Author: Aviation Safety India

New Delhi: As India’s air transport gradually picks up, the country’s aviation regulator has upped the ante on not just physical but even financial safety aspects of the sector’s stakeholders.

The DGCA has maintained a delicate balance between reintroducing some of the suspended safety norms owing to Covid-19 outbreak and giving some relaxation in terms of administrative paperwork requirements to the sectoral players and crew.

However, the sharpest vigil is being kept on the overall safety aspect of airlines and airports.

In terms of the safety aspect, DGCA Director General Arun Kumar cited that safety audits of all major metro airports have been completed.

“Safety audits of airports at Delhi, Mumbai and Chennai among others have been completed,” Kumar said.

“All airports will be audited in a phase-wise manner. Not just airports but airlines are also being audited,” he said.

“Recently, two major airlines (Air India and SpiceJet) have been audited on various safety aspects. Now, the rest of the airlines will be audited,” he said.

“Despite Covid, audits will continue and no compromise with safety will be allowed.”

Even financial audits are being conducted, revealed Kumar.

“This ensures that no compromise is made with safety issues due to strained financial condition of the airlines,” he said.

Besides, he disclosed that engine replacements on A320neos is nearing completion.

This process will make India one of the first countries in the world where this type of aircraft flies with both new engines, thereby mitigating machinery-related safety risks.

In addition, he disclosed that to ensure faster delivery of services, DGCA’s e-governance initiative – ‘eGCA’ – will be completed by the year-end.

It envisages to bring all the functions and services provided by the DGCA to an e-platform.

The project is being implemented in four phases and is expected to be completed by the end of 2020.

These developments assume significance as India’s civil aviation sector has shown signs of revival in passenger traffic growth as well as registered aircraft in the country.

In July, traffic grew sequentially to 21.07 lakh from 19.84 lakh which was reported for June 2020.

However, traffic remained deep in the red on a year-on-year basis during July as it plunged by more than 82 per cent to 21.07 lakh from 1.19 crore passengers who were ferried during the corresponding period of the previous year.

The three-member probe team have apparently conflicting views as one member has cited technical glitch as the reason for the air accident while another has blamed pilots for the lapse.

Members of a probe team constituted almost two years ago to investigate the air accident at Trichy International airport on October 12, 2018, are apparently at loggerheads in fixing the responsibility for the incident.

The Air India Express plane, carrying 136 passengers, had a narrow escape when it hit the boundary wall of the Trichy International airport while taking off to Dubai on October 11, 2018.

It landed safely at the Mumbai airport when the ATC intimated the two pilots who were unaware of the brushing off and continued flying for about two hours. The aviation regulator Directorate General of Civil Aviation (DGCA) immediately suspended the licence of the two pilots for three years without issuing any show-cause notice.

Sources have confirmed to Outlook that the three-member probe team, constituted soon after the incident, have apparently conflicting views as one member has cited technical glitch as the reason for the air accident while another member has blamed pilots for the lapse.

“It is due to this reason why the AAIB is keeping quiet on the report of an incident that took place almost two years ago. This is not only jeopardising the career of two pilots but it has thrown all air safety norms to the wind,” the source said.

Aurobindo Handa, Director General, (AAIB), didn’t respond to Outlook’s questions sent via email.

One of the pilots, Captain D Ganeshbabu, challenged his suspension in the Madras High Court on May 23, 2019, and pleaded innocence and the court asked the DGCA, AAIB and the Ministry of Civil Aviation to respond.

DGCA, in its repose, told the court that preliminary investigation suggested pilots’ fault and rest was being investigated by the AAIB.  The AAIB and the Ministry of Civil Aviation haven’t filed any reply yet. In the most recent hearing, held on July 1, they sought more time to file affidavits.  

Ganeshbabu told the court that the cause of the incident was a faulty recline seat which collapsed moments before the take-off when the aircraft was at 110 knots (203 km/h) speed. He said that he immediately adjusted his seat. He felt a slight shake on taking off which was not unusual. Neither cabin crew nor any passenger reported any abnormal vibration or noise.

Aviation experts say that it is a case of blatant violations of air safety norms both by AAIB and the aviation regulator Directorate General of Civil Aviation.

DGCA’s procedure manual regarding suspension says, “In order to meet the end of natural justice, a Notice of Suspension to the alleged offenders shall be required to be issued, whether or not it is legally binding and obligatory.”

“The charge is required to be mentioned in the Notice and appropriate time should be given to submit his explanation,” it adds.

Ganeshbabu in his petition has alleged that neither he nor his co-pilot, Anurag, were given any such opportunities and both were arbitrarily suspended.

“What will happen to the morale of a pilot if the regulator makes him a scapegoat? What could be a bigger threat of aviation safety than this?” SS Panesar, a veteran pilot and air-safety expert asked.

He added, “I filed several RTIs to find the status of investigation in Trichy case and every time I got a similar reply that the investigation is in progress. The DGCA has refused to share any documents.”

Even AAIB too has compromised with its own rules and international safety norms. Out of three-member probe team – Amit Gupta, Dinesh Kumar Yadav and Captain Gaurav Pathak – Gupta and Yadav belong to DGCA. This formation of a probe team with experts from DGCA violates international air accidents investigation norms and India’s commitment to the International Civil Aviation Organisation that AAIB is independent of DGCA.

“Can a DGCA officer find fault in DGCA’s functioning? The purpose of AAIB is to separate the regulatory functions from the investigation as regulator’s negligence is one of the major causes of air accidents and incidents,” Panesar said.

Before the formation of AAIB on July 30, 2012, the DGCA used to investigate all the air accidents. However, aviation experts protested to separate investigation from DGCA. A committee formed by the government in the 1990s, under the Chairmanship of Air Marshal JK Seth, stated that the DGCA couldn’t be a prosecutor, a jury and a judge in a case against its own.

Further, ICAO’s investigation norms say that the final report of the investigation should be released in the shortest possible time and, if possible, within twelve months of the date of the occurrence.

“If the report cannot be released within twelve months, the State conducting the investigation should release an interim report on each anniversary of the occurrence, detailing the progress of the investigation and any safety issues raised,” ICAO’s Annex 13, that outlines the process of aircraft accident and incident investigation, says.

“Since the probe started in October 2018, AAIB has not even once released any interim report in this case. It is not even apprising the court about the status of the investigation,” said a safety expert requesting anonymity as he is associated with AAIB.

The 46 experts of Aircraft Accident Investigation Bureau are required to carry out the investigation of aircraft accidents. However, the panel investigating the Kerala plane crash has only one member from the AAIB.

The Aircraft Accident Investigation Bureau has ignored its own panel of 46 experts in setting up a 5-member probe team to find out what led to crash of Air India Express aircraft at Kozhikode International Airport on August 7.

A Boeing 737 aircraft, carrying 191 passengers, skidded off a tabletop runway, fell into a gorge and split into two earliet this month. Twenty passengers, including the two pilots, lost their lives.

Five days later, on August 13, Group Captain Aurobindo Handa, Director General Aircraft Accident Investigation Bureau (AAIB), issued an order for setting up a five-member panel with an investigator-in-charge to probe the accident.  

The five member panel is headed by Captain SS Chahar, a former examiner of Boeing 737 NG with SpiceJet. His team members include Ved Prakash (Operations Experts), Mukul Bhardwaj (Senior Aircraft Maintenance Engineer of B737), Group Captain YS Dahiya (Aviation Medicine Expert) and Jasbir Singh Larhga (Deputy Director AAIB).

The AAIB has a regular workforce of seven safety personnel and an independent panel of 23 pilots and cockpit crew, 12 engineers, four aviation operation experts, two experts each for aviation psychology and aerodrome and one expert each as In-Flight Safety personnel and air safety investigator.

Empanelled in October 2018, these 46 experts, according to the AAIB’s circular of June 9, 2016, “are required to carry out the investigation of Aircraft Accidents and serious incidents as member of Committee of Inquiry (COI) whenever called upon to do so by the Aircraft Accident Investigation Bureau.”

Except one regular member Jasbir Singh Larhga, Deputy Director, AAIB, the rest four of the current probe team come from outside. A complaint against Larhga about allegedly tampering with the pieces of evidence of Ghatkoper Air crash has already been pending before the aviation ministry.  

In the fifth meeting of the Asia Pacific Accident Investigation Group, under the aegis of ICAO in August 2017, the Indian representative had said that the country has “established Aircraft Accident Investigation Bureau (AAIB) of India independent of the DGCA.”

The government informed the same Group in October 2012 in its second meeting that it formed an AAIB on July 30, 2012, and “training on the aircraft accident investigation techniques and management has been organized for the benefit of the officials of AAIB and industry under an MoU signed with BEA France.”

“In the past eight years, we haven’t been able to enrich AAIB with adequate and competent manpower. This is a mockery of aircraft accident investigation in India. It looks like the country doesn’t have a single competent investigator to investigate the Calicut crash,” a safety expert empanelled with AAIB said requesting anonymity.

He said the panel of the experts was just an “eye-wash”.

Before the formation of AAIB on July 30, 2012, the DGCA used to investigate all the air accidents. However, aviation experts protested to separate investigation from DGCA.

A committee formed by the government in the 1990s, under the Chairmanship of Air Marshal JK Seth, stated that the DGCA couldn’t be a prosecutor, a jury and a judge in a case against its own.

International air safety norm also, to which India is a signatory, mandates the separation of investigation and regulation.

Though several aviation experts describe Captain Chahar as “a man of integrity”, questions are being raised over his inclusion in the probe panel since he lacks the necessary experience for aircraft accident investigation.

Outlook had earlier reported that AAIB’s circular dated June 7, 2016, available on the website of the Union Aviation Ministry, states that an air safety investigator should have minimum 25 years of experience in an air safety investigation; should have been a member of the transport aircraft accident investigations, and should have undergone courses in aircraft accident investigations. However, Captain Chahar doesn’t have any of these qualifications.

Group Captain Handa has not responded to questions mailed to him.

I have always wondered how a normal situation turns abnormal in a split second. Is it a twist of fate or is the brain programmed to do so in order to help in cognition? How does the crew performing an approach to land continue to land on an unstable approach despite the SOP’s which have multiple checks and call outs from the second pilot? The general perception is that the brain is facilitating attention by blocking out certain sensory inputs but the flip side is that when the pilot is focusing on the vision to sight the runway, the brain can also be filtering out sensory inputs from the co-pilot to discontinue the approach and go-around for safety reasons. Similarly, if you are engaged in an intense conversation over the phone while driving, it doesn’t matter if the phone is held in the hand or you are using a hands-free, the brain is more engaged in the conversation than driving and unexpected objects might be missed.

Preventing distractions

Imagine yourself parking your car in a tight space with music playing or your fellow passenger talking to you. You would notice that the music or the chatter decreases as the level of attention on manoeuvring the car increases.Similarly, if you attempt to solve a mathematical problem which increases in difficulty while you are running, the pace decreases as the level of difficulty increases.

What is happening here? The brain is shutting down certain processes or inputs in order to divert the cognitive power or in our case the attention to the task in hand.

When it is dark and raining or the crew just might be fatigued and wants to get back home, the priority might just be to sight the runway lights and the pilot flying’s brain might filter or block the co-pilots inputs.

Discovering Thalamus

It was widely believed that the cortex which is the outmost layer of the brain on the front is responsible for housing the attention steering mechanism into the brain. Francis Crick who was the co-discoverer of the DNA structure suggested in 1984 that a simpler structure called Thalamus might also play a role in this process. Crick proposed that the Thalamus might filter the sensory inputs based on what we want to focus on.

Unconscious control

To test Crick’s theory, three Macaque monkeys were trained to pay attention on spots of light when focussed on their arm. The results showed a quick surge in the region of Thalamus that relays information to the Cortex & a split second later a drop in the thalamic reticular nucleus (TRN), a structure known to turn off sensory information during sleep.

The experiment concluded that the TRN acts as a gatekeeper and selectively allows images which deserve attention to pass through the Thalamus to the Cortex. If Thalamus was the gateway to the Cortex then TRN was the gatekeeper.

Hierarchy of attention

Michael Halassa, a neuroscientist at the MIT discovered how animals select what to focus on when their attention is divided amongst different senses. While working on an experiment with mice’s attention by using established techniques of shutting down various brain regions to see what interfered the performance, they discovered a new gating system.

The Pre Frontal Cortex (PFC) was issuing high level commands to other parts of the brain. It was also observed that if the trial required the mice to pay attention to vision, turning on neurons in the visual TRN interfered with their performance. When those neurons were silenced, the mice had more difficulty focussing to sound.

In effect, the network was controlling the inhibitory processes, not excitatory ones, with the TRN inhibiting information that the prefrontal cortex deemed distracting. If the mouse needed to prioritize auditory information, the prefrontal cortex told the visual TRN to increase its activity to suppress the visual thalamus — stripping away irrelevant visual data. The brain was working in a reverse process.

The research also concluded that the filtering mechanism not just filters one sense from another but filters within one sense too. When the mice were cued to pay attention to certain sounds the TRN helped filter the unwanted sounds from the background.

Ian Fiebelkorn, a cognitive neuroscientist commented ” what is interesting is that the filtering starts even before the he information reaches the visual cortex”. This is obviously a weakness of the brain that jettisons what might be important information.

Safety mechanism

Ian Fiebelkorn says that there is a safety mechanism in the brain which distracts the brain periodically. The attention span gets weaker about four times a second. This brief suppression period gives the opportunity to the brain to prevent staying overly focussed in one location.

mindFly analysis

It is considered a good trait to stay focussed on the task in hand. However, from a flight crew’s perspective, it is more important to stay in the present or being mindful of the body and the surrounding environment. The brain has certain filtering mechanisms as explained above. There are also certain defence mechanisms that distract the brain periodically. Therefore, a balance is required between focus and distraction. The control over the breathing process provides a median around which the two processes of focus and distraction are controlled.

Similar to the human spinal cord, muscles on both sides need to be developed in order to have a stable balance. therefore both focus and distraction have a purpose and they must be appreciated and controlled. The co-pilot, therefore, must not just give a call and wait for the appropriate response as per the SOP but at times give repeated calls or physically tap the Pilot Flying out of the lock. The window of opportunity is always there but it’s for the crew to be adequately trained to recognise.

An example of an unstable approach and mitigation can be by an audio and visual indication of a go-around. The pilot will receive the message through one of the two senses. The last option is to touch.

Danger- What if the co-pilot is also stuck in the same situation as the pilot flying is? That is the danger of mirroring, the co-pilot must have different references to scan.

On 11th Dec 2016, the Robinson R44 helicopter owned by Aman Aviation Aerospace Solutions Pvt. Ltd. got airborne from Juhu airport on a joy ride on around Mumbai. The helicopter was 06 minutes into the flight at 500 feet above ground level (AGL) when the pilot intimated the air traffic control regarding his intention of a forced landing at Powai area due to a clutch failure. The helicopter lost height hit a bunch of trees and caught fire.

There were 3 passengers and one pilot on board. In the accident, 2 passengers and 1 pilot died. 1 passenger received serious injuries. Whereas the final investigation report states that the probable cause of the accident was due to the reported clutch failure, the cause of the failure could not be determined. However, new evidence clearly establishes the cause of the failure to be due to worn out and damaged V-belt. The investigation has attempted to conceal this crucial evidence.

The probable cause as per the final report was the failure of the clutch assembly.

Whereas the probable cause is stated to be the clutch mechanism as shown above, the component was not sent to the manufacturer to determine the reasons for failure. The reason for failure as per the final report was unknown.

The V belt which transfers the engine power to the link to the main rotor of the helicopter as per the investigation report was physically normal. However, the photographs in the final report were enlarged using technology and some glaring facts were revealed.

The final report has concealed a number of evidence and facts in order to allegedly protect the operator. The probable cause of the accident was due to failure of the V Belts due to improper maintenance practices of the operator and poor oversight of the operator’s operations and maintenance activities by the regulator.

At least 18 people were killed and many injured when the Air India Express flight from Dubai with 190 onboard overshot the Kozhikode airport’s runway — a tabletop runway, while landing in heavy rains and fell 35 feet down a slope and broke into two portions on Friday night. The pilot-in-command Captain Deepak Sathe and his co-pilot Akhilesh Kumar were among those who lost their lives.

The crash at Kozhikode brought back bitter memories of the flight accident in Mangaluru in 2010. Mangaluru airport is also built on tabletop.

What is a tabletop runway?

The Kozhikode airport in Kerala has a table-top runway and is operated by the Airports Authority of India (AAI).

Generally, tabletop runways are constructed on a hilly or an elevated terrain and are built in a way that there is a trench or valley at the front and back of the length of the runway. Therefore, an accurate landing is very important. The tabletops are very tricky and known to be extremely challenging even for the best of pilots.

It is to be noted that landing on tabletop runways requires a precision approach with little to no room for errors. Following the devastating Mangalore plane crash, the Directorate General of Civil Aviation (DGCA) had banned wide-bodied aircraft from landing at Kozhikode airport. These aircraft require a larger strip of runway to slow down. Therefore, tabletop runways make them susceptible to accidents.

Tabletop runways and air accidents

Apart from the Kozhikode and Mangalore, Lengpui airport in Mizoram, Pakyong airport in Sikkim, Simla and Kullu in Himachal Pradesh are built on tabletops.

In 2010, Air India Express Flight 812, a Boeing 737-800, flying on the Dubai-Mangalore route overshot the runway on landing at the Mangalore International Airport, killing 158 passengers.