Mangalore crash report – The “truth blanket”

Capt.Zlatco Glusica's daughter Merima at his grave in Belgrade, Serbia, on the first anniversary of Mangalore crash

By Captain Mohan Ranganathan

Capt M Ranganathan

After a crash, if the pilot is alive, nail him. If he is dead, blame him’ is a saying among pilots. The Court of Inquiry report on the Air India Express flight AIE 812 has lived up to that. The report which has been released shows that the decision to blame the pilot was their sole mandate and they have covered up the failures of all others involved – The Airport Authority of India, The DGCA and Air India.
The poignant image of Captain Glusica’s daughter in front of his grave , probably with a feeling that he was crucified. Her thoughts will be repeating the famous statement from the Bible: “ Father forgive them for they know not what they are doing”.She has every right to feel that her father has been crucified and double –crossed in the report.
The pointers were very clear from the beginning when the ATC tapes were quietly leaked out to the press. The captain ignored all calls to go around when his copilot had repeatedly called out that he was high and fast.
The incompetence of the COI was evident , right from the beginning when the Preliminary report was released on the ministry website. They could not get the location of the crash right!

When the Court of Inquiry got runway 24 wrong

What was marked as Runway 24 was Runway 27. When this was pointed out in the media, the image was pulled off in a hurry and replace with the following image, which appears in the final report :

When the 'runway error' was corrected by the Court of Inquiry

The indications were clear that the objective was not to find out the truth and come out with procedures to prevent another tragedy. It was a single minded objective to blame the captain and give a fairy tale ending to all the others who are equally responsible for the fatal tragedy.
IN November 2007, the DGCA safety oversight audit on Air India Express, had found several deficiencies and the management was notified to make the corrections. The findings included the fact that the airline did not have a Head of Safety and Chief of Training as per the DGCA regulations. In June 2010, when a fresh audit was carried out on the airline, the same deficiencies were found. Yet, the conclusion in the report does not blame the airline nor the DGCA for permitting the continued operation by an airline which did not conform to basic safety norms.
The Head of safety should have been held responsible for the wrong circular he had issued about hard landings. The captain had been counseled earlier for a “hard landing” which fell into that category but which was well within the manufacturer’s limit. The fatal flight which was descending at a very high rate, was corrected to make a smooth landing. The circular would have been at the back of the captain’s mind. Yet, this was covered up by the Court of Inquiry.
The most serious aspect is the failure of the COI in not indicting the Airports Authority of India. The report covers up the dangerous rigid concrete structure that holds the Instrument Landing System Localiser antenna. This is completely against the ICAO Standards which prohibits anything other than a frangible structure in that area. The report clearly states that the right wing broke when it struck the concrete structure and the post accident fire is evident in the vegetation in the slope beyond the boundary wall. The illegal structure was rebuilt and operations continue with this dangerous structure remaining.

The ILS antenna that caused the wing of the aircraft to broke apart. In this picture taken just after the crash, the broken wing too can be seen

The report has stated that the fire services reached the site within 4 minutes. However, the truth was disclosed by the Chief of Fire services at Mangalore, Mr.H.S.Varadarajan. in a recent newspaper interview. His statement that appeared in the is as follows:

After every fire, people conveniently forget the firemen who rescued them, by risking their own necks. The heroic efforts of firemen in the Air India Express IX 812 crash too have gone unsung. After nearly a year, their efforts were labelled as ‘nothing extraordinary’.
The fireman’s manual on aircraft disasters and fires depicts a burning aircraft as a bomb waiting to explode. The oxygen tubes, the helium-filled gadgets, and the hydraulic systems are full of highly combustible material which gives firemen only 160 seconds to carry out any rescue operation.
“It is called ‘2.5 minute window’. Within this time, the fire will travel through the tubular structure of the plane engulfing the entire passenger area. Attempts to save lives will have to be made within that time,” “The IX 812 crash happened in a valley where approach was difficult but our vehicle reached there in eight to nine minutes of the crash. The first gush of aqua film forming foam was administered within 13 to 15 minutes of the crash. But, by that time, fire had engulfed the entire plane and the broken parts of the belly had strewn around in three different places and had turned into mounds of fire.”
“We were criticised for using the AFFF. But it is the only material that can extinguish high intensity fire ignited by highly volatile material like aviation turbine fuel (ATF). Any water sprayed on the burning plane will just evaporate even before it reaches the target area,” said Varadarajan who had fought fire in the 1999 Bangalore air crash and another in Yelahanka air base.
To carry out effective rescue and recovery operations in an emergency situation, it is necessary to cordon off 500 metres around the crash area. “No unauthorised person should be allowed inside. In the case of Mangalore crash, everybody who was anybody entered the site. Indeed, some of them tried to help us but most of them only added to the confusion. The narrow road between Kenjar and Adyapady was blocked with all kinds of vehicles including private cars and two wheelers, not allowing the emergency vehicles to operate freely,” he said.
“The victims’ bodies were damaged so badly that it was hard to identify them. The disaster management machinery had no clue about a procedure called ‘Triage Area (TA)’ where the fireman on duty will deposit the recovered body. This facility was missing at the crash site.

The concrete structure still remains and so do the narrow roads which makes the area beyond the runway difficult to reach. Another tragedy will result in the same kind of tragedy. Like a fairy tale ending, the officials in AAI and the airline will live happily ever after. More families may join those who lost their lives on the fatal 22nd May 2010. Unless people wake up to the danger, we are not far from another tragedy.

(Captain Mohan Ranganathan is a member of India’s Safety Advisory Committee of the Aviation. The aviation safety expert and veteran pilot has more than 20,000 hours of flying experience to his credit).

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