Civil Aviation.

The photo of the reconstructed wreckage of flight-812, given in the CoI report

In all probability, this picture is fake.
It can’t be the actual photograph of the debris arranged (if at all they were arranged) on the open platform near the new terminal of the Mangalore airport.

To take a photograph like this, the photographer should be directly above the platform, many meters up, to get the whole view.

There were no such vantage points there.

I had been to the place twice in July 2011 (A few days after the Col left) and could take some photographs and video myself of the whole setup. Please see the video embeded below and the pictures.

The wreckage of flight-812 on a platform near Mangalore airport terminal

The wreckage of flight-812 - another view

 

 

 

 

 

 

 

The wreckage of flight-812 - another view

Now have a closer look at the first photograph published by the CoI. What is the grey coloured surface on which the wreckage is resting?
The concrete platform? Of course not.
Then what?

Again have a look at the engines on left and right. Now how come the engines are larger in diameter than the fuselage!.

Your guess is right. The picture is something cooked up in computer by a very amateur artist with Photoshop.
The CoI must have taken the pictures of each part separately or collectively and the artist did the reconstruction on computer screen as per the direction of some one familiar with the shape of the aircraft.

The picture is included in the Chapter named “Factual Information”.

The huge separation between the wordings and the truth is truly representative in nature of  the CoI report.

The 191 odd pages of the report is heavy with the attempt to subvert or to twist the facts.

What I planned initially was to point out all those instances of subversion one by one in the last part of this series. But now that seems immaterial.

The series may be concluded with three paragraphs from the CoI report itself. The compulsion of the CoI to make the Commander and, to some extent first officer, alone responsible for the crash is evident from the contradictory sentences:

During interaction with other pilots, who had flown with Capt Glusica, he was
reported to be a friendly person, ready to help the First Officers with professional
information. Some of the First Officers had mentioned that Captain Glusica was
assertive in his actions and tended to indicate that he was ‘ALWAYS RIGHT’.

On 17th March 2010, Capt Glusica had been called to the Flight Safety
Department of Air India Express regarding a ‘Hard Landing Incident’ on a flight
operated by him from Muscat to Thiruvananthapuram on 12th December 2009. While the Chief of Flight Safety had stated that the counselling was carried out in an amicable and friendly manner, it was given to understand from his colleagues that Capt Glusica was upset about the counselling.

In the absence of Mangalore Area Control Radar (MSSR), due to
un-serviceability, the aircraft was given descent at a shorter distance on
DME as compared to the normal. However, the flight crew did not plan
the descent profile properly, resulting in remaining high on approach.

(Concluded)

Jacob K Philip is Editor of Aviation India

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May 24th, 2011 at 6:38 pm

Posted in Air crash,Safety

An investigation built upon gravest of violations

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Air India Express flight 812: An investigation gone hauntingly wrong-IV

By Jacob K Philip

The sole objective of an aircraft accident or incident investigation is the prevention of future accidents and incidents and not to apportion blame or liability. The emphasis of an aircraft accident or incident investigation is on remedial actions. An aircraft accident provides evidence of hazards or deficiencies within the aviation system. A well-conducted investigation should therefore identify all immediate and underlying causes of an accident and recommend appropriate safety actions aimed at avoiding the hazards or eliminating the deficiencies. The investigation may also reveal other hazards or deficiencies within the aviation system not directly connected with the causes of the accident.

It is from the opening sentences of the Procedure Manual of Accident/ incident investigation( Issue I rev 2 dated 5.10.2006), the Bible of air accident investigators in India. The manual is published by Directorate General of Civil Aviation (DGCA), strictly adhering to the standards put forward by International Civil Aviation Organisation (ICAO).

Capt. Zlatco Glusica

Capt. A.H. Ahluwalia

The Court of Inquiry(CoI) appointed by the Government of India to investigate Air India Express flight 812 crash is guilty of violating the very essence of the above dictum.
As we have seen in the previous parts of this note, from the very beginning of the 11 month long investigation and up to its conclusion in April this year, the CoI was directly and indirectly trying in all their earnest to appropriate the blame and liability to the Pilots of the aircraft, who were no longer able to defend themselves- Because they were dead.
The first document that was allowed to sneak in to the media was the taped conversation between first officer AH Ahluwalia and the Mangalore Control tower. That was the beginning of the the long and systematic process of the victimization of Capt. Zlatco Glusica.
Then the content of the Cockpit Voice Recorder, with the heavy breath, snoring and all, reached the media adding more strength to the erring-commander theory.

The resting place of Capt.Zlatco Glusica in Belgrade. On May 22, first anniversary of Mangalore crash. (Sent in by Merima Glusica, daughter of Capt. Glusica.)

During their questioning, six of the eight odd survivors of the crash were coerced in to believing that something of course was wrong with the Commander.
The conclusions of the final report, which as a whole is never going to be placed in the public domain, too was along the same line- Among a few other trivial things, the sleep of Capt. Zlatco Glusica caused the crash. First officer AH Ahluwalia too was guilty because he had not took over the control of the aircraft from the reckless Glusica.
But in the single minded efforts of the CoI to put the major chunk of the blame on two dead people, most of the eight aspects of a crash investigation were getting sidelined.
As per the Manual, the Inquiry team team should conduct the following investigations, assigning equal importance to all.

  1. Operations of aircraft
  2. Flight Recorders
  3. Structural Investigation
  4. Power Plant Investigation
  5. Systems Investigation
  6. Maintenance Investigation
  7. Human Factor investigation
  8. Organization Factor Investigation

We have already seen here how pathetically the structural investigation, the third one, was conducted.
And so far,  no information from the CoI (leaked or otherwise) give any clue regarding the quality and extent of investigations 4, 5, 6 and 8.  The summary of the final report given to selected media too remain silent on this part of the investigation.
Or, can the CoI abstain from investigating some sections if the cause of the crash is that clear for them?
Never. Says the Manual:
9.20.2:

Each aircraft system must be accorded the same degree of importance regardless
of the circumstances of the occurrence. There is no way to determine adequately
the relationship of any system to the general area without a thorough examination.

9.23

It is argued that modern aircraft accidents occur, for the most part, as the result of
complex interactions between many causal factors.

Mangalore crash too was not an exception.
There were an approach radar that was not functioning ; the dictum of Air India management that hung like the Sword of Damocles above the commanders , especially the expatriates, that hard landing and go around are grave crimes that could cost them their jobs; the ILS localizer antenna errected at the end of the runway flouting the safety rules that that should be fragile…
How long the list actually was only something that could have been determined by an impartial and scientific investigation by the CoI.
For flight-812 investigation, that exactly was the factor missing.

(To be concluded in next part)

Jacob K Philip is Editor of Aviation India

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May 22nd, 2011 at 4:07 pm

Posted in Air crash,Safety

A case that was settled eight months before the verdict

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Air India Express flight 812: An investigation gone hauntingly wrong-III

By Jacob K Philip

It was three months after the Air India Express crash that killed 158 people that the Court of Inquiry (CoI) appointed by the Ministry of Civil Aviation interviewed the survivors of the crash.
They were questioned during the first public hearing of the CoI held during August 17 to 19 at Mangalore Airport old terminal.
Of the 8 survivors, six had reached the airport to appear before the CoI, on getting summons.

The questioning of all the six was along the same line.
There were queries regarding the behaviour of the cockpit as well as cabin crew during the flight, about the possibility of excess luggage on board etc.
Those questions were obviously as per the following rules of the Manual of Accident/ incident investigation

Rule 9.15.2

….The crew histories should cover their overall experience, their
activities, especially during the 72 hours prior to the occurrence, and their behavior during the events leading up to the occurrence.

Rule 9.15.4:

.. Since weight balance and load are critical factors that affect aircraft stability and control….. It will be necessary to check flight manual load data sheets, fuel records, freight and passenger documentation to arrive at a final estimate. Elevator trim settings may give a clue to the center of gravity at the time of the occurrence.

But one of the questions that put forward to all the six survivors was really perplexing and alarming.

Do you think the accident occurred because of the fault of the pilot?

What kind of an answer was the CoI expecting?
What if the answer was “no”? Would the CoI would have decided to believe them and furthered the investigation along that line?
And what if the replies were in affirmative? Could they have used it as a supporting fact in the final report while putting the blame on the pilot?
We know the answer.

Then what actually was the purpose of the question?

It could have been only to give a preconceived idea to the witness; only to create an atmosphere conducive enough where the guilty-pilot-theory readily accepted.
The very question was also in plain violation of the Manual of Accident/ incident investigation.

Rule 7.2.1

The investigation of aircraft accidents and incidents has to be strictly objective and totally impartial and must also be perceived to be so.

The selective leaking of the relevant portions of the ATC tapes and CVR that put the blame squarely on the Commander of the aircraft as well as the first officer may be read along with this.

The total disregard by the CoI, from the very beginning, of the option of exploring the possibility of a faulty aircraft was also in perfect harmony with this.

Making available the whole content of the black boxes- CVR & DFDR- to the representatives of Boeing Company (manufacturers of the crashed aircraft) days before them testifying before the Court of Inquiry was also in tune with that particular scheme of things.
Imagine a situation where, one of the accused in a murder case appearing before the court after studying very well the case diary supplied by the police themselves.
And try to visualize also the situation where the respondents of the same case are being lead by the judges along predetermined paths where they are coerced into blaming some one particular.
(To be continued)

Jacob K Philip is Editor of Aviation India

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May 20th, 2011 at 2:40 pm

Posted in Air crash,Safety

When evidence reached scrap metal shops

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Air India Express flight 812: An investigation gone hauntingly wrong-II

By Jacob K Philip
When Air India’s Jumbo Jet Emperor Kanishka exploded mid-flight and got scattered in Atlantic near Ireland cost on June 23, 1985, the investigators had a gigantic task at hand. The Royal Canadian Mounted Police of Canada organised dives in excess of 7,000 feet in 1985, 1989 and 1991 to collect wreckage from the ocean floor, to pick up the aircraft debris scattered across the ocean floor.The numerous parts recovered from the thousands of squire meters beneath the sea by where all cleaned, numbered and shipped to a facility in Ireland where they were all kept for more than two decades. The recovered parts were latter arranged to re-create the shape of the aircraft, to find out what exactly caused the explosion.
In case of Pan American World Airways’ Pan Am Flight 103 that was disintegrated in an explosion many thousands of feet above southern Scotland, on 21 December 1988 too, the same procedure repeated. Only that, the recovery of parts of size ranging from a few cm to many meters from the acres of barren land of Lockerbie village was comparatively easy. More than 10,000 pieces of debris were retrieved, tagged and entered into a computer tracking system. The fuselage of the aircraft was reconstructed by air accident investigators, revealing a 20-inch (510 mm) hole consistent with an explosion in the forward cargo hold.

Here in India too, the air crash investigators are obliged to conduct the same exercise. As per the Procedure Manualof Accident/ incident investigation, published by DGCA (Issue I rev 2 dated 5.10.2006),  the reconstruction of the aircraft with all the debris collected carefully from the crash is mandatory.

Rule 9.7.2:

Stage 1 Identify the various pieces and arrange them in their relative positions
Stage 2 Examine in detail the damage to each piece, and establish the relationship of this damage to the damage on adjacent or associated pieces.

The care with which the parts are to handled is much too clear from the following rules

9.17.2.1

Before commencing reconstruction work, 1. Photograph the entire site and wreckage.2. Complete the wreckage distribution chart.3. Inspect and make notes on the manner in which the various pieces were first found, by walking around the site.

9.17.2.2:

The difficulty in reconstructing a component, such as a wing, lies in identifying the various pieces of wreckage. If the wing has broken up into a few large pieces, the task is relatively simple. If, on the other hand, the wing has broken into a number of small pieces as a result of high impact speed, reconstruction can be extremely difficult. The most positive means of identification are: • Part numbers which are stamped on most aircraft parts, which can be checked against the aircraft parts catalogue• Colouring (either paint or primer)• Type of material and construction• External markings• Rivet or screw size and spacing.

The many visits I could make to the crash site of Air India Express Flight 812 and the nearby Mangalore airport during the months of May, June and July 2010 had made one thing much too clear.
Air India, the owner of the aircraft and the Court of Inquiry that investigated the  crash couldn’t have shown more disregard to the above stipulations.
For forty days on a stretch after the May 22 crash, the debris had remained in the crash site soaked in dust and mud enduring heavy rain and sun.
And the removal of these precious evidence to ‘reconstruct’, the shape of the aircraft couldn’t have been more hilarious.

Fiza, a local construction firm was hired to do the job and they heaped the picked up parts  in lorries and then dumped on an open platform near the new terminal of Mangalore airport. According to an official of Fiza, the total weight of the debris recovered from the crash site was just 16 tonnes.It may be remembered that the total empty weight of a Boeing 737-800 is 41 tonnes. To assume that 25 tonnes of a flying machine which was mostly metal and fire resistant composites were consumed by fire, one would need wildest of imaginations.
So what happened to the remaining parts?
All of Mangalore knew the answer.
Just after Air India’s debris removal was officially complete and the police men were withdrawn from the site, hoards of scrap metal collectors descended on the crash site.It was for three continuous days that the ‘metal scavengers’ looted the site. The bounty was so much so that they had to hire even mini lorries to ship it to various scrap dealers in Mangalore city.

Now we may read this sacred rule 6.5.2:

Whenever an accident occurs, the Owner, Operator, Pilot-in-Command, Co-pilot of the aircraft shall take all reasonable measures to protect the evidence and to maintain safe custody of the aircraft and its contents for such a period as may be necessary for the purposes of an investigation subject to the Indian Aircraft Rules 1937. Safe custody shall include protection against further damage, access by unauthorized persons.

The Court of Inquiry that landed again at Mangalore on June 13, 2010, had done a scientific examination of the ‘reconstructed’ aircraft, the media people were told, though none of them were ever allowed near the ‘reconstruction’.
And this was how they actually done it. (I could take this with my digital camera two days after the CoI team left):

It was while examining these  16 tonnes of the 41 that a member of the CoI team noticed the downward position of the flap locator, a finger sized metallic switch in cockpit used to move the flaps in the wings. The reason for the aircraft to generate not enough lift to take off in the last moment was becoming clear then.  The panicked pilots must have forgotten to to push up the switch.

If a finger sized metallic part could have spoken so much about the crash, imagine the sheer volume of the precious evidence the scrap metal collectors of Mangalore merrily sold in numerous shops scattered across the city?

(To be continued)

Jacob K Philip is Editor of Aviation India

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May 16th, 2011 at 4:44 pm

Posted in Air crash,Safety