Near miss at Mumbai airport: accidents waiting to happen11/06/2009
Near miss at Mumbai airport: accidents waiting to happen
A potentially horrendous disaster was somehow averted at Mumbai airport on May 31. Two aircraft with close to 250 passengers and crew on board simultaneously tried to take off from Mumbai’s two intersecting runways and would have collided with each other but for last minute action by both pilots and Air Traffic Control (ATC) to abort the take-offs. As is customary in such cases, an inquiry is being conducted by the Director General of Civil Aviation (DGCA) while the pilots and the air traffic controllers involved have been taken off duty pending the investigation. No firm conclusions can therefore yet be drawn as to causes. But again as usually happens in India leaks and rumours are flying thick and fast, obscuring the truth and building up a smokescreen behind which everyone, and thus no one in particular, is to blame. Yet there are already a number of indicators pointing to structural problems in Indian civil aviation safety with many factors contributing to accidents just waiting to happen.
The near collision In aviation parlance, a “near miss” is an “unplanned event that did not result in casualties or damage”. Many experts however believe that the term “near collision” is a more useful term since it better captures the reality that an accident almost occurred, rather than appearing to somewhat contradictorily suggest, as “near miss” does, that an accident was almost avoided. In any case, the point is that near collisions are always closely studied worldwide because fortunately, they happen hundreds or thousands more often than actual accidents and, at no cost, they provide invaluable lessons about what could go wrong, how and why, and what corrective steps need to be taken to prevent future such occurrences especially at the systemic level of safety procedures and institutional safeguards. The near collision in Mumbai occurred when Air India’s Airbus 310 flight 348 to Delhi was speeding down one runway (Runway 9-27) prior to take-off, while simultaneously Jet Airways Boeing 737 9W-651 to Kolkata was similarly building up speed for take-off on the other intersecting runway (Runway 14-32). IC-348 was traveling at 70-80 knots (127-145 kmph), whereas the Jet craft was traveling at 90-100 knots (164-182 kmph), dangerously close to the “decision speed” (beyond which aborting take-offs could cause a crash) of 129 knots for B-737. Fortunately, ATC noticed the Air India plane rolling and directed the pilot to abort take-off, and the Jet pilot managed to do the same, apparently on his own initiative. How both aircraft were rolling to take-off at the same time, what instructions did they receive from ATC and when, and how exactly was the accident avoided, are precisely the subjects of the mandatory investigations now on.
Ambiguous communication Pilots of both the aircraft insist they had received clearance for take-off from ATC. If this is found to be true from examination of the radio-communication recordings, which surely should have become available and been fully transcribed by now, then the controllers in question have a lot to answer for. Equally, ATC could not knowingly have cleared two aircraft for take-off simultaneously on intersecting runways. Clearly some miscommunication had occurred, either by the ATC or by one or both of the pilots in understanding instructions received from ATC. ATC spokesmen said take-off clearance had been given only to the Jet flight, not to the Air India flight and that, when the latter was noticed traveling down the runway, it was ordered to stop. A General Manager of the Airport responsible for air traffic and other air-side operations reiterated this position. But a spokesman for Air India insisted that ATC had given its pilot clear instructions: “AI 348 cleared for take off, Runway 27”. However, according to some press reports, the spokesman also stated that “the AI flight was cleared for take-off and after that the pilots were asked to hold.” If so, this would be astonishing indeed for, once “take-off” is “cleared”, there is no question of telling the aircraft to “hold” or wait anywhere! If the controller’s intention was to tell the Air India plane to taxi to Runway 27, hold and be ready for take-off, then the instruction should not have used the words “cleared” or “take-off” but “ready”, “hold” and “departure” instead. Further, whatever instructions were issued by ATC, these would have immediately been repeated verbatim to ATC by the pilot as per standard operating procedure to confirm the instructions eg “Roger, Control, AI-348 cleared and ready for take-off, Runway 27,” which would have given ATC another chance to realize the error and stop the aircraft from rolling. The cockpit voice recordings should clear up what instructions were issued and acknowledged. It is surprising indeed that, more than 10 days after the incident, doubts on this score have been allowed to linger despite DGCA having said that the inquiry would be completed in a “couple of days”. Air traffic control procedures are designed to obviate misunderstandings. Given differences in nationality, language, idiomatic usage, accents etc, standard and unambiguous terminology in English has been approved by the International Civil Aviation Organization (ICAO) and is used by controllers and pilots worldwide. In one of the worst air accidents ever, two Boeing 747 Jumbo jets collided on the runway at Tenerife airport on a Spanish island in 1977 killing over 600 passengers and crew, when one of the aircraft was “cleared for take-off” by ATC who actually meant to tell the pilot to wait for further instructions! Since Tenerife, the word “take-off” is never used except when actually setting the aircraft rolling on the runway. Similarly the words “cleared” and “approved” are never used except to signal go-ahead for final actions. In another near-miss, a pilot who was told to taxi and hold “short of the runway” could not understand the idiomatic English and thought he was being told to “cross the runway” and almost did! With pilots of different nationalities flying aircraft all over the world, including on aircraft under wet-lease with foreign pilots flying on domestic routes, there is even greater need to ensure precise unambiguous communication.
Under-staffed, under-trained, overworked ATCOs Unfortunately, incidents involving air traffic control are becoming more common not only because of increasing air traffic, especially in India with over 20 percent growth per year, but also due to a critical shortage of well-trained air traffic controllers (ATCOs). This is a worldwide phenomenon, but India is among the worst afflicted, with several additional structural problems at the heart of aviation safety and civil aviation infrastructure and institutions. Almost the entire emphasis of government in the past decade or more under both the NDA and UPA dispensations has been on privatization of airlines and airports, and on deregulation of civilian aviation in general. As a result, air traffic has expanded exponentially, but air traffic infrastructure and safety measures have not kept pace, and scant attention has been paid to these by government authorities. Delhi and Mumbai airports are both now under private management with foreign collaboration, an idea pushed through by the UPA government in the face of stiff opposition by Left parties, Airports Authority staff and many aviation experts all of whom argued that privatization of terminal and city-side operations would not add any value to airport operations whose main problems lay in poor air-side infrastructure and air-traffic management. Today, both these airports handle more than 700 flights daily, but with barely 100 ATCOs each. In India as a whole, there are about 1000 ATCOs compared to an estimated requirement of 2500, and the recruitment pipeline is too thin to meet demand. ATCOs are recruited directly by AAI through examinations and interviews, and then sent for a year-long training programme in the single training institute in Allahabad that can handle only about 30 trainees in each batch. Another training academy planned in Hyderabad is yet to start work. Unlike many other countries, India does not have a system of licensing ATCOs as prevails with pilots, which could have increased the available pool. And the quality of training too, with few refresher courses, leaves much to be desired. In most advanced countries, and in several developing nations, ATCOs are considered a special type of air service provider like pilots, due to the unique and important roles and responsibilities of both, with distinct working conditions and remuneration patterns. The International Labour Organization (ILO) holds that “ATCOs… have problems which are unique to their profession, and their concern with safety could broadly be compared with that of pilots.” In fact in many European countries, ATCOs operate under an entirely separate organization as in the UK’s National Air Traffic Service. Not so in India where ATCOs are just another set of AAI employees. The problem of inadequate numbers of ATCOs, the managerial preference for paying overtime even at the cost of ATCO fatigue rather than bear the costs of recruiting and training additional ATCOs is undoubtedly a worldwide phenomenon. But it has assumed enormous proportions in India threatening to overwhelm the entire system.
Infrastructure & Institutional Reform Added to this is the problem of inadequate infrastructure and delays in or failure to upgrade technologies. Air Surface Movement Ground Control Systems should have been procured and installed at all major airports but are currently available only in Delhi and Mumbai, with fog-prone Kolkata having been sanctioned one after a near collision in January this year involving an aircraft aborting landing a mere 300 feet above ground after spotting a cargo plane on the runway! It is another matter that even with this system in place the Mumbai ATC did not notice both aircraft moving towards the intersection point last month! While the AAI is starved of funds and approvals are delayed, the Civilian Aviation Ministry is mostly busy with supporting private airport operators and addressing their concerns on building convention centres and shopping malls to increase their profitability! Justice Lahoti heading the Inquiry Commission into the mid-air collision over Charkhi-Dadri near Delhi in November 1996 killing over 550 people observed that “the workload of [the] Controller was definitely excessive…” He also observed that “the Indian Govt adopted open sky policy but the same has… resulted in… tremendous increase in air traffic without matching additions to ATC infrastructure… For proper growth of civil aviation in the country, the ATC has to be given a special place in the scheme of things or else [our] country will continue to lag behind.” It is ironic that these conclusions should have been reached by an essentially lay person whereas civil aviation authorities have continued to ignore what stares everyone in the face. Recognizing the special function of ATCOs, the ILO recommends that “trade unions and/or the appropriate organisation concerned should be consulted” on all issues relating to ATCOs working conditions and remuneration. In contrast in India the AAI, Government and regrettably even the Courts, have refused to recognize or deal with the ATCOs Guild and have put down every attempt at collective bargaining with an iron hand. Perhaps they are following the example of former US President Ronald Reagan who cemented his reputation as a right-wing conservative by crushing the ATC Unions’ strike early on in his Presidency. Not just the ATC but the entire system of air traffic management in India is crying out for major reforms and vastly improved infrastructure. Without such an overhaul, air safety in India will continue to suffer at high cost to airlines, passengers and the country’s reputation. Two other major institutional reforms are urgently required.
Independent Safety & Regulatory Agencies An independent Regulatory Authority for civilian aviation has been a long-standing demand, keeping in mind the experience of other countries. The US which actually de-regulated civil aviation during the Reagan years, is now living with the consequences of the collapse of many airlines, proliferation of fly-by-night operators and heightened problems of air safety. In India too, the pro-liberalization powers-that-be have resisted calls to set up an independent Regulator to look into routes, fares, flying conditions and so on, and have left it to the DGCA to perform this function too. DGCA already acts as the authority for licensing of airlines and pilots, type certification of aircraft and oversight of air safety. On top of it all, DGCA is also tasked with conducting accident investigations! There is clearly a clash of interests involved here since DGCA signs off on aircraft maintenance and repairs, oversees air services, advises AAI on safety issues and also reports to the Minister of Civil Aviation. How then can one reasonably expect it to conduct accident or near-miss investigations properly, identify responsibility, and also make systemic recommendations which could go against or put pressure on any of its “client” organizations? We still do not know who was responsible for the near-miss in Mumbai involving the President’s helicopter fleet in February this year. Initial investigations pointed to “negligence”, by who is not clear, and a final report is not yet available. In fact, 70 cases of airfield accidents all over India are pending with the DGCA since 2007. As in most cases with DGCA, interim reports have been announced but final reports and follow-up on recommendations are rare. It is high time an independent Air Safety Agency is created in India. The US has the National Transportation Safety Board besides the Federal Aviation Authority, and similar organizations exist in Canada, Australia, France, the UK and most European countries, precisely in order to avoid conflict of interest between bodies responsible for implementation and those called upon to investigate and recommend procedural or legislative changes. These safety agencies abroad have responsibilities spanning air, sea and land. It is too much to expect such cross-cutting of jurisdictions in India but a separate air safety authority is certainly feasible and eminently desirable. A veteran international ATCO (not from India) lamented that although detailed and meaningful recommendations have repeatedly been made “it always takes an accident for things to change.” In India, regrettably, not even accidents or near-accidents seem to change things.