An investigation built upon gravest of violations

Air India Express flight 812: An investigation gone hauntingly wrong-IV

By Jacob K Philip

The sole objective of an aircraft accident or incident investigation is the prevention of future accidents and incidents and not to apportion blame or liability. The emphasis of an aircraft accident or incident investigation is on remedial actions. An aircraft accident provides evidence of hazards or deficiencies within the aviation system. A well-conducted investigation should therefore identify all immediate and underlying causes of an accident and recommend appropriate safety actions aimed at avoiding the hazards or eliminating the deficiencies. The investigation may also reveal other hazards or deficiencies within the aviation system not directly connected with the causes of the accident.

It is from the opening sentences of the Procedure Manual of Accident/ incident investigation( Issue I rev 2 dated 5.10.2006), the Bible of air accident investigators in India. The manual is published by Directorate General of Civil Aviation (DGCA), strictly adhering to the standards put forward by International Civil Aviation Organisation (ICAO).

Capt. Zlatco Glusica

Capt. A.H. Ahluwalia

The Court of Inquiry(CoI) appointed by the Government of India to investigate Air India Express flight 812 crash is guilty of violating the very essence of the above dictum.
As we have seen in the previous parts of this note, from the very beginning of the 11 month long investigation and up to its conclusion in April this year, the CoI was directly and indirectly trying in all their earnest to appropriate the blame and liability to the Pilots of the aircraft, who were no longer able to defend themselves- Because they were dead.
The first document that was allowed to sneak in to the media was the taped conversation between first officer AH Ahluwalia and the Mangalore Control tower. That was the beginning of the the long and systematic process of the victimization of Capt. Zlatco Glusica.
Then the content of the Cockpit Voice Recorder, with the heavy breath, snoring and all, reached the media adding more strength to the erring-commander theory.

The resting place of Capt.Zlatco Glusica in Belgrade. On May 22, first anniversary of Mangalore crash. (Sent in by Merima Glusica, daughter of Capt. Glusica.)

During their questioning, six of the eight odd survivors of the crash were coerced in to believing that something of course was wrong with the Commander.
The conclusions of the final report, which as a whole is never going to be placed in the public domain, too was along the same line- Among a few other trivial things, the sleep of Capt. Zlatco Glusica caused the crash. First officer AH Ahluwalia too was guilty because he had not took over the control of the aircraft from the reckless Glusica.
But in the single minded efforts of the CoI to put the major chunk of the blame on two dead people, most of the eight aspects of a crash investigation were getting sidelined.
As per the Manual, the Inquiry team team should conduct the following investigations, assigning equal importance to all.

  1. Operations of aircraft
  2. Flight Recorders
  3. Structural Investigation
  4. Power Plant Investigation
  5. Systems Investigation
  6. Maintenance Investigation
  7. Human Factor investigation
  8. Organization Factor Investigation

We have already seen here how pathetically the structural investigation, the third one, was conducted.
And so far,  no information from the CoI (leaked or otherwise) give any clue regarding the quality and extent of investigations 4, 5, 6 and 8.  The summary of the final report given to selected media too remain silent on this part of the investigation.
Or, can the CoI abstain from investigating some sections if the cause of the crash is that clear for them?
Never. Says the Manual:
9.20.2:

Each aircraft system must be accorded the same degree of importance regardless
of the circumstances of the occurrence. There is no way to determine adequately
the relationship of any system to the general area without a thorough examination.

9.23

It is argued that modern aircraft accidents occur, for the most part, as the result of
complex interactions between many causal factors.

Mangalore crash too was not an exception.
There were an approach radar that was not functioning ; the dictum of Air India management that hung like the Sword of Damocles above the commanders , especially the expatriates, that hard landing and go around are grave crimes that could cost them their jobs; the ILS localizer antenna errected at the end of the runway flouting the safety rules that that should be fragile…
How long the list actually was only something that could have been determined by an impartial and scientific investigation by the CoI.
For flight-812 investigation, that exactly was the factor missing.

(To be concluded in next part)

Jacob K Philip is Editor of Aviation India

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