Rome was burning but Nero was fiddling. While several lives were lost in bomb blasts at various locations in India, the Home Minister was busy changing his safari suits! Finally, as a postscript to 26/11, the Prime Minister and the new Home minister say “Sorry”. Will this mitigate the hurt and anger that prevails against the inaction and neglect? Is it better to be safe or sorry?
The late U.S. President John Fitzgerald Kennedy said: “There are risks and costs to a program of action, but they are far less than the long-range risks and costs of comfortable inaction”. Wise words for our government?
In aviation, accidents may be a product of human error, either due to an active or latent failure. Active failures are those due to pilot error while a latent failure is that which lies dormant due to a systemic failure but which rears its head at a later stage. This has been explained in detail by the British psychologist James Reason who introduced the concept of the “Swiss Cheese” model in safety. The hypothesis is based on four layers of cheese representing various actions. When the holes in the layers line up, the stage is set for an accident.
In a recent aviation accident data published by the Flight Safety Foundation, the accident data from 1995 to 2007 shows a total of 1332 reported accidents. Runway Excursions are events when aircrafts overrun at the runway end or veer off the side of runway. Runway Confusions happen because of the use of incorrect or “wrong runway” for landing or take off. There have been 379 (29.1/year – 28.5 per cent) cases of Runway Excursions and four (.3/year – 0.3 per cent) incidents of runway confusions reported. The data may not contain several more as many countries do not report all the cases to ICAO or safety organisations.Serious warnings
After May 2007, we have had more than nine runway overruns and four cases of runway confusions in India. The numbers point to an alarming 30 per cent of overruns and a more alarming single year (four wrong runway landings) equivalent of a 12-year average (four) in runway confusion in worldwide statistics.
These are serious warning pointers that have appeared and we continue to ignore them. Three holes are aligned and we wait for the fourth to synchronise! Two events in the recent past are perfect examples. A private airline’s flight landing on the wrong runway which was closed at Kolkata and the stressed Air Traffic Controller at Chennai telling an Air Force pilot to shut up. Will these come under the active or latent category?View from the cockpit: While runway 19R in Kolkata was cleared for landing, the pilot landed the aircraft on 19L;
On December 1, 2008, the private airline’s flight was cleared to land on Runway 19R (Right runway) at Kolkata, as maintenance work was taking place on the Left runway (19L). Men and material were on the closed runway. Yet, the American pilot landed on the closed runway and it was providence that it did not become a major disaster. The error of the pilot would place it in the category of “active failure”. On June 9, 2008, another of the same private airline’s flight with an American captain landed on Runway 10 at Delhi instead of Runway 09. Here again, runway 10 was closed and providence saved a disaster. On June 12 2007, another flight from the same private airline landed on Runway 09 when they were cleared to land on runway 10. Another “active” failure.
What is of concern is the “latent failure” of the system. The same airline has committed identical errors on three different occasions.
On two recent occasions the runway confusion was by experienced American pilots. Can this be brushed off as a minor error or should serious concern be raised? The DGCA seems to have brushed this aside as just a minor aberration. It appears that they have not learnt from the SQ 006 accident on October 31, 2000. The Boeing 747-400 aircraft attempted to take off from the wrong runway in Taipei during a typhoon, destroying the aircraft and killing 83 of the 179 occupants. The airline and the authorities in Singapore have ensured the prevention of a recurrence by stringent training and adhering to safety standards. Indonesia, a country which matches or exceeds the corruption levels in India, shut down Adam Air after a series of accidents.
The three incidents in India have thrown up serious deficiencies: 1) Training and safety standards of the airline; 2) The failure of the monitoring and safety audit of the airline by the DGCA, and 3) The screening and quality of expatriate pilots employed by airlines in India.
India is a land of Information Technology and we boast of very high quality in technological advancement. In this context, it is appropriate to highlight what Bill Gates once said: “The first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency”.
Latest in technologyThe Boeing 737-800 aircrafts involved in the three runway confusion incidents in India over the last year have a very high level of technology. The instrument presentation is among the best and most modern. These have been evolved after the manufacturers have incorporated the most advanced “Glass cockpit” concept. The information presented on the PFD/ND ( Primary Flight Display and Navigation Display) is comprehensive and reduces the workload immensely. The ND incorporates the latest VSD (Vertical Situation Display) which very few aircrafts in India have. This feature facilitates the pilot to identify the exact runway, the vertical profile of the aircraft and the point on the runway where the aircraft is likely to touchdown. The aircraft, ideally, should be flown to the full extent of automation during a normal flight. The manufacturers recommend it to make flying safe. With all these features, if they made identical errors three times, they seem to conform to Bill Gates’ second rule.
The DGCA has failed to identify and monitor a potential disaster situation. If an airline with all the modern features in its aircrafts is involved in potentially dangerous situations repeatedly, warning bells should have sounded. The airline’s heads of training and safety departments have failed miserably and yet the DGCA safety audit (is there any?)
has neither come down on the airline nor have they tightened the screening process on the quality of expatriate pilots who come into the country.
Those pilots may be highly experienced but are they conversant with the use of the modern glass cockpit? Safety and lives of passengers seems to be secondary to the DGCA and people who control them. Are we going to wait for another apology as a postscript?
In the incident involving the ATC, it is passed off lightly as an error in manners due to fatigue and stress. The reason is a severe shortage of qualified manpower in the ATC. In October 2006, during the International Civil Aviation Organisation safety audit, they had pointed out this shortage and the DGCA had given a compliance note to the effect that this will be addressed immediately. Nothing worthwhile has been done.
What is more serious is the attitude of the ministry and the DGCA towards fatigue. This can prove to be a killer when fatigued and stressed flight crew are involved.
In June 2008, an Air India flight 612 on the Dubai-Delhi-Jaipur-Mumbai sector, overshot Mumbai because the crew overslept. The accident report is yet to be released by the DGCA and the airline has been on the denial mode from the time this came to light. The crew did not respond to radio contacts for more than 45 minutes and they overshot Mumbai by more than 80 kilometres towards the sea. It was pure luck and providence for the passengers and the crew on board that nothing untoward happened. This was a classic case of fatigue overcoming the crew.
Danger of fatigue
In July 2007, the DGCA issued the regulations for flight and duty time limits for pilots. It was based on scientific studies done internationally and welcomed by all except the airline owners. The ministry did some arm twisting and got this regulation cancelled, reviving an outdated 1992 circular. The matter is still in court. What many are unaware of is that the extra long haul flights that Air India does between Delhi or Mumbai and New York is not covered by this circular. The DGCA has issued dispensations to Air India to circumvent this. The high profile lawyers appearing for the airline owners and the ministry submitted in the court that the old 1992 circular has worked without any serious accident all these years and a change is not required. Maybe, the court will be interested in knowing that the Federal Aviation Administration, based on the recommendations of the National Transportation Safety Board of the U.S., has recommended almost 48 hours of rest for American pilots operating similar flights. Contrast this with Air India pilots, who have been permitted to operate with a minimum rest of around 14-18 hours by the Indian DGCA!
Several accident studies have indicated that one of the reasons is a delayed response to a vital action. This can be due to fatigue, a lack of understanding of the system or due to a phenomenon called “micro sleep”. Two to 10 second micro sleep events have known to occur for all human beings and it can occur when one is wide awake! For pilots, when this occurs during the flare and landing roll phase of the flight in adverse weather, it can make the difference between a safe landing and a fatal crash.
Three major accidents in recent times have identified delayed actions by the crew as one of the causal factors. The August 2005 Air France A340 overrun at Toronto while landing in heavy rain. The aircraft was destroyed by the post-accident fire. All 309 on board had a miraculous escape. One of the causes is a 12.8-second delay in selecting the reverse thrust. In December 2006, a Southwest airlines flight overshot the Chicago Midway airport runway while landing in snow. The runway length was limited and the conditions were marginal. The investigation revealed a 12-second delay in selecting the thrust reverser as one of the causes. In July 2007, a TAM airlines A320 overshot the Sao Paulo runway in Brazil, while landing in rain, on a runway with suspected friction characteristics. Here again, a 11-second delay is identified as one of the causes.Those Critical seconds: The time factor in recent runway overuruns.
How do the international community address these accidents? In the case of the Toronto and Chicago accidents, the recommendation to augment operational procedures as well as regulatory oversight have already been put in place. As far as India is concerned, nothing has been done to learn from those reports and recommendations. The investigation report of the TAM accident was released recently. They have identified, besides the causes, that several of the agencies involved need to face criminal prosecution. Among them are the Civil Aviation authority head, the Airport authority head, the manufacturer of the aircraft and the airline, including the training department.
Need for action
Yet, we amble along in the misguided security that we have not had a major fatal accident during the last several years. What we need in India is proactive action and not reactive knee-jerk. And we need a strong judicial system where citizens can seek timely justice. The people who control the destiny of aviation in India, the Ministry of Civil Aviation and the departments it controls — The Directorate General of Civil Aviation and the Airports Authority of India — ought to sit up and take notice. Or else, when a major aviation disaster strikes, the government will just say “Sorry” as a postscript.The author is an Airline Instructor Pilot on Boeing 737 with a flying experience of 20,000 hrs. He is also a Consultant for Wet Runway Operations Training and Accident Prevention.