AIR MARSHAL ASHOK GOEL (Retd.)
PVSM AVSM VM, Silver Estate,Pilibhit Bypass Road,
P.O. Rohilkhand University,
IX-812 22nd May 2010 and the disaster
The astrologer fraternity has already declared that this major disaster was due to numerological combination of the many twos. We may discount this theory in totality and come to the real professional assessment.
Media reports clearly indicate that the preliminary factors of aviation i.e. is weather, aircraft status, ground based NAV & landing aids and all other support elements like ATC, runway, were all in a high state of serviceability and readiness.
Other factors which are for critical assessment:
1. Aircrew Status
Whether they were medically fit and breath analyzer test had been done before each of the flight. Presumably the same crew has departed from Manglore at 8:00 Pm (IST). In that case they could be counted on duty from 5:00 PM onwards. Their arrival was between 6 and 6:30AM in the morning hours. It is a matter of judgment the crew flying the whole night would have crossed FDTL than laid down. It may be appreciated the flight between 4 o’ Clock morning till 6 in the morning is the most critical time of rest. It is during this hour that an individual feels most sleepy, sloppy, and sluggish. Many accidents have been caused during such early hours. Though FDTL (flight duty time limitations) are laid down but they seem to be not taken in to consideration all night operation.
2. Airfield Status
Manglore is just about 4 years old airfield with very little undershoot and stop ways, and is termed as tabletop airfield. There are many airfields in India (Lengpui, Dumduma, Portblair, Thoise, Leh Kargil, Carnicobar) which pose a greater challenge to the pilots for safe operations. These airfields are not unsafe, but operating agencies are to define categorically the types of aircraft to operate experience level of aircrew, and training patterns to qualify to operate at such airfields (for captains and Co-pilots both). These airfields are not unsafe but margin of error is negligible. A constant reminder and preflight briefing is the hallmark, and that is the responsibility of the operating agency.
3. DGCA Circular AIC Sl. No. 9 of 2007 dated 6 December 2007
This circular is professionally unsound, germinates complacency and finally accident prone. Though circular runs in 16 paragraph I quote the opening paragraph and para 12
“The pilot in Command who is solely vested with the responsibility of the safety of aircraft and passengers therein, may, authorize a Co-pilot of his flight to effect landing and take-off and route flying, under his direct supervision in accordance with the following conditions.
The Pilot-in Command shall ensure that during approach to land for a supervised landing, the aircraft is established on the correct approach profile by 1000 feet above the aerodrome elevation. He shall also ensure that the aircraft is stabilized during approach at the correct approach speed and aligned with the runway centerline and maintain a rate of descant within the specified limits for the type of aircraft and approach being made”.
Though the DGCA seems to have taken all precautions to ensure the safety in their wisdom, but it does not take care of the CRM, “transcockpit, gradient” and the attitude and behavioural patterns of different pilots.
If Co-pilots are expected to be trained to land the aircraft from right-hand seat, this training should be on simulater and in pure training sorties. We can’t play around risking the lives of passengers by training copilots for landing from RHS, whatever the reason may be. (Landing an aircraft from RHS poses greater challenge. Authorized to QFI’S or specially trained RHS qualified pilots in the IAF.)
If we take into consideration all the factors it is apparent the aircraft has made highly overshooting approach and touched down passed midway point of the runway, and the pilots’ assessment to decide the go round after touch down has played the havoc.
A Boeing 737 class of aircraft requires 4000-4500 feet of landing run (i.e. from touch down to complete stop) if flown at the correct approach speed. This air craft has air brakes, engine reverse, automatic breaking system (where the degree of breaking 40% to 80% can be adjusted) in addition the emergency brakes.
The above factor have been analyzed as preliminary causes of the accident, the analyses of CVR and FDR can reconstruct the flight if total transparency is observed.
We need to review the:
(a) Operating Agencies Training System
(b) Continuation and Refresher Training program
(c) and DGCA Circular
Transport aircraft accidents whether military aviation or commercial sector, 90% are due to human error (could call as pilot error accident). This is based on the statistical study on transport air craft accidents of the IAF and the study by Boeing Corporation (for commercial aviation) over a period of 30 years all over the world. Both reflect the same.
Air Marshal Ashok Goel (Retd.) served the Indian Air Force for 40 years. He has more than 10,000 hours of flying on 13 types of aircrafts. He has operated at airfields, like Dumduma, (6000 feet length, Thoise (when airfield was less than 6000 feet) and many so called difficult air fields. The aircraft operated were Boeing 707, IL76 and Gulf Stream. His last appointment in IAF was Director General Flight Safety and Inspection, IAF.