Mangalore Crash Inquiry Report: A Desperate Attempt to Save the Skin of AAI Also

Airports Authority of India is guilty of both erecting a concrete structure at runway end and providing not enough rest for the ATCs
(Mangalore Crash Report – Hidden Factors: 2)

By Capt. A. Ranganathan
When Air India Express Flight 812 crashed in the early morning of May 22, 2010, 158 lives were consumed by fire caused when the wing of the aircraft broke after it struck the concrete structure on which the ILS Antenna was mounted.

Thanks to the ‘smoke screen’ on Page 36 of the CoI report, the fact that the structure was erected there violating all the safety norms is very well camouflaged.

ICAO Annex 14, governs the Standards for Aerodromes. In Chapter 3, under section 3.5 comes Runway End Safety Area ( RESA). The Annex specifies that “ Runway End Safety Area SHALL be provided at each end of the runway strip.

The Dimensions of the Runway end Safety Area

3.5.2   A Runway End Safety Area shall extend from the end of a runway strip to a distance of at least 90m.

3.5.3  Recommendation – A runway end safety area should, as far as practicable, extend from the end of a runway strip to a distance of at least  -  240m where the Code number is 3 or 4

Objects on runway end safety areas

3.5.6 An object on runway end safety area which may endanger aeroplanes should be regarded as an obstacle and should, as far as practicable, be removed.

ICAO has recommended the higher figure of 240m taking into account that most runway overruns take place within 300m beyond the end of the runway. The term “ as far as practicable” would apply for an obstacle which exists naturally and not a man made structure. Considering that Mangalore runway is on a table-top terrain and with the area beyond the strip difficult for rescue operation, the RESA should have been 240m long. When the fatal accident took place, the arrow of guilt pointed to this structure. An effort has been made to portray that there did exist an area 240m beyond the end of the runway. The different statements on Page 36/175 shows their confused mind:

At the time of accident , there was a Basic strip of 60m followed by RESA of 180m ( now reduced to 175m).  After the end of the 237m within RESA, a concrete structure had been constructed on which ILS Localiser antenna is mounted.

Now see the extract of Page 36 of CoI report:

This is another clumsy attempt to cover-up a dangerous safety infringement. The figures of 180m or 175m do not appear anywhere in the ICAO Annex 14 under the heading Runway end safety area. Someone has attempted to indicate the figure of 240m ( 60 = 180 ) was provided but realised that the concrete structure was at 237m. Hence, the figure was reduced to 235m ( 60 + 175 ). A further precaution to protect a wrong structure is the falling back on the figure of 90m x 90m, which is the mandatory figure as per Annex 14 while 240 is a recommendation.

The report goes on to state : After the accident, the ILS was recalibrated on 16th June 2010. The damaged structure was rebuilt with another rigid structure within three weeks of the fatal accident !

Did they realize that the danger for all operations continue from that date? Was the DGCA right in renewing the license for the airport with this dangerous structure?

There is a DGCA C.A.R for Aerodrommes from which the following are extracts:

SERIES ‘F’ PART I

16th October, 2006 EFFECTIVE: FORTHWITH

SUBJECT: REQUIREMENTS FOR ISSUE OF AN AERODROME LICENCE.

4.6 The applicant for the aerodrome to be licenced for Public Use shall

demonstrate the functional arrangements and their integration for provision of CNS-ATM, RFF, AIS, meteorological and security services.

4.7 Final inspection shall be undertaken for on site verification of data,

checking of the aerodrome facilities, services, equipment and procedures to verify and ensure that they comply with the requirements.

4.8 The aerodrome licence shall be issued by the Aerodrome Standard Dte. after approval of DG under the appropriate category, if the DGCA is satisfied that applicant has complied with all relevant requirements. In case of the non-compliance of the requirement by the applicant, licence may either be refused or granted with limitations/ restrictions / conditions as deemed appropriate by the DGCA, provided that in such cases the overall safety is not compromised.

13. OBSTACLE LIMITATION SURFACES

Enclose obstacle limitation charts including type ‘A’ chart for the aerodrome including the details of obstructions, which are marked and lighted.

13.1 Objects in operational areas and their frangible type

a) Runway Strip

b) Stopway

c) Clearway

d) RESA

13.2 OBSTACLES

POSITION OF OBSTACLE

HAZARD TO FLYING

The license given to Mangalore is suspect and officials who conducted the safety audit have made a sham of the inspection. The concrete structure was definitely a hazard to flying and it is surprising if item 13.2 of the Application form was filled up otherwise.

Licensing done by DGCA in 2007 and Surveillance inspection done two days before the accident. It is pure divine grace which has prevented more fatal accidents in Mangalore.

Extract of Page 39 of CoI report:

The highlighted portions of the extract clearly spells out the danger to all aircrafts operating in and out of Mangalore. The dangerous structure on which the ILS antenna is mounted is present. The Rescue and Fire fighting is not possible outside the airport perimeter. Yet, officials of DGCA and AAI have certified that the airport with the present facilities is safe!

The other important factor is the fatigue factor of the Air Traffic controllers. Their shifts are designed to keep them on a continuous 12 hour duty period during the night. They are also exposed to the Window of Circadian low which would result is erroneous or delayed response. On the day of the crash, the ATCO has stated that the end of the runway was not visible and he has given instructions to the aircraft to back track as was the “ normal” practice ! The ATCO was not even aware that the aircraft had crashed !

The entire report on the crash appears to put the blame on the Captain alone. All the other agencies involved in contributing to the death of 158 persons has been blanked out in the smoke-screen. The danger persists and lessons have not been learnt.

(Captain A. 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.

Capt. Ranganathan can be reached at mohlak@gmail.com).

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