Air India Express accident at Calicut was facilitated by the regulator, how?

 

Air India Airbus Landing at Port Blair (Source Dr Puneet)

Blaming the pilots alone for an accident is like addressing the symptom rather than the root cause. The root cause of the Calicut accident of IX1344 on 7th Aug 2020 is the poor safety culture prevalent in India and the ineffective regulatory oversight.

This landing(YouTube video) can be categorized as a deliberate attempt to endanger the lives of passengers and crew. This is not the Calicut landing but a landing at another critical airport where most of the year the airport experiences tailwinds. Since the airport has a unidirectional runway ( landing from one direction only), the flight crew has no option but to land in tailwinds. The situation worsens during the monsoons when there is a tailwind and the runway is wet and braking action reduces.

Action has not been taken either by the regulator or by the airline safety. Why?

What is the role of the regulator?

The Directorate General of Civil Aviation (DGCA) is the regulatory body in the field of Civil Aviation, primarily dealing with safety issues. It is responsible for the regulation of air transport services to/from/within India and for enforcement of civil air regulations, air safety, and airworthiness standards.
The question then arises about effective regulatory oversight. Does the DGCA have adequate, trained, qualified, and honest staff who can discharge their duties to the best of their abilities? 

The IX1344 Air India Express (AIX) accident report highlights a few issues but it is unable to conclude the report due to the amateur level of the investigation team. The video posted by Dr. Puneet is an eye-opener and his effort must be appreciated by all for being a professional who knows the importance of safety and the risks associated with professions like aviation. 

How did the regulator facilitate the Air India Express accident?

a. Flight Crew Training requirements
  1. The Captain of the ill-fated AIX B-737 aircraft had a chequered career. As per the IX1344 accident final report, the Captain joined AIX after having served in the Indian AirForce & was trained on the B-737 in 2010. He was endorsed as a co-pilot. In about a year's time, he moved to Air India as a Co-Pilot on the B-777. This is a good career progression for a new joiner at AIX. 
  2. In a year's time as co-pilot on B-777, he was taken up for command on the B-777. This is a phenomenal jump for a co-pilot. However, the winning streak was cut short during training when issues with landing came to the fore and the training was stopped in 2013 in spite of corrective training.
  3. He then joined AIX back as a trainee Captain. Since he was earlier trained on the B-737 but which had lapsed after he moved to Air India on the B-777, the Flight Standards Department(FSD), DGCA issued permission for his retraining as per regulations that truncate the total re-entry training time. 
  4. Since AIX and Air India operate under separate AOP, they have separate training manuals. Therefore the pilot would need to follow the DGCA regulation (CAR) & undergo complete training as per provisions of the Operator Conversion Course/approved training syllabus as per Operations Manual Part D. 
  5. The FSD, therefore, permitted him to jump back & forth without following the CAR requirements.
b. Surveillance flights on critical airfields

The FSD, flight inspectors are required to carry out surveillance flights operating to/from critical airfields like Calicut, Port Blair, etc. As per the accident report, FSD, DGCA did not carry out any surveillance flight during the period Jan 2019 - June 2020. 
Calicut airport has Instrument Landing System (ILS) installed on both runways 28 & 10. The signal quality of the ILS runway 28 has been in question. The Etihad Airways incident at Calicut in 2019 had highlighted the signal disturbance on the final approach.
Surveillance flights would have raised the safety flags much earlier.

c. Monitoring prolonged flare & long landings

The accident report has highlighted the discrepancy in the data on prolonged flare between those sourced from DGCA and AIX. Long landings were not monitored by AIX. The long landing was one of the causes of the Mangalore AIX accident. In fact, AIX does not comply with the DGCA requirement of 100% flight data monitoring & the DGCA seems to be OK with it.
DGCA failed to detect an unsafe trend that could have prevented the accident.

Port Blair airport experiences tailwinds most of the year with the wind speeds at times increasing beyond the permissible safe limits. Is the regulator monitoring this? Does the regulator have effective oversight of the airline safety setup?


Runway 04, Port Blair Airport wind data



d. Calicut airport infrastructure

Calicut airport has a tabletop runway which increases the risk factor for aircraft landing & taking off. Therefore it is imperative that there are adequate buffers where safety matters are concerned. 
DGCA has not ensured that Calicut airport meets the following requirements:
  1. Undershoot Runway End Safety Area (RESA). The official publication of the Airport Authority of India, the Aeronautical Information Publication depicts a RESA on both sides of the runway with dimensions of 240 X 90 m. This is not a correct depiction.
  2. The accident report has shown an undershoot RESA of minimum 90 X 90 m, which is an afterthought and is not notified or published in the AIP. The source of the drawing is not mentioned and the dimensions of the RESA are incorrect.
  3. DGCA has permitted AAI to operate the airport without the approach light system required for CAT I ILS. The final report defends the non-availability of the approach lights by citing the reason as "non-availability of land". The fact is thatat ICAO has a provision wherein, if there is a slope preceding the runway, approach lights can be installed on the slope. This option has not been exercised by AAI nor has it been enforced by the DGCA.
  4. The DGCA has not enforced the requirement for the installation of runway centerline lights at Calicut. The accident report has defended the non-installation by selectively citing a convenient clause in the DGCA regulation which requires the installation of centerline lights if the width of the runway lights is more than 50m. The Width at Calicut is 48.5m.
  5. DGCA requirement states in para 5.3.12.2 Runway centreline lights shall be provided on a precision approach runway category I, particularly when the runway is used by aircraft with high landing speeds or where the width between the runway edge lights is greater than 50 m.” The underlined requirement mandates that centerline lights are installed. The Etihad Airways accident investigation report also recommended that centerline lights must be installed at an airport like Calicut.
  6. Perimeter road at Calicut is narrow enough to allow only one fire tender to pass. A previous DGCA audit raised a finding that the perimeter road must be two-laned. The AAI complied with the finding & the same was closed by DGCA. The width of the perimeter road remained the same but instead, a white divider was painted on the road. What a mockery of the system.
  7. After the accident, the same perimeter road was unable to handle vehicles moving in both directions.
e. Safety Management System

India does not comply with the ICAO timelines for the implementation of the Safety Management System. The operators like AIX have contributed to the same. The accident report has pointed out this deficiency.
The pilot's training record has repeatedly highlighted an area of concern. Landing flare height (low or prolonged float) & decision making. An in-depth analysis was not carried out either by AIX/AI or by the regulator. The accident report mentions that the pilot had Type II Diabetes. An acute condition can affect the depth perception of the individual.
An effective SMS would have highlighted these two areas of concern and connected them. Since training and medical work in silo, each could not determine the cause or the effect. The DGCA did not have effective oversight of the airline SMS.

Conclusion


There is plenty to say but everything boils down to the intent of the policymakers at the top echelon. Safety and training are placed below Commercial and Operations when it comes to prioritizing. It is only after an accident that some eyebrows are raised but that too doesn't last long.

Therefore the probable cause of the IX1344 accident at Calicut should be due to the lax attitude of the regulator in maintaining flight standards & ineffective oversight.

The blog has been written based on the data provided in the Final report of the IX1344 accident published by the AAIB, India.

Safety Matters Foundation is an Indian NGO working towards establishing a generative safety culture.

https://safetymatters.co.in 












Comments

  1. Brilliantly put. I wonder if you as one person can conclude and gain insight from open source data, why is it that DGCA and other aviation organisations in India mandated to perform these essential duties with all the wherewithal cannot.

    I must relate an incident to you which happened to me when we meet next Amit.

    ReplyDelete
  2. Sadly, the easiest blame-game is where the pilot is blamed!
    DG's remarks within days after this mishap were a revelation of this stark reality! Their attitude within the Org too reeks of this reality!

    ReplyDelete
  3. Great read. Sad to see the regulators not doing their job.
    I personally believe it would be best to set up an independent organisation like the NTSB in India. Currently accident reports aren't independent investigations but are doctored reports.
    This phrase rings true in many such reports. "If the pilot is alive, hang him. If he is dead, bury him."

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