India was downgraded by FAA to Category 2 in early 2014. Following this humiliating audit assessment, some changes have been made and now India is getting ready for a review in March/April 2015. So, this is the occasion to highlight once again what actually ails Indian Civil Aviation so that the core issues can be separated from the noise and rumors. It is only through proper understanding of the on-ground situation will it be possible to separate the truth from politically motivated rumors and ensure necessary corrective actions are taken in the right direction. After all, the first step in solving any problem is acknowledging that there is a problem, and then as a second step taking ownership of the problem for further corrective actions to be implemented.
I had covered this subject at great length in my book “Waiting…To Happen!” where, using the case study of Air India Express IX812 crash at Mangalore, an assessment of what ails Indian Civil Aviation was undertaken. All the lessons Indian Civil Aviation needs to learn can be learnt from a football club! I offered this analogy in my book where even the cover image was specially designed to convey this message. The image depicts a football goalpost with a figure in Pilots uniform instead of a goalkeeper. The person is diving to save a goal, and instead of a ball, coming-on is an aircraft. The message is clear. Pilots are no different than goalkeepers. They are our last line of defense and the only team members capable of using their hands to save a loss. However, just like the goalkeepers, in the end they are merely humans and members of a team. If rest of the team does not perform, the goalkeepers can do little to save the loss. This is also evident from the fact that major football clubs often fire their Managers, Coach or Captain in the event of a poor season performance, but rarely do we see a goalkeeper getting the axe. However, in the aviation industry, and particularly in India, we seem to have a greater focus on the goalkeeper than the team management. Following examples will help clarify this point.
IX812, Mangalore 22 May 2010. The officially conducted inquiry closed the case with a “Pilot Error” verdict. However, the facts are that the airport was neither built, nor maintained, in accordance to standards stated in the Indian Civil Aviation Regulations. Runway friction had not been checked for many years and the runway had extensive rubber deposits leading to a loss of breaking friction; RESA was non-compliant with minimum required length; surface of RESA was hard and had not been prepared to offer a deceleration; the base of ILS localizer located inside the runway strip was made of concrete and was therefore not frangible. Right wing of the aircraft struck this concrete base and was sheared off, fuel spilled and came in contact with the right engine and started a fire that spread rapidly, consuming the entire aircraft within minutes. 8 survivors have given evidence that others were alive but overwhelmed due to rapid spread of fire. Runway controller was not looking at the aircraft and even 5 minutes after the crash is heard on radio calling the aircraft and issuing back-track instructions. No crash alarm was ever sounded. ARFF responded only when someone called them and informed that they can see fire at the end of runway. By then the aircraft had fallen down a ravine. This happened because the mandatory 1000m area required at the end of runway did not exist. There is no record of the airport ever having conducted a crash exercise, which is mandatory every 2 years. No procedures existed for responding to this situation. No access roads had ever been contemplated. No coordination with local firefighting departments and local administration had ever been concluded. ARFF vehicles took 30 minutes to reach the crashed aircraft. 152 of the 158 killed had no evidence of trauma, impact or decelerative injuries. Cause of death for all of them was established due to burns and asphyxiation due to smoke in lungs. The airport had undergone a routine surveillance audit by the DGCA just two days before the crash and received a “Satisfactory” rating.
Is this Pilot error? Yes, the pilot did make mistakes. But there is also evidence that he was suffering from Hypoxia. Despite all the mistakes of the pilot, the event was survivable and would not have resulted in a disaster if the airport had been constructed and maintained in accordance to standards. Quoting Justice Moshansky from the Dryden accident report, “… while the crew must accept accountability for their decisions, it is clear that the Civil Aviation System failed them by allowing them to be placed in a situation where they did not have the support they needed and should have received.”
Jaipur, 05 Jan 2014. AI890 from Guwahati to New Delhi diverted to Jaipur, after holding for over one hour, due to poor visibility. On arrival, visibility had reduced below minima at Jaipur also. Now low on fuel, pilot had no option but to attempt a landing. On touchdown in near zero visibility, aircraft burst tyres and suffered a runway excursion. Left wing of the aircraft struck a tree 52 m south of runway edge, 1340 m down the 2780 m Rwy 27. Aircraft had exhausted fuel and hence there was no fire, but if the aircraft had any fuel in that wing the result of this collision would have been similar to what happened with IX812 in 2010.
Once again, ARFF could not reach the aircraft because they had never trained to respond to an emergency in low visibility. Once again, while the airport had been assessed as “satisfactory” by the DGCA in last surveillance audit, there was no evidence of any crash exercise and the airport did not comply with standards because as a Code 4D airport, it should have had a 75 m runway strip on either side, clear of any obstruction. DGCA issued many directives with regards to Pilot training standards as a consequence of this accident, but the issues of non-standard airport, lack of ARFF preparedness and regulatory lapses were glossed over.
Issues with Pilot proficiency checks, pre-flight medicals and validity. There have been many cases where DGCA has acted to suspend licenses of pilots flying with proficiency checks due, without pre-flight medicals or with expired licenses. The issue here is that pilots are employed by an AOP holder and perform inside an organizations policies and procedures. It is the operator’s responsibility to ensure employed pilots meet the regulatory standards and comply with applicable regulations. The pilots do not work for DGCA, but for an operator who holds a valid AOP. Disciplining the pilots is the job of their employer. Responsibility as well as accountability for enforcing compliance rests with the AOP holder and in the event of non-compliance, the AOP holder needs to be disciplined, through sanctions, financial penalties or even temporary/permanent suspension of the AOP. Focus needs to be on the team management, who needs to ensure that the employed goalkeeper is properly trained, holds the required certifications and plays in accordance with the rules of the game!
So, what ails Indian Civil Aviation? Research at ICAO has demonstrated that most accidents today are caused due to organizational factors. I have explained the following diagram in great detail in my book, “Waiting…To Happen!”, but I believe the figure below is also self-explanatory.
Active failures (Errors/Violations) by humans constitute only 20% of the whole. All human performance happens inside an organizations policies and procedures. If these are weak/not implemented, sooner than later the humans will be overwhelmed and pushed to err. Human error is a symptom, not a disease. The disease is “Poor Organizational Management” and this is what ails Indian Civil Aviation.
Lessons from Football. We need to learn our lessons from the way we manage our football teams! Our team to manage Aviation Safety can be described as follows:
Manager: Ministry of Civil Aviation.
Coach: An Independent Accident Investigation body.
Linesman: ICAO.
Captain: National Regulator, DGCA.
Forwards: License/AOP holders “Accountable Managers”.
Midfielders: Managers in an AOP holder’s organization & DGCA Auditors.
Defenders: Line Management, Ground crew, Engineers, Air Accident Investigators.
Goal Keeper: Pilots.
Rules of the Game: Primary Civil Aviation Regulation.
This analogy can then be transcended down to any level of any organization. The CEO or the equivalent, even a departmental head then becomes the Team Manager and other designations below appropriate to the complexity and size of the organization.
Unfortunately, in Indian Civil Aviation today, the Team Management consists of bureaucrats with no professional experience in Civil Aviation. There is no functional independent aircraft accident investigation body akin to NTSB or AAIB. This team is playing without a coach. The team Captain, DGCA, is a bureaucrat too, selected for his civil services, and not civil aviation, skills. The Captain does not understand the complexities and strategies of the game. The DGCA also sits on the management boards of AAI and AI. This is like having the team Captain also manage the opposite team and, thereby creating a conflict of interest, interfering with his ability to regulate in a fair and unbiased manner. There is no accountability enforced on rest of the team members.
The team plays on strength of its goalkeepers and there is constant stress on them due to non-performance of other team members. This leads to a failure of the man-machine interface due to the human part of system being over stressed as is evident from the large numbers of “human error” events that have occurred in recent past displaying symptoms of the disease called “Poor Organizational Management”.
The rules of the game or Civil Aviation Regulations (CAR) are flawed too. ICAO has published “Standards and Recommended Practices” (SARPs) which are very intuitive and have wide applicability. But ICAO SARPs are not legally implementable. The CARs are the law and only they can be enforced inside India. While copying ICAO SARPs, all Recommendations have been converted into Standards. This has been done across the board, without any justification and without any assessment/evaluation on their need, applicability or implications. This has resulted in the CARs being in-implementable on many occasions or leading to exorbitant and wasteful expenditure to implement something that does not add any value to the operation. This also results in wasted resources and higher operating costs, making the entire industry in-profitable and susceptible to collapse. This also then results in violations by the operators, which are then ignored because the law itself is in-implementable. The result is a system where rules are followed or ignored at will, depending on the organizations financial abilities and political clout rather than based on a risk assessment and implementation of justifiable mitigation measures. There is an urgent need therefore to correct this situation and reform the rules of the game – the Primary Civil Aviation Regulation.
To sum-up. In the end, the diagram below represents what the relationship ought to be between a Regulator and a Service Provider. This is what needs to be implemented with a strong leadership and accountability at every level in every organization. A detailed explanation has been included in my book “Waiting…To Happen!” under the heading “Dilemma of the two P’s”.
Stay Safe,
The Erring Human.
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