The Hindu Business Line : Snags in air safety standards

The recent crash of a small four-seater aircraft in Bangalore, in which four young pilots were killed, is a reflection on the safety culture in Indian aviation.

A. Ranganathan

Accidents do not happen due to a single reason. Several events lead to a dangerous situation, and a system has to have several checks and balances to prevent an accident. The Swiss Cheese model of accident causation was originally propounded by British psychologist James T. Reason in 1990, and has since gained widespread acceptance and use in healthcare, in the aviation safety industry, and in emergency service organisations. It is sometimes called the cumulative act effec t.

James Reason hypothesises that most accidents can be traced to one or more of four levels of failure: Organisational influences, unsafe supervision, preconditions for unsafe acts, and the unsafe acts themselves. In the Swiss Cheese model, an organisation’s defences against failure are modelled as a series of barriers, represented as slices of Swiss cheese.

The holes in the cheese slices represent individual weaknesses in individual parts of the system, and are continually varying in size and position in all slices. The system as a whole produces failures when all of the holes in each of the slices momentarily align, permitting (in Reason’s words) “a trajectory of accident opportunity, so that a hazard passes through all of the holes in all of the defences, leading to a failure

Human error

Recently, a small four-seater aircraft crashed after take off in Bangalore. Four young pilots died. There was no Madhavrao Scindia or Balayogi on board, to create any interest or concern. The investigation has concluded that the accident was due to the wrong type of fuel that was filled into the tanks. One of the young pilots selected the wrong type and the fueller carried out this selected order. This tragedy is a clear indication of the absence of a proper safety culture and safety mentality of Indian aviation.

Indians are not used to Swiss cheese and they are more familiar with “Cheese singles” which have no holes. Hence, we feel that aviation in India is in very safe hands and we can claim to have been adjudged the best among 198 nations by none other than the ICAO (International Civil Aviation Organization) audit team! Fairy tales have the ending, “We all lived happily ever after.” Looks as though the attitude of the aviation authorities in India follows that dictum.

Let us look at this accident on the Swiss cheese model. We have four young pilots who have gone through a flying club, obtained their licence after being checked out by the DGCA (Directorate General of Civil Aviation). Their knowledge, fitness, competence and skill were well tested. Yet one of them did not recognise the difference between aviation turbine fuel, which is clear yellowish in colour, and AvGas that should have been put in, which is bluish.

This error cost four lives. What do we learn from this? Recently, to placate the operators and overcome the shortage of qualified engineers, the DGCA has permitted pilots to carry out refuelling and transit checks. Can we be sure that a similar error cannot take place?

Accountability

The refuelling was done by a qualified personnel belonging to a major oil company. The airport where the ill-fated aircraft was refuelled belongs to HAL, a major international and test flight airport. One would assume that the personnel manning the fuel trucks are highly qualified and would know the difference between the fuel required by a piston engine aircraft and a turbine-powered aircraft.

To make it foolproof, the nozzles of the fuel dispenser are different for AvGas and ATF (aviation turbine fuel). The AvGas nozzle has a flat end, and is painted red. Now we have two persons who did not recognise colours! The holes in the Swiss cheese start to line up. The aircraft engines had started because there was fuel in the pipeline. After take off, when the AvGas exhausted and there was only ATF in the fuel line, the engine dies due to fuel starvation.

Prior to this, the engine would have started to run rough and it is strange that the pilot, or the four pilots, did not recognise the engine sound. Another point on the quality of training imparted and the quality of the checks conducted before awarding the licence. The report further states that the pilots panicked and the aircraft crashed. I wonder how they came to this conclusion as the aircraft does not have a flight recorder. Now the Swiss cheese holes have all lined up!

This accident has thrown up the issue of the quality of manpower in Indian aviation. What one has to keep in mind is that the quality of pilots who join airlines will be of similar standard and knowledge levels, when they join as co-pilots or first officers. With the large-scale expansion of several airlines, flying schools and training centres churn out manpower in large numbers with little concern for quality or standards. Can we blame them? After all, the airlines only want to fill up the numbers. Who cares about quality or standards.

Accidents don’t happen all the time and when they do, memory is short. Accountability is almost non-existent in our aviation system. Indifference is the order of the day. Strangely, the letters “A” and “I” are synonymous with Indian aviation and also the now the merged entity, Air-India.

Why the indifference?

Let us look at why airlines are generally indifferent and not accountable. Last month, the DGCA issued new regulations governing flight and duty time of pilots. The Chief Operating Officer of Air-India had gone on record to state these will not be followed.

It has been pointed out that several FAA (Federal Aviation Administration) licence-holders beyond the age of 60 are flying in India. The FAA rules clearly prohibit them from flying airline flights, yet we in India allow them to. Australia does not allow pilots over the age of 60 to fly unless they are with another pilot who is also a captain. Yet, we in India let first officers or co-pilots fly with them. Never mind if their standards or knowledge may not meet airline standards. Holes in the Swiss cheese are slowly taking shape.

This illegal procedure has been pointed out to both the Civil Aviation Ministry and DGCA officials. Yet, they have not stopped pilots with invalid licences from flying.

Why this callous attitude? The answer is simple. Those with money and power are seldom at the receiving end when it comes to lawsuits in our country. And, aviation has plenty of money and power. The implications and ramifications of an accident are very serious but no one really cares. Maybe the following two cases may be a wake-up call.

A wake-up call?

On July 1, 2002, a charter aircraft carrying Russian children collided with a cargo plane over European airspace — 71 were killed. Recently, a Swiss court sentenced four of the air traffic controllers for manslaughter. The judge had also pointed out organisational deficiencies and held the managers responsible for “potentially dangerous working practices”.

On September 29, 2006, a GOL airlines Boeing 737 collided with a Embraer Legacy jet over Brazilian airspace. All 154 passengers and the crew on board the 737 died and the Legacy pilots landed in an Air force field with a broken wing. They survived but are facing manslaughter charges in the courts. The pilots are Americans but that has not helped them.

Several airlines in India are operating with foreign pilots with invalid licences and inexperienced co-pilots. A recent report has confirmed that several of the personnel manning the radars in air traffic control are not qualified. Recently, a Virgin Atlantic A340 with more than 300 passengers had an “air miss” with an Indian Air Force 737 carrying VIPs, in the Delhi region. The day is not far off before mid-air collisions occur in India. What will the repercussions be if it involves an international carrier and an Indian aircraft operated by a pilot who does not hold a valid licence? How long will the holes in the Swiss cheese stay away from lining up?

The dictionary defines “accident” as an unexpected event. When something is known and there is no effort to stop the consequence, the law has several options. In some countries they call it manslaughter, but we may qualify that under IPC 304, which falls under the ambit “culpable homicide not amounting to murder”.

When will safety concepts improve and when will our civil aviation system wake up?

(The author is an airline captain with 19,000 hours experience and specialises in accident-prevention studies.)

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