Category: Safety

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.

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.

 

 

 

 

 

 

 

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

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).

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.

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

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

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

By Jacob K Philip

On 22nd of this month, it will be one year after the tragic crash of Air India Express IX-812 at Mangalore that killed 158 people.
It seems the last major news break related to the accident was duly celebrated by the media with the submission of the investigation report by the Court of Inquiry (CoI) on 26 April 2011, 10 months after it was constituted. Thanks to the selective and somewhat precisely scheduled leaking of certain parts of the report to the press, now everyone is aware that the crash happened because the ‘Serbian’ commander of the aircraft was asleep for the first 100 minutes of the flight.
Though the relatives and dependents of more than 100 dead passengers are yet get compensation, the public already has accepted the crash as a well concluded story.

So there shouldn’t be much left to write an anniversary story.

But no news reporter who had followed the story from the beginning can leave it thus.

It never was something as simple as an expatriate pilot causing a horrific crash by simply sleeping at the controls.

There were many, many things the public was never properly made aware of, about the crash.
The incomplete, erroneous way the court of inquiry conducted the investigation too should have been laid bare before the people of India.

The aviation reporters of the country by now should already have asked themselves why the manufacturer of the crashed craft was never questioned or investigated.

The media should also have investigated Capt. Zlatco Glusica in his home country.

Air India Express and Air India the parent airline too were never sufficiently subjected to unbiased scrutiny of the mass media.

It was a phone call from a ‘law maker’, as they say, of the country, that made me to start worry about the whole business of the CoI which was appointed by the govt of India on 3 June 2010.

Soon after the CoI was constituted, three of the members of the CoI had flown to US to ‘decode’ the content of the two back boxes- the DFDR and CVR- at the facility of NTSB.

It was after two weeks of their return to India that I got the call.
That was in July.
He was very excited. He said one of the pilots had fallen asleep during the flight and his snoring and all was there in the CVR. Loud and clear.
That sure was news.
But I had to be sure. Okay, how he came to know about it? Well, that was simple.  It was a fellow lawmaker, who happened to own a major private airline who revealed that to him. One of the members of the CoI was an employee of that particular airline and after hearing the CVR in US, he right away told his boss all about the unbelievable content.

But the Associate Editor of the Daily where I was working was not that adventurous to print this explosive exclusive straightaway.

No proof- he calmly pointed out. So let us wait.

And our wait prolonged well in to first week of September 2010.
Coinciding with the second hearing of CoI at the national capital from September 6 to 9, this particular info was leaked to the press. All channels broke the news for the whole day. Dailies celebrated it on 8th.

Though many veteran pilots who testified in that session of the hearing  told the CoI that sleeping in the cockpit, was not that alarming or dangerous, that never was got prominently reported. Some commanders had even pointed out that it was a healthy practice for the pilots to sleep taking turns under ‘controlled conditions’. A little sleep would only raise the level of alertness.
On their part, the CoI too seemed to be agreeing with those observations. Many of the experts who attended the hearing too had noted that. It was a kind of reassurance for them that the investigation was proceeding in a scientific, unbiased manner.

But the fact remained that one of the members of the CoI who was pledged to secrecy, had way back revealed this sensitive info in a very callous manner to his boss who was the owner of rival airline of Air India Express.
And the way the ‘sleep news’ was planted in to selected national media too was reason to worry.
Especially because the taped conversation between the pilots of the aircraft and Mangalore ATC too had found it way to some media as early as June 2 , well before the CoI’s first hearing at Mangalore airport from August 17-19.

None could fail to notice that leaked content of both the tapes were highly incriminating Capt. Zlatco Glusica, the Commander of the crashed flight.

A pattern was beginning to emerge, for those who were closely watching the investigation.

(To be continued)

Jacob K Philip is Editor of Aviation India

By Jacob K Philip

In a few days the media is bound to leave totally behind the sad and untimely death of Arunachal Pradesh Chief Mnister Dorjee Khandu in the treacherous heights of Luguthang, a sleepy, remote village in his own constituency. Just like it was for Andhrapradesh’s YSR tragedy.Till another crash involving another VVIP, or till some yatras of heir apparent, the crash is going to evoke no further intrest for the national media-

Unless the origin of  two calls from a satellite phone that were made to the cell phones of a Tawang MLA Tsewang Dhondup and principal secretary to the chief minister Yeshi Tsering in the afternoon of Saturday, 30 April are traced out.

Unless veracity of the account of the little scholl children in a remote Bhuttan village of sighting a similar color helicopter is verified.

Unless the reason for sudden inactivation of the transponder of the brand new helicopter is found out.

Unless the extraordinary failure of the ISRO satellites, and Sukhoi radars to ‘see’ the metallic debris a few kms from Tawang (even as they could count out another six possible sites between them) is accounted for.

Yes- There could be much more to the crash of the brand new Eurocopter AS350 B3 helicopter on April 30 and the deaths of CM Dorjee Khandu, crew members Captain J S Babbar, Captain T S Mamik, Khandu’s security officer Yeshi Choddak and Yeshi Lhamu, sister of Tawang MLA Tsewang Dhondup.

The copter that took off on Saturday fr

om Tawang at 9:56 am for state capital Itanagar, was to land at Itanagar at about 11.30 am. But Guwahati air traffic control lost contact with the helicopter  20 minutes after take off.

The State machinery was alerted and a massive search was ordered- Only to cancel within a few hours.

Two phone calls were the reason.

Around 2.30 PM, MLA Tsewang Dhondup got the first call. Dhondup saw it was from a satellite phone and the voice was that of Chief Minister Khandu.
Now from a story published in The Telegraph:

The MLA informed the chief secretary and the principal secretary to Khandu that “he believed” it was Khandu who called him. The caller apparently said “he was taking off” presumably from somewhere in Bhutan. “We are trying to get details of that call,” said a source.There was one small snag here: Khandu did not have a satellite phone, not that the Centre knew of. Two, while there could have been such a phone aboard, the pilot would have used it to call the base station in all probability, the sources said. The misinformation that was spread through the media after that about the landing of his chopper could only end when Bhutanese authorities said they had no knowledge about any landing. The reports would eventually lead Prime Minister Manmohan Singh to call Governor J.J. Singh.The governor had earlier spoken to the media about Khandu’s reported landing in Bhutan.Around that time, the air force called off the search and rescue operations which triggered speculation that the search operation..

From a PTI report:

Chief secretary Tabom Bam said in the afternoon that the chopper which lost contact with ATC in the morning had landed safely at Daporijo in Upper Subansiri around 2:30 pm.Bam said that he was not been able to contact Khandu personally, but the Sashastra Seema Bal had confirmed that Khandu and those with him were safe. “The IGP (SSB) has confirmed he is safe.”

The Hinustan Times had the details of the 2nd call and more information regarding the first call:

Dhondup, whose sister Yeshi Lamu was also on the chopper, received a call around 1.30pm from a satellite phone he believes belonged to Khandu. The caller said the chopper had landed in eastern Bhutan. The caller contacted principal secretary to the chief minister Yeshi Tsering in Itanagar too, saying Khandu was safe. The calls came a couple of hours after the helicopter disappeared on Saturday morning. Deepak Kumar, inspector general of police, wrote to the state’s home secretary, AK Srivastav, outlining the contents of the call Tsering received.“I asked Tsering if the call received was from the chief minister,” Kumar said. “He said the voice sounded like the CM but he could not identify it.”

Now another PTI report:

Chief secretary Tabom Bam said in the afternoon that the chopper which lost contact with ATC in the morning had landed safely at Daporijo in Upper Subansiri around 2:30 pm.Bam said that he was not been able to contact Khandu personally, but the Sashastra Seema Bal had confirmed that Khandu and those with him were safe.

But the State Government officials later said CM did not carry a satellite phone. Pawan Hans people said there were no sat phone in the copter.
Then who made the call?
Suppose, some one, for some reason, was posing as the Chief Minister imitating his voice and all. But would he have used a Satellite phone, if it was known that the CM never had such a phone? Notwithstanding this, if it indeed was the call of an impostor, then again another question arises:
Why should they want the officials believe that the CM was safe?To delay the search? To make sure that no help was reached at the crash site? To ensure that no one was saved? But there again is terrible flaw in the theory.It is now known that the accident had taken place around 10.30 AM. The copter might have caught fire instantly and everyone would have killed within minutes of impact. Then why bother to delay the search & rescue operations by making a call by 2.30 PM?
Now the Bhuttan angle of the story.

From Calcutta Telegraph:

Then, during the interactions between Indian and Bhutanese officials, the latter said a schoolboy from the Bhutan-Arunchal border had reportedly seen a helicopter hovering.“Here, the schoolchildren have seen the chopper going towards a high mountain — Tsongsong — in Bhutan,” sources told The Telegraph. The red chopper apparently hovered for a while, attempting to land in the hills underneath and on failing, crossed the Tsongsong peak.

Shouldn’t  the reference made by the mystery caller about CM’s copter landing in Bhuttan be read along with this ?
The color of Dorjee’s helicopter indeed was red.

Express India report on May 1:

Saturday, the head of chancery of Bhutanese Embassy in Delhi claimed to have spotted the missing helicopter. But, when the Cabinet Secretary, K.M.Chandrasekhar called up the Bhutanese govt to verify the claim, the latter denied any such information.

PTI report again:

In the evening, SSB IGP Sanjeev Singhal in a statement to a daily said, “In the initial information we had said the helicopter had landed somewhere along the Arunachal-Bhutan border and that everyone was safe…”

The Transponder
The helicopter had carried a location transponder that can communicate at 406 MHz frequency in the event of any emergency or it could also be manually operated. But there never was any signal from the copter which was less than one year old. Express India report on May 1:On Saturday, satellites engaged in search operations, made two passes on Tawang but did not pick up transponder signals. The satellites could not locate anything this morning too. On Sunday morning also, two Sukhoi fighter planes passed through Tawang to pick up infra red signals, but without any success.

Villagers beating Technology

Hindustan Times Report (May 04):

On Wednesday, Luguthang village panchayat leader Thupten Tsering and some 40 others beat Isro’s satellite imagery and IAF Sukhoi-30s infra-red aerial mapping to locate the wreckage at 16,000ft. Luguthang wasn’t one of the eight spots, six in India and two in Bhutan, that Isro and IAF zeroed in on as possible sites.

ISRO and Sukhoi’s were looking for metal debris in the ground. Then why they could not locate the copter parts in a village as near as at Luguthang?
An IANS report:

“The wreckage of the helicopter was strewn all over the area with signs of a black coating over the metallic pieces due to the fire that engulfed the chopper soon after it crashed,” a person who identified himself as Pema and is a local yak herder who saw the crash site said.

(Jacob K Philip is Editor of Aviation India)