SANDEEP UDUPA

Mangalore Air Crash Report

Mangalore Crash Report

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Table of Contents

1. Introduction ……………………………………………………………………………. 2

2. Flight Trivia …………………………………………………………….……….…….. 2

3. The Crash ………………………………………………………..…………………… 3

4. The Victims & The Survivors …………………………………………………………………….……… 4

5. Rescue and Response …………………………………………………………………………..… 5

6. The Investigation ………….…………………………………………………………………. 5

7. The Investigation Report ………….…………………………………………………………….…… 6

8. Court of Inquiry ………….……………………………………………………………….… 7

9. The Fire Department ………..………………………………………………………………..…. 8

10. Compensation ……….………………………………………………………………….… 9

11. Violation of Mandatory Procedures ………………………………………………………………………….... 9

12. The Politics …………………………………………………………………………... 12

13. Current Scenario …………………………………………………………………………... 13

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Introduction:

In what could be one of India’s most catastrophic air disaster in over a decade (and third most

horrible in the past fifty years), the Mangalore air crash tragedy turned out to be a life altering

experience for all of the 166 persons that were on board.

On22 May 2010, the Air India Express Flight 812, a scheduled passenger service from

Dubai to Mangalore overshot the runway on landingat around 01:00 UTC, fell over a cliff and

caught fire, spreading wreckage across the surrounding hillside. Ofthe 160 passengers and 6

crew members on board, only eight passengers survived.

With its 158 fatalities, the accident was the third deadliest aviation disaster in India

(after the 1996 Charkhi Dadri mid-air collision which killed 349 and the 1978 crash of Air India

Flight 855, which killed 213). The crash caused the highest number of aviation fatalities in 2010

and was the second of the year to involve a 737–800. It was also the second time that an

aircraft had overshot the runway at Mangalore.

The deceased crew on board VT–AXV Of 22 May 2010 (IX -812)

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Flight Trivia:

The aircraft registration was VT–AXV, a Boeing 737-8NG, one of Boeing's 737 Next

Generation series with the manufacturer's serial number being 36333 and line number

2481.The aircraft was delivered to Air India on 18 January 2008.

Commanded by Captain Zlatko Glušica, the remaining crew consisted of First Officer H.

S. Ahluwalia and four cabin attendants. Glušica was a British and Serbian national with over

10,000 hours of flying and over 7,500 hours of command experience. He was a former

employee of Jet Airways. Ahluwalia, the first officer, was also a former employee of Jet Airways

who joined Air India in April 2009. They were both based in Mangalore and both were killed in

the incident.

Following its scheduled departure time of 22:35 UTC from Dubai International Airport in

Dubai, the plane crashed upon landing on the 8,033 feet (2,448 m) runway number 06/24 at

Mangalore International Airport at around 01:00 UTC. Situated in a hilly area, the airport is one

of the seven Indian airports designated as a "critical airfield" by the Directorate General of Civil

Aviation (DGCA), wherein such airfields prohibit "supervised take offs and landings", so that

only the captain (not the first officer) may pilot an aircraft during take-off and landing. The

airport is one of three airports in India having table top runwaysthat require a very precise

landing approach.

The Crash:

After touching down, Air India Express Flight 812overran the runway and crashed down

the hill at its far end. The final conversations between Air Traffic Control (ATC) and the pilot

prior to landing showed no indications of distress.

Images available from shortly after the crash showed the remains of the aircraft on fire

and lying on its belly with smoke rising from the wreckage.

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Picture of the plane soon after the crash

The then Civil Aviation Minister, Praful Patel said that the aircraft was following an

Instrument Landing System (ILS) approach for landing on the newer runway, which was

commissioned in 2006. Sequence of specifics before the crash is as follows:

The pilot reported to ATC that an ILS approach was 'established' about 4.3 miles

(6.9 km) from touchdown

Landingclearance was then given at 2,000 feet (610 m) from touchdown

The airplane concluded its ILS approach on runway 24, touching down 300 feet

(91 m) past the touch down zone

It then overran the runway and ploughed through a 90 meters (300 ft) sand arrestor

bed which did not stop it

As the aircraft passed the arrestor bed, its starboard wing collided with the concrete

socket of the ILS localizer antenna

It eventually plunged over the cliff and on to the hillside, coming to a stop 660 to

980 feet(200 to 300m ) past the top of the slope.

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The minister also stated that weather conditions were normal with a visibility of 3.7

miles (6.0 km) and said wind conditions were calm and there was no rain at the time of the

crash. A drizzle started only after the accident.

The Victims&The Survivors:

Apart from the six crew members, a total of 160 passengers were on board at the time

of the crash. Although there were 169 names on the original passenger list, 9 did not board the

flight. All the bodies were recovered from the wreckage.

Initial reports from survivors suggested a tyre burst as the aircraft attempted a go-

around. Some other recollections from the survivors also indicated the plane breaking into two

parts, followed by dense black smoke invading the cabin. Some passengers who were able to

jump out through an opening in the window were essentially the survivors. Withthe help of the

inhabitants of the nearby village, these survivors were able to escape.

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Rescue and Response:

Members of the public services were assisted by local

volunteers in a joint rescue operation at the scene of the crash

Local villagers were among the first on the

scene to help while an estimated 15 fire trucks,

20 ambulances and 100 rescue workers were

immediately allocated to rescue operations.

The Karnataka Police force, bomb squad,

Karnataka Fire & Emergency Services,

Karnataka State Reserve Police and all hospitals were working together to help out. The Central

Industrial Security Force (CISF) sent 150 personnel to Mangalore to help in the relief and rescue

operations. Bodies of all of the deceased were recovered from the crash site on the day of the

crash, with relatives of the deceased receiving 87 of the bodies.

The Investigation:

Initial investigations revealed that the plane landed about 2,000 feet (610 m) beyond

the usual touch down point on Mangalore's new 8,040 feet (2,450 m) runway 24. A team of

airline officials and staff from the Airports Authority of India were rushed to the scene to

investigate the incident and assist with rescue efforts. Boeing also announced that a team

would be sent to provide technical assistance following a request from Indian authorities.

The Directorate General of Civil Aviation ordered an inquiry into the crash, which began

the same day. The National Transportation Safety Board (NTSB) also assisted the investigation

by sending a team of specialists including a senior air safety investigator, a flight operations

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specialist, an aircraft systems specialist and technical advisers for Boeing and the Federal

Aviation Administration.

In direct response to the accident, the Government of India decided to set up an

independent air accident enquiry board called the Civil Aviation Authority that would function

independently of the DGCA. Effectively this meant that the DGCA would be the regulator and

the CAA the investigator. The Director General of the DGCA said that it would be set up through

legislation and would comply with the recommendations of the International Civil Aviation

Organization.

The Investigation Report:

According to audio transcripts obtained from ATC, Serbian pilot ZlatkoGlušica, aged 55,

was given clearance to land however,he suddenly aborted the attempted landing. The aircraft's

throttle handle was reportedly found in the forward position, suggesting that the pilot had

attempted to abort the landing and take-off again. According to unnamed ATC sources at

Mangalore, the co-pilot Ahluwalia was said to have warned his commander more than once to

go around instead of landing, and that this warning had come at a height of 800 feet (240 m),

well before the aircraft made a touchdown.

The Cockpit Voice Recorder (CVR) was recovered on 23 May, and the Flight Data

Recorder (FDR) two days later. The recorders were sent to New Delhi by the Directorate

General of Civil Aviation for data acquisition and analysis and subsequently to The American

National Transportation Safety Boardfor investigation.

The enquiry report submitted by the Civil Aviation Ministry claimed that Glusica slept for

over 90 minutes during the flight. The American National Transportation Safety Board says it

was the first instance of snoring recorded on a Cockpit Voice Recorder (CVR). Analysis of the

accident revealed that had the pilot "deployed détente reverse thrust and applied maximum

manual braking at touchdown", the aircraft could have been stopped within the paved overrun

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area of the runway. The captain had aggravated the long landing by attempting a go-around

following deployment of the thrust reversers.

Court of Inquiry:

On 17 August 2010, the Court of Inquiry began a three day public hearing in Mangalore

to interview airport officials and witnesses. On day one, airport and airline officials overthrew

that the aircraft had approached at an altitude higher than usual, and that it had landed beyond

the landing zone (LDZ). They also mentioned that the airport's radar was operational from

20 May 2010. The airport chief fire officer testified that crash tenders had taken four minutes to

reach the aircraftbecause the road leading away from the airport perimeter to the crash site

was very narrow and undulating. This was followed by day two transcript of the cockpit

conversation to ATC.

Doctors who conducted post mortems on the bodies recovered recorded that most

victims had died of burns. On day four, Air India's flight safety officer informed the inquiry that

the aircraft's thrust lever and thrust reverse levers were both in the forward position, possibly

indicating that the pilot intended to go around.

On 8 September 2010, details from the Cockpit Voice Recorder (CVR) and Flight Data

Recorder (FDR) were presented to the Court of Inquiry. The CVR analysis revealed that one of

the pilots was asleep in the cockpit. For 110 minutes the CVR had picked up no conversation

from the pilots, with the report adding that the sound of nasal snoring and deep breathing

could be heard during this recording. The FDR analysis indicated that the flight started its

descent at an altitude of 4,400 feet (1,300 m), instead of the normal 2,000 feet (610 m). The

aircraft also touched down at the 4,638 feet (1,414 m) mark on the runway instead of the 1,000

feet (300 m) mark, whereupon the pilot then tried to take off with just 800 feet (240 m) of the

runway remaining which resulted in the crash.

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Both pilots had been aware of the wrong flight path since they are both heard saying

"Flight is taking wrong path and wrong side", while the aircraft's instruments gave repeated

warnings of this.

On 16 November 2010, five months after the Court of Inquiry was constituted, it submitted its

report with input from the NTSB and Boeing, and stated that pilot error was the cause of the

accident since the flight path was incorrect.

The Fire Department:

The investigation report 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. He quoted; “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 labeled 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, and 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.”

The fire department was also criticised for using the AFFF. But that was the only

material that could have extinguished the high intensity fire ignited by highly volatile material

like aviation turbine fuel (ATF). Any water sprayed on the burning plane would have just

evaporated even before it reached the target area.

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Compensation:

The Prime Minister of India, Manmohan Singh announced 2 lakh for the families of the

dead and 50,000 for the injured to be allocated from the Prime Minister's National Relief

Fund. Karnataka Chief Minister Yeddyurappa has also announced compensation of 2lakh to

the families of the dead. In addition to this, the Civil Aviation Ministry advised that the Airline

will provide up to 72 lakh to family members of each victim as per the provisions of the Indian

Carriage by Air (Amendment) Act which follows the Montreal Convention.

The Airline announced interim compensation of 10 lakh for passengers above 12 years

of age, 5 lakh for passengers below 12 years of age and 2 lakh for every injured passenger.

This compensation was over and above the ex-gratia payment announced by the Prime

Minister. Additionally, Air India had said it would offer jobs to the survivors.

As of 11 June 2010, an amount of 170 million had been distributed as compensation to

the families of the victims and to the eight survivors. Victims' families had become increasingly

vocal as to the inequitable nature of compensation paid out by Air India and also of the alleged

hostile attitude of the airline's counsel.

Violationof Mandatory Procedures:

When Air India’s Jumbo Jet Emperor Kanishka exploded mid-flight and got scattered in

Atlantic near Ireland coast on June 23 1985, the investigators had a gigantic task at hand. The

Royal Canadian Mounted Police of Canada organized dives in excess of 7000 feet not only

immediately after the crash, but in 1989 and 1991 also to collect wreckage from the ocean floor

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and to pick up the aircraft debris scattered across the ocean floor.The numerous parts

recovered from the thousands of square meters beneath the sea were all cleaned, numbered

and shipped to a facility in Ireland where they were all kept for more than two decades. The

recovered parts were later arranged to re-create the shape of the aircraft as a part of the

investigation and also to find out how the explosion happened and what exactly caused it.

In case of Pan American World Airways’ Pan Am Flight 103 that was disintegrated in an

explosion many thousands of feet above southern Scotland, on 21 December 1988, the same

procedure repeated. More than 10,000 pieces of debris were retrieved, tagged and entered

into a computer tracking system. The fuselage of the aircraft was reconstructed by air accident

investigators, revealing a 20-inch (510 mm) hole consistent with an explosion in the forward

cargo hold.

As per Rule 9.7.2:

Here in India too, the air crash investigators are obliged to conduct the same exercise.

As per the Procedure Manualof Accident / Incident investigation published by DGCA (Issue I rev

2 dated 5.10.2006), the reconstruction of the aircraft with all the debris collected carefully from

the crash is mandatory, irrespective of the circumstances in which the crash occurred.

However, in case of the Mangalore crash, for forty days on a stretch the debris had

remained in the crash site soaked in dust and mud enduring heavy rain and sun. This negligence

on the part of Air India, the owner, and the Court of Inquiry that investigated the crash was

bound to be subjected to a great deal of criticism.

The clearing process was initiated by Fiza, a local construction firm, which was hired to

do the job and they heaped the picked up parts in Lorries and then dumped them on an open

platform near the new terminal of Mangalore airport. According to an official of Fiza, the total

weight of the debris recovered from the crash site was just 16 tons, as compared to 41 tons of

metal and fire resistant composites which make up the total empty weight of a Boeing 737-800.

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The unfortunate episode continued even after the removal of debris was officially

complete and the police men were withdrawn from the site. Hoardsof scrap metal collectors

descended on the crash site and for three continuous days that the ‘metal scavengers’ looted

the site with the metal remains shipped to various scrap dealers in Mangalore city.

As per Rule 6.5.2:

As per the Procedure Manualof Accident / Incident investigation published by DGCA

(Issue I rev 2 dated 5.10.2006), whenever an accident occurs, the Owner, Operator, Pilot-in-

Command, Co-pilot of the aircraft shall take all reasonable measures to protect the evidence

and to maintain safe custody of the aircraft and its contents for such a period as may be

necessary for the purposes of an investigation subject to the Indian Aircraft Rules 1937. Safe

custody shall include protection against further damage, access by unauthorized persons.

The Court of Inquiry involved in the Mangalore crash calamity had done a scientific

examination of the ‘reconstructed’ aircraft. It was while examining these 16 tons of salvaged

aircraft pieces that a member of the Court of Inquiry team noticed the downward position of

the flap locator, a finger sized metallic switch in cockpit used to move the flaps in the wings.

The reason for the aircraft to generate not enough lift to take off in the last moment was

becoming clear then.

The panicked pilots must have forgotten to push up the switch.If a finger sized metallic part

could have spoken so much about the crash, the act of shame was the loss in precise

investigation due to the sheer volume of the precious evidential scrap metal that was sold in

numerous shops scattered across the city.

To carry out effective rescue and recovery operations in an emergency situation, it is necessary

to cordon off 500 meters around the crash area with no unauthorized person being allowed

inside. In the case of Mangalore crash, everybody and anybody entered the site. Indeed, some

of them tried to help the victims, but most of them only added to the confusion. The narrow

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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. 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 Politics:

The post investigation indications were clear that the objective was not to find out the

truth and come out with procedures to prevent another tragedy, but 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 neither blames the airline nor the

DGCA for permitting the continued operation by an airline which did not confirm to basic safety

norms.

The Head of safety should have been held responsible for the wrong circular that was

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

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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

slope beyond the boundary wall. The illegal structure was rebuilt and operations continue with

this dangerous structure remaining.

Current Scenario:

Twenty two months after the horrific crash of Air IndiaBoeing IX 812, which resulted in

the death of 158 passengers, the legal counsel for Air India – Mulla & Mulla - Mumbai, has

settled 114 cases, eight of them partially. Kapi lAseri, chief finance officer, Air India, said a total

of 96 cases have been settled on full and final basis and eight in part for an overall amount of

83 crore, including the survivors.

The airport manager at Mangalore, Peter Abraham confirmed that after the crash, the

rescue operators had difficulties when trying to reach the plane.The concrete structure still

remains and so do the narrow roads which make the area beyond the runway difficult to reach.

The current condition is such that any other tragedy will result in the same kind of tragedy.

Although the officials in AAI and the airline claim to have completed the necessary formalities

and liabilities, it is essential that people wake up to the apparent danger at airports like

Mangalore, otherwise we are not far from another catastrophe.

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Mangalore crash report – The “truth blanket” Decision Height_files

Catastrophic Air India Plane Crash in Mangalore (Report)

arkarthick.com_files

Mangalore air crash 114 cases settled for Rs 83 crore - Times Of

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Massive Cover Up In Mangalore Air Crash Investigation By Jacob K

Philip_files

articles.economictimes.indiatimes.com

www.hindustantimes.com/.../Mangalore-crash...

www.pprune.org › ... › South Asia and the Far East

www.indianaviationnews.net/.../mangalore-crash-report-–-the-

“truth

realityviews.blogspot.com/.../mangalore-air-india-crash-

complete.htm