Category: Uncategorized

By Jacob K Philip

A chain of unusual and erroneous actions taken by the pilots caused the crash of a helicopter last year in India that was carrying M. A. Yousuf Ali, the chairman of UAE-headquartered multinational company Lulu Group, says the report of an investigation ordered by the DGCA, India’s aviation regulator.

Unlike the media widely reported that time, the three year old Agusta Westland AW109SP helicopter was not making an emergency landing but was actually falling into a swamp at Panangadu, near Kochi, in the south Indian state of Kerala, as per the investigation report.

The incident occurred on April 11, 2021 a few minutes before 9am at Panangadu. The copter, that had taken-off from a helipad at ‘Y Mansion”, the residence of Yousuf Ali, was heading to land on the roof-top helipad of ‘Lakeshore’, a private hospital. The aerial distance to the hospital from Yousuf Ali’s residence was just 3.7km and the total flying time was estimated to be 5 minutes. While the copter was in the approach stage to land on the Lakeshore helipad, it fell into the open swamp from a height of about 300ft. Upon falling, the helicopter partially sunk into the soft mud, with dirt water entering the cockpit by up to 2 feet. Engines were shut down and all the occupants vacated the helicopter by standard exit and were transported to nearby hospital. There was no injury to any of the occupants on board, and there was no post incident smoke or fire.

Though the pilots later said they had made a forced landing due to loss of engine power after experiencing a sudden drop in altitude, the DGCA report says there were nothing wrong with any of the systems of the helicopter including the engine. Also, the pilots had made no landing – forced or otherwise.

It was a series of actions by the pilots right from the taking off of the machine, that culminated in the crash that April morning, concludes the report.

To start with, when the helicopter took of from the ‘Y Mansion’,  at Chilavannoor, Kochi, the pilots activated ‘Engine torque limiter function’ of the copter. This function limits the torque (power) produced by the engine to 220 % instead of its maximum capability of 324%. Why this limit was set is not clear.

Secondly, when it was time for the copter to take a left turn to align with the roof-top helipad of the Lakeshore hospital, the pilot increased the pitch of the craft (raised the nose) to an unusual high value of about 15 degrees. Though with the nose up, the engines needed more power to maintain the speed, that was never given. As a result the speed was reduced to 40 kts from 80kts and the copter began to descend rapidly. Three seconds after the pitch was increased to 15, it again was raised to 21 degrees, again unusually, by the pilot. As a result the the fall became quicker at 2000ft/minute and the horizontal speed became almost zero. On realizing the craft was falling, the pilots tried to increase the engine power, so as to climb up. But because of the ‘Engine torque limiter function’ they had earlier switched on, the fuel supply to the engine got reduced after the power reached the 220%. Less fuel means less power and the pilots could not climb up from the 300ft altitude there found themselves in and the helicopter fell to the ground within seconds.

The report explains that, because of the actions of setting a limit to the engine power and then increasing the pitch attitude, the helicopter also had entered into a non-recoverable stage called ‘Vortex Ring State (VRS).’ With VRS setting in, the lift produced by the rotor is massively reduced and the rate of descent of the helicopter is increased accordingly. By pulling on the collective, the effect is amplified. The VRS can be ended only by switching to autorotation or by taking up horizontal speed. But at Panangad that morning, the speed was actually getting reduced to half of the normal speed, seconds before the crash.

The DGCA report concludes that the erroneous actions taken by the pilots resulted in the crash was also because of the loss of situational awareness and not sticking to the standard operational procedures.

While examining the cockpit voice recorder, the investigators found that the voices in the cockpit were overlapped by the conversations among the passengers in the cabin. It was because the cockpit was not isolated from the cabin, even during the critical stages of the flight. The reason why the pilots lost the situational awareness can be these distractions from the cabin. Though the well experienced pilots were familiar with the short route, they failed to realise for some seconds that the copter was flying too low. Also, the first Officer (who was acting as the ‘pilot monitoring’) failed to monitor flight parameters during the critical phase of flight. It was only when the copter reached the altitude as low as 300ft, that pilot in command realised the gravity of the situation. Though he immediately increased the power to go up, because their own previous action of switching the ‘Engine torque limiter function’ on, the power refused to go up after it reached 220% and the fuel supply to the engine too got reduced. The rotor speed was dropped because of this and even the the automated warning ‘ROTOR LOW’ was sounded. By then the copter had got entangled in the irrecoverable Vortex Ring State and there was nothing that could have done but to braze for the crash.
And the helicopter at that moment happened to be above a marshy land was just providential. Otherwise the crash would have been real disastrous.
The investigators also have pointed out that the pilots in this flight (and in their previous flights too) were carrying out cockpit checks communicating with ‘gestures’. Because the procedure of ‘challenge and response’ was not carried out as per the SOP, the chances are high that crucial parameters of the flight was overlooked.

Dr. Binoy Kampmark

If there comes a point when people will decide not to fly, the issue may well be less to do with any moral or ethical issue with climate change than the fact that commercial flights have become atrocious. They are naked money-making concerns with diminishing returns on quality. The key factor that plays out here is what economists like to term inelastic demand. Prices can be raised; service quality can be reduced, but customers will keep coming. The demand remains, even if the supply leaves much to be desired.

The phenomenon is distinct over the long-haul carriers, which have, at least until recently, been spared the stripping phenomenon. Singapore Airlines, which prides itself for an almost aristocratic bearing towards its customers, proved skimp its Melbourne to Singapore leg. An insulting sampling of “toasties” was offered as a starter, a culinary outrage that did not go unnoticed. Indian passengers who had selected special meals in advance were on the money; pungent curries and dhal filled the cabin as this ridiculous excuse of a meal was handed out to customers. A few desperate, and disgusted punters asked the flight attendants if there were spare vegetarian options.

Budget airlines may have something to explain in this regard. The revolution of the cheap fare came with the reduction of expectations. No frills travel came with a certain contempt on the part of the service providers: food and drink would no longer be gratis; seat allocations would have to be purchased in advance and check-in or carry-on luggage would have to be paid for. A turning point was Dublin-based Ryanair’s attempt to go easy on toilet numbers – one per aircraft – and charge customers for their use. As the company’s penny-pinching CEO Michael O’Leary said at the time, “We rarely use all three toilets on board our aircraft anyway.” Bladders be damned.

Instead of aspiring to a higher level of service, the traditionalists have voted to go down a notch or three. What budget airlines do badly, we can do worse. The law of diminishing returns is pushing all air travel carriers downwards in what has been seen to be an exercise of “calculated misery”. The experience is appalling and unpleasant, but need not necessarily be intolerable. The result is a curious revision of the term “upgrade”. As Alex Abad-Santos laments in Vox, passengers upgrade their seats, not to get a more spectacular service or experience, but “to avoid hell.”

Managing such misery is hardly original, though Tim Wu of Columbia Law School can be credited for giving a good overview of it when writing in 2014 for The New Yorker. “Here’s the thing: in order for fees to work, there needs to be something worth paying to avoid. That necessitates, at some level, a strategy that can be described as ‘calculated misery’. Basic service, without fees, must be sufficiently degraded in order to make people want to pay to escape it. And that’s where the suffering begins.”

Nothing says such suffering than crammed economy seats on a long-haul flight. Shoulders and arms are jammed; legs can barely move. The trend was such that Bill McGee, a writer with more than a passing acquaintance with the airline industry, would note, referring to the United States, that the most spacious economy seats “you can book on the nation’s four largest airlines are narrower than the tightest economy seats offered in the 1990s.”

Things are not much better in terms of the European market. Mediocrity mixes with indifference, even on flights which are half-full. A flight from London Heathrow to Copenhagen with Scandinavian Airlines was characterised by a certain snooty indifference on the part of the flight attendants. Much babbling was taking place in Finnish – why would you want to assist passengers? Little by way of interest in the customers was afforded. Curt instructions were issued; requests for coffee were received with glacial stares. Naturally, to receive a meal and drink that wasn’t water that had seen better days required forking out of the plastic fantastic. Gone are the days when international airlines behaved as such, wishing to make matters decent, comfortable and even pleasantly bearable; the European air space finds itself populated by the stingy and the tight-belted.

Commercial airlines from SAS to Singapore Airlines have taken whole sheafs of extortion from the budget airline book of making customers pay for selecting seats. The stress here is budget service at caviar prices. This cheeky form of thieving imposes a cost on the act of jumping the queue for a better place on the flight. And this is not all. You book a ticket with a flight, only to find at the airport that you had purchased a “light” version, meaning that you have to pay for carryon luggage.

High time for a customer revolt, but the industry is distinctly programmed. Even when airlines have been well disposed to their customers, such as JetBlue, the corporate monsters of Wall Street have howled. It’s bad form to provide decent service within reasonable expectations. Efficiency, and filling the seats, is what matters, whatever the quality. Fee-free services, being conscious of the brand and a “customer-focussed” approach was simply not on. Eventually, JetBlue caved in and joined the market of calculated misery.

 Dr. Binoy Kampmark was a Commonwealth Scholar at Selwyn College, Cambridge. He lectures at RMIT University, Melbourne. Email: bkampmark@gmail.com

By OV Maxis
Deputy General Manager (ATC)
Airports Authority of India
Going  through the reports of the February 7th Air India-Vistara air-prox incident, it can be seen that that the Area Controller at Mumbai had descended UK997, Delhi-Pune Vistara flight to 29000ft and had given permission to AI631 Delhi-Mumbai Air India flight  to climb only up to 27000ft to keep them vertically separated enough. What made the Vistara pilot to descent below the cleared level is still not evident. As the matter is under investigation it will be inappropriate to draw inferences. However, a listening error on the part of the pilot/ controller cannot be ruled out. The ATC tape replay can reveal the truth.

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It has become a common practice for the journalists to put the blame on ATC blatantly in any incidents where ATC personnel are involved without going fully through the details and circumstances.

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The attempt to glorify the lady commander of Air India is liable to be viewed as reciprocation from the journalist for leaking out the confidential information. Poor awareness of civil aviation of the journalist who covered the story is also evident from the report. It has become a common practice for the journalists to put the blame on ATC blatantly in any incidents where ATC personnel are involved without going fully through the details and circumstances. In this case also the ATC was projected as the villain and the lady commander as a heroine

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Read also:
An incident story that turned into an accident
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Even if the lady co-pilot of the Vistara airline committed some mistake, she deserves equal appreciations as received by the Air India lady commander (from the media). Why because, she was very alert and responded to the resolution advisory of the Traffic Collision Averting System(TCAS) in no time as evidenced from ADS-B pictures.

TCAS is the last resort to the pilot to avert a mid air collision in the event of ATC/pilot error. The pilots get visual indication of the conflicting traffic as early as 60 seconds (20NM) laterally and at about 6000 ft vertically in blue color on the cockpit display. When the intruder traffic is within 40 seconds and vertically below 850ft, display changes to yellow and pilot get a warning (Traffic alert). when collision is imminent. 25 seconds before (vertically 650ft), pilot receive RA along with audio instruction to climb or descend. The pilot is expected to act within 5 seconds and follow the RA instruction. Following RA collision can very well be avoided.

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Now who is the real heroine?
The co-pilot of Vistara who handled the situation alone or the much more experienced lady commander of Air India who had the assistance of a co-pilot in the cockpit?

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In this particular case both the lady pilots meticulously followed the RA instructions generated by the TCAS. In fact, the Vistara pilot executed a rapid descend and played an equal or a better role in avoiding the collision. In spite of receiving an instantaneous RT communication from the controller blaming her actions at that critical moment, she kept the presence of mind and immediately executed the steep descend warranted by RA. Considering the fact that at the time of the incident she was the only pilot available in the cock pit as the commander was away in the toilet she really deserves an appreciation for the most crucial emergency action and thereby avoiding a possible collision.

Now who is the real heroine, whether it is the co-pilot who handled the situation alone or the more experienced lady commander of Air India who had the assistance of a co-pilot in the cockpit?

If tomorrow, the investigations absolve the Vistara lady pilot of any violation of ATC clearance, she will emerge as a real heroine. Let us watch. These are only a public perception under the influence of a biased media. The real fact is that both have discharged the call of their normal duties and responsibilities in such an emergency situation. They are trained and rated for these kind of emergency responses.

And something more about the ATCOs who often portrayed in bad light in media reports like this:

There is a system in place in every ATC units to record the control instructions and radar situation display to facilitate future the investigation if required. The purpose of the investigation itself is to identify the deficiencies in the system and to prevent its reoccurrence. ATCOs undergo stringent and regular skill/ proficiency/performance tests to keep the currency of their ATC ratings. No inferior controllers are rated and deployed on channels.

And one should also not forget the fact that an ATCO may have to control 20 to 30 aircraft at a time in a very congested airspace like Mumbai He has to resolve multiple conflicts of air traffic on different routes/ locations at a time. He is working under severe stress as there is no scope for any error in the decisions he takes in split seconds.

Mistakes can happen at times as he is also a human being but as said above, he is very much accountable for his mistakes.

(OV Maxis is an air traffic, aviation safety expert with more than 30 years of experience. He can be reached at ovmarxis@yahoo.com)

By Jacob K Philip

An aviation hazard, known as “Sea of Blue Effect” combined with the fatigue of the cockpit crew could be the reason of the taxiway excursion by an Air India Express flight during the wee hours of 5th September at Kochi international airport.

An analysis of the incident done with the help of aviation experts having many years of experience with Airports Authority of India and Air India excludes all possibilities, but this phenomena, which though specifically mentioned in the Aerodrome Design Manual (Part IV) released by International Civil Aviation Organization (ICAO), is rarely documented and reported in India so far.

The incident

On September 5, the Air India Express Abu Dhabi-Kochi flight 452 landed at Kochi International Airport at 2.20AM on runway 27. After landing, the aircraft exited the runway through link C2 and then turned right to go to the apron of the new terminal T3. To reach the designated apron, the aircraft was instructed to exit the taxiway using the link-taxiway F in the left, after B and E. Everything went well till the aircraft reached near the exit E.  As per the reports of the incident, the aircraft  took the left turn 90m before the actual exit F. So, instead of entering the apron, the aircraft crossed into the space between link taxiways E and F and its rear wheels got caught in the 1m wide open drain that runs parallel to the taxiway. While the wheels descended into the drain, the bottom side of the two engines of the Boeing737-800 aircraft hit the paved surface beneath. The nose-wheel assembly too damaged as the most of the weight of the aircraft got suddenly transferred  to it.

The Sea of Blue

To see how an experienced pilot could cross into an open space mistaking it for the link-taxiway, we may visualize what the pilots of the aircraft were seeing from the cockpit of the aircraft during its movement  towards exit F.

When the aircraft moved forward at a speed of 18knots, the pilots must’ve been seeing  clearly  the taxiway stretching ahead. The thick yellow line marking the centre-line of the taxiway too must’ve been visible, thanks to the edge lighting.  A little farther ahead on the left, there were four links-taxiways perpendicular to the taxiway that connect the taxiway with aprons.  These links -denoted by Roman alphabets  B, E, F and G- too had blue edge lights.

When the aircraft initiating the 90 degree turn to enter the link-taxiway, the glow of the blue lights fitted along the edges of the four parallel exit paths can together appear as a huge, rectangular illuminated surface. This optical illusion is the Sea of Blue Effect.  It occurs because blue light that travels as shorter, smaller waves gets scattered more than other colors.  The light thus scattered from the edges of the five link-taxiways spaced just 125m apart can easily overlap, hiding the open land between them. So the chances are abundant for the pilot either to totally miss the actual exit that got submerged in the ‘blue sea’ or to confuse between the exit (link-taxiway) and the area  between the link-taxiways.
And it seems Flight IX452 did commit the second mistake- it turned 90 degrees to the left through the open area between E & F links-taxiways, instead of entering the link F.

But why only this pilot?

Many cockpit crew before him too would have got confused, no doubt. Only that they all could overcome the illusion just in time.  And the reason why this pilot succumbed to the playing-of-tricks by blue lights could be the very timing of the flight. IX452 that landed at 2.20 am at Kochi airport was the same aircraft that flown from Kochi to Abu Dubai as IX419 the previous evening. IX419 that took off from Kochi at 5.20pm had landed at Abu Dhabi by 7.50 pm. Within one hour, the aircraft departed to Kochi as IX452, operated by the same crew.  That means the pilot who mistook the open land as a link taxiway was continuously flying the aircraft from 5.20pm to 2.20 am, but for a one hour gap from 7.50 to 8.50pm.

And it may also be noticed that the taxiway excursion was happened 20 minutes after the beginning of the Window of Circadian Low. (WOCL, the interval of time from 2.00am to 6.00am, is a period during which people working through night can experience maximum fatigue). The end of the flight coinciding with the WOCL is more dangerous. Seeing that the duty time is almost ended, a fatigued person’s all urges will be to do away with it as soon as possible. It was only natural for the pilot to become more impatient seeing he is almost  there- a turn and then the apron and the end of the journey. And this fatigue-triggered impatience could have made him an easy prey of the  Sea of Blue illusion.

The other possibilities

1. Reduced visibility

It is understood that the visibility at the airport during the time was more than 800m. For an aircraft moving at 20kmph, this visibility is more than enough to see the turns & obstructions ahead.

2. Objects on the runway

Obstacles happen to be on the runway can cause the nose wheel lose control, while going over it. But nothing of this sort was reported.

3. Faulty nose wheel moving erratically, resulting in unintentional right turn.

This indeed is a chance, especially for this particular aircraft. On March 11th 2014, while operating as  IX-193, this VT-AYB aircraft had its nose-wheel damaged during taking off from Lucknow for Dubai. Seeing parts of nose wheel gear on the runway, the ATC called the aircraft back. But the damage was repaired soon after, and the aircraft was flying all these three years after the incident.

4. Hydroplaning & skidding

when there is lots of rain water on runway layers of water can accumulate between the wheels of the aircraft and the runway, leading to a loss of traction and  loss of control. But the rain was not that strong Tuesday night, for this to happen. Moreover, the plane’s speed was only around 20kmph.

(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)

By Jacob K Philip

It could be an attempt by the first-officer to land at Rostov-on-Don itself  despite the objection of the captain that led to the crash of Flydubai flight981 at the airport  on 19th morning, this month. The transcription of the last minute of the two-hour long cockpit voice recorder points to this possibility alone.
Though Rossiya-1, a Russian  television channel, that leaked the transcription, has suggested that the crash was caused by an inadvertent activation of the elevator while the aircraft was climbing, an analysis of the transcribed voices  indicates something far more grave and intriguing.

This was how the Channel had interpreted the CVR data:

“The transcript suggests that the pilot lost control of the plane immediately after switching off the autopilot.  The pilot accidentally switched on a stabilising fin at the tail as he tried to pull the plane back to a horizontal position. With this fin activated, the plane practically does not react to the pilot’s control panel. And thus the nose dive and crash.

And here is another paragraph from a news report based on this interpretation:

“On the second landing attempt, the crew decided to pull up and try again, but 40 seconds after beginning the ascent, one of the pilots switched off the autopilot, possibly in response to sudden turbulence, the report said. Seconds after the autopilot was turned off, the plane plunged to the ground”.

The problem with these analyses was that none of them had  looked closely at the dialogues between the pilots. Instead, they went on assuming a lot of things regarding the auto pilot and the movements of flight control surfaces, without the backing of the data from the Flight Data Recorder, which was still being analysed.  The accidental activation of the elevator or a runaway  elevator were mere assumptions without the backing of any proof.

These were the sequence of events  that unfolded at  Rostov-on-Don that fateful morning:

Captain Aristos Sokratous (38) and first officer Alejandro Cruz Alava (37)  were not being able to land the Boeing-737-800 in harsh weather conditions.  They had tried to land once but had to abort it because of  poor visibility. And then began the extraordinary hovering  that lasted well beyond two hours  over Rostov-on-Don. Even as at least two other flights had opted for alternate airports (within 250 km), to the amazement of the ATC, Flight 981 opted to stay put.   After  2 hours, they decided to give it another try. But had to abort the landing again and they initiated a go-around.   But within one minute, the aircraft fell almost like a stone and crashed, killing all aboard. The transcription of the CVR has the sounds in the cockpit during that last, tragic one-minute.

The timeline and the voices:

• Before 01:40:40GMT (The transcription aired by the channel does not specify the exact time):  ‘Going around’,  -‘Climbing to 50’, -‘Climbing to 50’
• 01:40:40GMT: “Do not worry, do not worry, do not worry!”
• 01:40:45GMT: “Don’t do this, don’t do this, don’t do this!”
• 01:40:50GMT : ‘Pull! Pull! Pull!
• 01:40:54GMT ‘Aaaaaa’ (inhuman cries)

“Do not worry, do not worry, do not worry!”

At 01:40:40 one of the pilots says, “Do not worry, do not worry, do not worry!” (Before this, they already had aborted the landing and initiated a go around and had started climbing to 5000 ft). (Most probably that was Captain Sokratous. Because the chances for a first officer to say this to his commander are so remote).

The obvious implications of the words “Do not worry”, repeated thrice are this:

1. One of the pilots was worried about something.
2. The cause of the worry was already known to the other one, who seems to console, reassure.
3. The re-assuring pilot was not sure if the other one would cease to worry- that was why the repetition.

What was the worry?

The answer could be there in the manoeuvre they just had initiated: Go around.

He must have been worried about doing a ‘go around’ again.  The next voice (heard 5 seconds after) proves this assumption was correct:

“Don’t do this, don’t do this, don’t do this!” 

What it he was doing, for the captain to yell like this?  The answer is here:  It was at this point that the plane started its fatal dive.

So the pilot, who was worried about yet another go-around, initiated the descent on his own, against the ‘loud and clear’ instruction of the Captain.

Pull Up, Pull Up

This call to pull the aircraft up comes five seconds after.  While the aircraft was falling at disastrous speed, the voice heard yelling Pull Up, Pull Up very well could have been uttered by the Commander of the plane. And it can also be the automated ground -proximity warning.  Whatever it was, one fact is clear:  The pulling up was never done.

Inhuman cries

The nerve-chilling cries heard four seconds later imply another important thing.

It was not an attempt to crash the aircraft deliberately (as in the German wings crash case). That is, if the cry was from both the pilots.

The aircraft hit the ground within seconds, exploded, killing all aboard.

More about the “Dont Worry”

It could be argued that the pilot was not worried about the “go around”, but about some blunder he could have  committed in manoeuvring the plane, like an inadvertent pulling of a lever, activation of a switch, just as suggested by Rossiya-1.  If so, the Captian would then have been looking for a solution, a correction. He could have been trying to correct the action and at the same time only telling his colleague that, “it was okay, I will correct it, don’t worry”

What the first officer could’ve been doing while his captain been busy correcting an error he had committed? By all probability, he would have been watching it all, with guilt written all over his face. And the last thing he would do at that juncture would be touching the console again.

But what happens 5 seconds later? The Captain yells this :

 “Don’t do this, don’t do this, don’t do this!”

The first pilot had  just done something that should never have been done!  Again?!

That is unbelievable.

There is only one explanation:  His initial worry was never about some blunder he had committed.

So why he acted against all the norms of subordination and CRM? What was the urgency?

Or again, what was his worry?

The answer will be in the CVR itself- that is, in the 119 minutes prior to the last one minute. Though it never was leaked to any media, that 119 minutes must be full of the words exchanged between the two pilots. While just hovering over an airport for two hours, looking for an oppotunity to land, no colleagues can remain silent. The answers will be there in the chat between the two while flying in numerous loops over  Rostov-on-Don.

The hovering for a couple of hours

The perplexing hovering for two hours when there were ample opportunities to fly to another and land there, may be explained, by the extra-ordinary attempt made by the pilot to land despite the shocked intervention of the captain.

It could have been because of the persuasion of the first officer that the captain decided to remain there.   He wanted to land at the airport that day. That exactly could be why  he appeared worried when the second attempt to land was aborted and the captain imitated a climb to 5000 ft.  He might’ve feared that they would be going to another airport soon.  And that explains his taking over the control.

But why?

Why he was worried about not being able to land at that airport on that fateful morning of March 19?

That obviously is the most crucial question.

(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)