COURT OF INQUIRY INTO THE CAUSE OF ACCIDENT TO B737-800 AIRCRAFT VT-AXV ON 22.05.2010 AT MANGALORE AIRPORT
An Air India Express Boeing 737-800 aircraft VT-AXV met with an accident at Bajpe Airport, Mangalore on 22nd May 2010, while operating a scheduled flight IX-812 from Dubai to Mangalore, resulting in tragic death of 152 passengers and 6 crew members.
A Court of Inquiry has been ordered by the Government of India, vide Notification No AV.15013/02/2010-DG dated 3rd June, 2010. As per the notification, the Headquarters of the Court of Inquiry will be at New Delhi. The court is required to submit its report by 31st August, 2010.
Constitution of the Court of Inquiry: –
The court consists of the following: –
(a) Air Marshal (Retd) BN Gokhale : Chairman
(b) Capt Ron Nagar : Assessor
(c) Shri SS Nat : Assessor
(d) Shri Babu Peter : Assessor
(e) Shri Gurcharan Bhatura : Assessor
(f) Shri SN Dwivedi :Secretary to the Court
A brief Bio-data of each member of the Court of Inquiry is given below: –
Air Marshal BN Gokhale
Air Marshal BN Gokhale PVSM AVSM VM (Retd) was commissioned into the Indian Air Force in June 1968. He has flown over 3500 hours on various fighter and trainer aircraft and has taken active part in 1971 operations. He is a Qualified Flying Instructor and a Fighter Combat Leader from the prestigious Tactics and Combat Development Establishment. During his illustrious career, he has held several operational and staff appointments, He has commanded a frontline
fighter squadron during the Siachen Operations. He has been Chief Operations Officer of an operational base and has also commanded a premier air base. Air Marshal Gokhale has been an Instructor at the Defence Services Staff College and Inspector at Directorate of Air Staff Inspection. He has had assignments abroad which include Flying Instructor in Iraq and Indian Defence Advisor in Embassy of India, Cairo. Apart from being a graduate of the Defence Services Staff College, he is an Alumnus of Air War College, USA and a Fellow of Aeronautical Society of India.
He has served as Air Advisor to the Chief of Air Staff, Assistant Chief of Air Staff (Operations) and Air Officer Commanding-in-Chief of IAF Training Command, Bengaluru, prior to taking over as the Vice Chief of Air Staff. On retirement as the VCAS in Dec 2007 he has been appointed as Scientific Consultant to the Principal Scientific Advisor to Govt of India. He is also appointed as Consultant to DRDO and National Security Council.
Captain Ron Nagar
Capt Ron Nagar is the Senior Vice President (Flight Operations and Training) with King Fisher Airlines Pvt. Ltd.
He is an accomplished pilot with 37 years of experience in Flight Operations wherein he has been Executive Director (Safety) and Chief Executive (Training) at Indian Airlines. He has been a Training Captain for 30 years, a TRE (Examiner) on Boeing 737,Airbus A320 family and HS 748.
He has participated in several international seminars and training courses, related Human Factors, Aviation Security, IOSA awareness, Aircraft accident prevention, Emergency Response and Crisis communication. He was also a Simulator instructor and has evaluated Simulators.
Shri SS Nat
Shri SS Nat, Deputy Director General of Civil Aviation, India (Retd) is a Type-rated Aircraft Maintenance Engineer Licence holder with rich experience in Civil Aviation. He has successfully completed DGCA approved Maintenance Training on Heavy Aircraft and Jet Engines.
He has worked for about 30 years in the Directorate General of Civil Aviation (DGCA), India in various capacities and retired as Deputy Director General in 2006. He was Head of Airworthiness Wing of DGCA from 1996 to 2004. He has been associated in the formation of various Civil Aviation Requirements during his tenure with DGCA.
He has also carried out Audits, Surveillance inspections and Surprise Checks on Scheduled, Charter and General Aviation operators during his tenure with DGCA to ensure compliance of regulatory requirements.
He was a member of the initial stage accident investigation Team for the crash of Alliance Air’s Boeing 737 aircraft at Patna on 17 July 2000.
Shri Babu Peter
He is a graduate of Electrical Engineering from Regional Engineering College Calicut, Kerala. He joined Air India as a Graduate Engineer in 1971, and has worked as a Licensed Aircraft Maintenance
Engineer over 25 years. He holds valid licenses on several Boeing and Airbus aircraft and their Engines.
He was the Director of Engineering Air India from 2002 to 2004 and the Director of Engine Overhaul in Air India from 2004 to 2005. He later moved over to Indian Airlines as Functional Director and Board Member and retired from Indian Airlines in 2006.
He is presently working as Executive Vice President Engineering in GoAir. He is also a Fellow of Aeronautical Society of India and was the Chairman of Academic Committee in the year 2008-09. In the past he has also been Assessor to the Court of Inquiry in to two aircraft accidents in the past. Boeing 737 accident at Palam, in 1995 and Dornier 228 accident in Kochi.
Shri Gurcharan Bhatura
Shri Gurcharan Bhatura specializes in Air Traffic Management and Airport Operations. After completing the ab-initio programme for Air Traffic Controller, he started his career at Delhi airport and acquired all the possible ratings. Director General Civil Aviation appreciated his services when he saved a Boeing 747 aircraft from landing on a wrong runway at Delhi Airport. Subsequently he specialised in airport operations and held the position of Airport Director at Chennai, Kolkata and Mumbai airports. He is also recognized for his analytical abilities and management skills. Prior to his retirement in 2005, he was Executive Director in AAI.
A fellow of the Aeronautical Society of India and Chartered Institute of Logistics and Transport, he is presently Director General of Foundation for Aviation and Sustainable Tourism – a think tank in Civil Aviation. With 42 year long association with Civil Aviation Industry, he has written several well-researched articles on related subjects.
Shri SN Dwivedi
Shri S N Dwivedi is Graduate in Electrical Engineering and Post Graduate in Management. Presently, he is working as Director of Airworthiness at DGCA Hqrs., New Delhi and has vast experience in Civil Aviation Department since 1986 till date. During his service in Civil Aviation Department, he has completed the various professional and technical courses covering Heavy Aircraft and Jet Engines including Boeing 737 and Airbus A – 320 aircraft.
Shri S N Dwivedi has been involved in Court of Inquiries for investigation of the following aircraft accidents:
? Indian Airlines Boeing 737-200 Aircraft VT-ECS accident on 2nd December, 1995 at IGI Airport, Palam, New Delhi, headed by Air Marshal (Retd.) JK Seth, PVSM, AVSM, VM.
? Archana Airways LET – 410 Aircraft VTC accident on 11th July, 1996 at Kullu, headed by Air Marshal (Retd.) S Ramdas, PVSM, AVSM, VM.
? High level inquiry committee into escalator accident on 13th December, 1999 at IGI Airport, Palam, New Delhi, headed by Shri RC Jain, IAS (Retd.)
? Alliance Air Boeing 737-200 Aircraft VT-EGD accident on 17th July, 2000 at Patna Airport, headed by Air Marshal P Rajkumar, PVSM, AVSM, VM.
Convening of the Court:
On the very next day of the Government Notification, the court convened on 4th June, 2010. The Court took stock of the situation and available information. The Chairman along with all the members met the officials of the Ministry of Civil Aviation regarding some of the administrative arrangements.
Investigation Process:
In an accident of such a nature, the DGCA appoints an Inspector of Accident immediately. This is done to take stock of all the activities relating to accident till the Court of Inquiry is instituted by the Government of India. The Inspector of Accident is required to submit his reports giving his observations / findings to the Court of Inquiry constituted by the Government of India. Thereafter, the Court of Inquiry takes over the charge of accident investigation.
Senior officers of DGCA reached Mangalore on 22nd May, 2010 itself for a first hand appraisal. The search for Cockpit Voice Recorder (CVR) and Digital Flight Data Recorder (DFDR) known as ‘Black Box’ was initiated. CVR records the conversation of the flight crew among themselves and with ATC including any sound in the cockpit. DFDR records various parameters of the aircraft, engines and their systems. CVR and DFDR were recovered from the wreckage with the outer casing damaged due to heavy fire and impact during accident. However, the data storage module appeared to be intact. Since suitable facility to retrieve the data from partially damaged CVR and DFDR do not exist in our country, the Court of Inquiry decided to carry out decoding of these recorders at the facility of M/s National Transportation Safety Board (NTSB), Washington DC, USA.
Visit to the Accident Site:
The members of the Court of Inquiry visited Mangalore airport and the accident site from 7th to 9th June, 2010. The members of the court observed two minutes silence to pray for the departed souls at the crash site.
The members of the Court of Inquiry met with Emergency Response Team which took part in the post crash Search and Rescue (SAR) operation; and heard their observations of the fateful day. The court visited ATC Tower, Area Control, Fire Station, and Meteorological Office and met the personnel who were on duty on the day of the accident. The court also met and interacted with the officials of District
Civil Administration, City Police, City Fire Service, District Health Administration and Air India Express personnel at the airport, who were involved in the post accident search and rescue operation.
The Court also visited the city hospitals where two of the eight survivors are undergoing treatment. The Court interacted with the team of doctors treating them in the hospitals. The survivors narrated their experiences to the Court.
Interaction with Key personnel of M/s Air India Express:
The Court visited the facilities of M/s Air India Express at Mumbai and met its key officials in the evening of 9th June, 2010. The Air India Express officials made presentations regarding their Organisational Structure, Flight Operations, Maintenance and other facilities including Emergency Response Plans.
Brief of Boeing 737-800 aircraft:
Boeing 737-800 aircraft is an upgraded version of Boeing 737 aircraft family. The passenger seating capacity of this aircraft is 186 and is manned by 2 operating and 4 cabin crew. Its maximum take off weight is 77110 Kg. The aircraft is powered with two CFM-56 Jet Engines. The Manufacturer’s Serial Number (MSN) of the ill-fated aircraft is 36333, Line No. 2481 and it was manufactured during the year 2008. This Boeing 737-800 aircraft was delivered to Air India Express during January, 2008. This aircraft had accumulated 7189 Flight Hours and 2829 Landings, till the date of accident.
Brief of the Crew-members:
The Commander of the ill-fated aircraft was Capt Glusica Zlatko , of Serbian origin and British Nationality paired with First Officer HS Ahluwalia, an Indian National, as co-pilot. There were four cabin crew members namely Miss Sujata Survase, Miss Tejal Anil Kumar Kamulkar, Mr Yugantar Rana and Mr Mohammad Ali.
Capt Glusica Zlatko had a total experience of about 10,200 Flying Hours, out of which, he had total Command Experience of about 7630 Flying Hours. He had flown about 2770 Flying Hours as Pilot-in-Command (PIC) on Boeing 737 aircraft. He was examined by the DGCA and issued with authorization called Foreign Aircrew Temporary Authorization (FATA) to operate Indian registered aircraft.
First Officer HS Ahluwalia had a total flying experience of about 3650 hours. He had flown about 3350 hours as Co-pilot on Boeing 737 aircraft and operated 66 flights to Mangalore Airport.
Synopsis of the accident:
Air India Express Boeing 737-800 aircraft VT-AXV was operating scheduled Flight No IX-812 from Dubai to Mangalore on 22nd May, 2010 with 160 passengers and 6 crew members on board. This aircraft was given clearance to land on runway 24 by the Mangalore Air Traffic Control (ATC) Tower. However, during landing, the aircraft departed the paved surface including the Runway End Safety Area (RESA). The right wing impacted the localizer structure at the end of the RESA. Thereafter, the aircraft hit the boundary fence, fell into the gorge and caught fire. Due to impact and fire, the aircraft was destroyed. In this tragic accident, 152 passengers and 6 crew members lost their lives. Seven passengers sustained serious injuries and one person escaped with minor bruises.
Rescue Operations:
The rescue operation was initiated by the officials of Airport Authority of India (AAI). AAI and Air India Express were assisted by the officials of District Administration. Local population was involved in the rescue operation In full force and their involvement was appreciated by all concerned. The survivors were rushed to nearby hospitals for treatment. Thereafter, Volunteers of Air India Emergency Response Team, commonly known as Air India Angels, worked tirelessly to provide succour to the injured and to the bereaved families.
Analysis of CVR and DFDR:
A team consisting of three members of the Court of Inquiry left for Washington DC, USA from 21st to 25th June, 2010 for analysis and decoding of the CVR and DFDR at the facilities of M/s National Transportation Safety Board (NTSB), Government of United States of America. All the activities were carried out under strict supervision of the Court of Inquiry.
The data recovered from these Recorders is being analysed by the Court along with other material evidence.
Notification:
A notification is being published in the News Papers inviting any information or evidence on this accident. Such information should reach the court by 20th July 2010 by Post, Fax or e-mail as per the details given below:
Shri SN Dwivedi
The Secretary to the Court of Inquiry – Boeing 737-800 aircraft VT- AXV accident at Mangalore
Office of DGCA, Technical Centre,
Opposite Safdarjung Airport,
New Delhi 110003
Tel. 011 24611357
Fax. 011 24692374
e-mail coi.voml@gmail.com
coivoml.moca@nic.in
sndwivedi@hotmail.com
Public Hearing:
The Court also plans to hold Public Hearings at Mangalore and Delhi for the convenience of those who wish to participate in the deliberations. Dates and Venue of these Public Hearings will be notified at a later date.
