The Hindu Business Line : Flight incidents in India — Dangerous cover-up of system failures

In countries where safety takes priority over commercial considerations, aviation incidents are used as lessons to put in place better training and safety oversight procedures. Unfortunately, there is no such focus in our civil aviation system.

A. Ranganathan

One who asks a question is a fool for five minutes; one who does not ask a question remains a fool forever. — Chinese proverb

The aviation system in India suffers from a chronic disease.

Unfortunately, the system lacks ‘apoptosis’, which is required for cell death in multi-cellular organisms. Civil aviation in the country is run and controlled by a single cell — the Ministry of Civil Aviation. The heads of various ag encies seem to be selected less for their knowledge or experience and more for their pliable and compliant nature.

If the Ministry cannot find a suitable candidate from the department with these features, the posts are filled up with persons from the Administrative cadre who lack awareness of the subject.

Several recent events in the aviation sector show up the system in poor light. A good and safe system would address the root of the problem and find a permanent solution. In the US, independent agencies such as the National Transportation Safety Board, use their databanks on accidents / incident investigations, to identify the fundamental reason behind a problem and the ideal solution to prevent a recurrence.

In India, since the system lacks independence or professionalism, we resort to cover-ups.

Asleep at controls?

On June 4, 2008, an Air India (formerly Indian Airlines) flight on the Dubai-Delhi-Jaipur-Mumbai sector left Dubai around 1.30 am Dubai time. On the last leg, from Jaipur to Mumbai, both the cockpit crew were out of communication with the Air Traffic Control for more than 45 minutes.

When a media report, almost a fortnight later, described this situation as ‘the cockpit crew sleeping at the controls’, the airline officials went into denial mode. They denied that the crew overslept and stated clearly that there was a “communication failure for a few minutes” and that the aircraft overshot Mumbai just by a few kilometres, and not as mentioned in the media report.

The aircraft was flying at an altitude of 30,000 feet. The flight passes through the Ahmedabad air traffic control area and gets transferred to the Mumbai control while approaching Songadh. Ahmedabad ATC had tried to contact the aircraft several times before this point but without any response. Aircraft flying in the region had also tried, without success.

When Mumbai ATC tried to establish contact, either directly or through aircraft in the region, there was still no response. Finally, contact was established through a system called SelCal (selective calling).

Each aircraft is assigned a four-letter code, like a telephone number. When the ATC wants to establish contact with an aircraft, they uses this facility, without disturbing other aircraft.

Procedure not followed

The period the aircraft was out of radio contact was more than 45 minutes. International procedure requires that an aircraft which loses communication with air traffic control has to follow a pre-defined procedure:

Use the code 7600 on the transponder;

Fly to the destination Primary Navigation facility (in this case the Mumbai VOR);

Join the race-track holding pattern over the facility at the last assigned altitude;

Commence a descent overhead in the holding pattern as close to the Expected Approach time;

Fly the full instrument approach procedure and land.

The Air India aircraft did not change the transponder code to 7600. The crew did not try to establish radio contact on all the available frequencies or radios. If they were able to respond to the SelCal, it means their HF/RT (High Frequency Radio Transceiver) was functional. When they came overhead of the primary navigation facility at Mumbai, the ‘BBB’ VOR, they did not turn left to join the holding pattern, but crossed the facility and continued on for a good 45 nautical miles (around 80 km) and not ‘15 km’, as mentioned by the airline’s spokesperson.

The procedure for the holding pattern is a turn on a heading of 266 degrees, but the aircraft had continued over the sea on a heading of about 198 degrees, which is the heading maintained from Songadh to Mumbai.

Until the aircraft crosses the ‘BBB’ VOR, the last selected waypoint on the route from Jaipur to Mumbai, the auto-pilot would have maintained the aircraft on the “managed mode” — using the Lateral Navigation and Vertical Navigation (LNAV and VNAV) features of the flight management system.

After crossing the VOR, the autopilot would have tripped out of the managed mode to just the ‘Heading Select and Vertical Speed- HDG SEL & V/S”. The aircraft will continue to fly the last heading maintained at the time of reverting from the managed mode, and the last vertical speed, in this case ‘0’, as the aircraft was flying level.

The question here is: Either the crew overslept or they had communication failure. If they overslept, the question of fatigue comes into picture and there is a clear deficiency in the airline’s operating system. If it was a communication failure, the crew were unaware of the international communication failure procedure and it is questionable how they were allowed to operate flights when they were not competent.

Runway confusion

The second case is what is termed in aviation safety terminology as “runway confusion”. In June 2007, a private airline’s aircraft landed on the wrong runway at Delhi airport. Strangely, a year later and almost to the date, the same airline committed the same error, at the same airport. It is a clear case of lack of training standards that such an event can take place on a clear day in visual conditions.

Fortunately, in both the instances, the runway, which was closed, was not occupied by personnel or vehicles. Memory is short in India. The air safety world is aware of what happened to a Singapore Airlines 747 which took off on a closed runway at Taipei. Training and procedures were introduced by that airline to prevent a recurrence of such an event.

In countries where safety takes priority over commercial considerations, these events are addressed immediately and training and safety oversight procedures are introduced to prevent a disaster. Unfortunately, our civil aviation system believes more in cover-ups and how to improve the commercial aspects rather than safety aspects.

In 2007, Indian aviation saw more than nine over-runs in wet runway conditions. Runway maintenance procedures are not as per the standards laid down by the International Civil Aviation Organisation (ICAO). It has been pointed out repeatedly to the Airport Authority of India and the DGCA that the friction testing tyres used by the AAI are not accurate, and the runway friction readings given out by them are inflated and dangerous.

In a recent letter to the Chairman of the AAI, Ms Delia Harverson, a leading expert from the UK who conducted the workshop for the AAI in Chennai, pointed out that the AAI continues to follow incorrect procedures. This was backed by an e-mail from the head of the Annex 14 section of the ICAO. The callous attitude of the AAI is evident from the fact that no response has been forthcoming nor any corrective action initiated.

Safety first

Contrast this with what the NTSB did, in response to just a single overrun accident in the US — the Southwest Airlines overrun at Midway, Chicago. It came out with a set of recommendations (see Box) that will soon be implemented. The installation of engineered materials arresting system (EMAS ) has prevented serious damage to aircraft structure as well as injuries to passengers in overrun accidents at JFK airport in New York.

Similarly, airlines have incorporated procedures to evaluate the actual landing distance required when landing in rain and the runway conditions are poor. Knowing the safety culture of the aviation system in the US, these recommendations will be implemented very soon.

In spite of so many overrun accidents in wet conditions in India, we are not prepared to modify our procedures. Let us hope that these errors and lapses do not prove costly for human lives.

NTSB’s recommendations

In Safety Recommendations A-08:16-20 published on June 27, 2008, the National Transportation Safety Board (NTSB) says:

Airport design upgrades are to be made proactively, not only as part of other runway improvement projects;

Certificated airports are required to install engineered materials arresting system (EMAS) in each runway safety area available for air carrier use;

Operators must accomplish arrival landing distance assessments before every landing, based on a standardised methodology involving approved performance data on actual arrival conditions, a means of correlating the aeroplane’s braking ability with runway surface conditions using the most conservative interpretation available, and including a minimum safety margin of 15 per cent;

Operators are to include, in their initial, upgrade, transition, and recurrent simulator training for turbojet airplanes, (1) decision-making for rejected landings below 50 feet along with a rapid reduction in visual cues and (2) practice in executing this manoeuvre; and

Operators are to include, in their initial, upgrade, transition, and recurrent simulator training for turbojet airplanes, practice for pilots in accomplishing maximum performance landings on contaminated runways.

(The author is an airline captain with 35 years flying experience.)

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