Post 787 fire, UK air accident investigator recommends review of all Lithium powered ELTs on all aircraft

by Devesh Agarwal

The United Kingdom's Air Accidents Investigation Branch (AAIB) has issued a special bulletin (read PDF here) on the fire that broke out on Ethiopian Airline's Boeing 787-8 Dreamliner ET-AOP, parked at London's Heathrow airport last Friday.

In the report, the AAIB said the fire occurred in the rear upper fuselage where the fixed Emergency Locator Transmitter (ELT) is located. The ELT model RESCU406AFN is made by US aviation major, Honeywell International.

The report says

Detailed examination of the ELT has shown some indications of disruption to the battery cells. It is not clear however, whether the combustion in the area of the ELT was initiated by a release of energy within the batteries or by an external mechanism such as an electrical short. In the case of an electrical short, the same batteries could provide the energy for an ignition and suffer damage in the subsequent fire.

There are no other aircraft system in this area of the plane which, with the aircraft unpowered, contained stored energy capable of causing such a fire,

However, the report also gives some benefit of doubt to Honeywell, saying

The ELT manufacturer has produced some 6,000 units of this design which are fitted to a wide range of aircraft and, to date, the incident on 12 July 2013 has been the only significant thermal event

The AAIB has made two safety recommendations in its report:

Safety Recommendation 2013-016
It is recommended that the Federal Aviation Administration initiate action for making inert the Honeywell International RESCU406AFN fixed Emergency Locator Transmitter system in Boeing 787 aircraft until appropriate airworthiness actions can be completed.

Safety Recommendation 2013-017
It is recommended that the Federal Aviation Administration, in association with other regulatory authorities, conduct a safety review of installations of Lithium-powered Emergency Locator Transmitter systems in other aircraft types and, where appropriate, initiate airworthiness action.

Aircraft manufacturer Boeing released a statement saying

As a party to the investigation, Boeing supports the two recommendations from the UK Air Accidents Investigation Branch (AAIB), which we think are reasonable precautionary measures to take as the investigation proceeds. We are working proactively to support the regulatory authorities in taking appropriate action in response to these recommendations, in coordination with our customers, suppliers, and other commercial airplane manufacturers.

We are confident the 787 is safe and we stand behind its overall integrity.

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Comptroller and Auditor General of India report on PPP at Delhi Airport

In a report titled "Implementation of Public Private Partnership, Indira Gandhi International Airport, Delhi" the Comptroller and Auditor General of India (CAG) has found faults in almost every step of implementation of the Public Private Partnership (PPP) model in the brownfield privatisation of New Delhi's Indira Gandhi International Airport (IGIA).

While acknowledging the PPP was the correct method to follow and praising the airport operating company Delhi International Airport Ltd., (DIAL) owned by a consortium headed by GMR Group,

It is acknowledged in this report that there have been significant improvements in services at the airport for the travelling public. The new terminal T3 was completed within time for the Commonwealth Games. The airport has been adjudged as the second best in the world in the category of 25-40 million passengers per annum by Airports Council International.

the report is probably the most damning indictment of former civil aviation minister Praful Patel and the ministry he led during the period of the airport privatisation.

Many observations in the present report would indicate that whenever DIAL raised an issue regarding revenue to accrue to it or expenditure to be debited to Government in contravention of the provisions of OMDA, the Ministry and AAI interpreted the provisions always in favour of the operators and against the interest of the Government.

The report accuses the Ministry of Civil Aviation, headed by Mr. Patel, of violating laws, and providing post contractual benefits to DIAL, to the detriment of the government as well as the travelling public.

Ministry of Civil Aviation and later AERA allowed DIAL to collect Development Fees amounting to Rs. 3415.35 crore. The order of Ministry in February 2009 allowing that was in contravention of the OMDA, AAI Act and the AERA Act.

Contrary to the provisions of OMDA, DIAL was allowed to use the amount collected as Development Fees to meet the project costs. In fact, only 19 per cent of the project cost came from equity, approximately 42 per cent came from debt. The remaining project costs were met from security deposits and Development Fees.

The report also highlights where DIAL was given benefits significantly over and above Government departments

It was noted that the concept of upfront fee was used to lease out an additional land of 190.19 acres for a paltry one time payment of Rs. 6.19 crore. Other Government offices like Director General of Civil Aviation and Bureau of Aviation Security were given a much harsher treatment when 7.60 acres of land was leased out to them at a license fee of Rs. 2.41 crore per annum.

The report highlights how by omitting the phrase “mutual agreement and negotiation of terms” which was present in the note approved by the Union Cabinet, but removed in the concession agreement OMDA, DIAL has unilateral rights to extend the concession period for an additional 30 years at the original already grossly under-rated terms of the OMDA.

The decision to adopt the joint venture route was taken based on the Cabinet Note of September 2003. While seeking approval for restructuring of the Delhi and Mumbai Airports, this Cabinet Note specifically envisaged an initial concession period of 30 years which could be extended by another 30 years subject to "mutual agreement and negotiation of terms". However, in the draft OMDA which formed part of the bid documents, the important condition "subject to mutual agreement and negotiation of terms" was omitted. The OMDA, which was signed in April 2006, did not contain any provision of mutual agreement and fresh negotiations before extension of the concession period. This is not only a violation of the commitment in the Cabinet Note but is also a unilateral and unfair advantage given to DIAL which is detrimental to Government interest as it does not provide the Government any scope for review of any of the conditions.

The report also highlights the liberal manner of how the OMDA is written to favour DIAL.

The possibility of any JVC event default in the small window of 5 years between 20th and 25th year is remote. Such a sweeping provision, without any scope of review at any time during the currency of the concession period, has effectively granted DIAL the sole right to operate the airport for a period of sixty years with the terms and conditions frozen in the OMDA.

Editor's note: The relaxation of requirements or confining performance to an extremely narrow window is a common thread found in virtually every India PPP airport concession agreement, all of which were signed during the tenure of Mr. Patel as civil aviation minister.

The report alleges the virtual give-away of land to DIAL, accusing the Ministry of giving DIAL land worth more than Rs. 24,000 Crore for a sum of Rs. 31 lakhs, and an annual payment of Rs. 100 only.

The projected earning capacity of this land in terms of license fee over the concession period of 58 years was indicated by DIAL itself as Rs. 681.63 crore per acre in a letter to the Joint Secretary, MOCA. Thus for the entire area of 239.95 acres, the potential earning from the land, according to the calculations worked out by DIAL itself, amounts to Rs. 1,63,557 crore. Audit would like to draw attention to the fact that this area is part of the entire area of land that has been handed over to DIAL at the lease rent of Rs. 100 per annum.

It has been ascertained from AERA [Airport Economic Regulatory Authority] that the current valuation of the land made by M/S Merrill Lynch in the report of 26th August, 2011 has been worked out at the rate of Rs. 100 crore per acre. Thus even in terms of this conservative estimate, the total current value of the land available to DIAL for commercial exploitation, would amount to approximately Rs. 24,000 crore.

Audit is constrained to observe that against the aforementioned calculations, MoCA [Ministry of Civil Aviation] allowed DIAL to use 239.95 acres of land for commercial exploitation at a consideration for one time payment of Rs. 31 lakh (5 percent of Rs. 6.19 crore) and an annual payment of Rs. One hundred only.

Both DIAL and the Ministry of Civil Aviation have refuted the observations of the CAG. In a release DIAL said

The Comptroller and Auditor General (CAG) has tabled a report on the Implementation of Public-Private Partnership at Indira Gandhi International Airport before the august Houses of the Parliament.

This report pertains to an audit conducted by the CAG on the performance of the AAI with particular reference to the privatization process of Indira Gandhi International Airport (IGIA). Therefore, the appropriate and competent authority for redressal of all queries on this issue is the Airport Authority of India (AAI) or the Ministry of Civil Aviation (MOCA).

Even though many of these issues have already been discussed between the ministry and auditors and were responded to in detail, they have not been reflected in the final report. Even the former Secretary Civil Aviation had expressed this view in a separate letter to the Audit Authority.

Hence, we feel sad that a showcase airport created with dedicated efforts and a well-thought-out policy of the national government has come in for adverse remarks. We have also noted with concern that the reputation of this company has been questioned regularly in the media based on incomplete and inaccurate facts. Hence, purely in order to put the records straight, we would like to state the following without prejudice to our rights:

1. Delhi International Airport Private Limited (DIAL) has NOT received any undue benefits from the government before, during or after the bidding process. The entire process of the privatization and selection of Joint Venture was based on a transparent, international, competitive bidding which was guided and presided over by competent bodies and has been upheld as such by the Hon’ble Supreme Court in 2006.

2. It is alleged that with the airport modernization project DIAL was effectively handed over land valued at Rs. 1,63,557 Crore for only Rs. 100 per year.

a. The purpose of leasing the airport land by AAI to DIAL was neither sale of land nor earning of a rental income from it.

b. The basis of providing the concession to operate the airport was the revenue share quoted by the bidders to AAI.

c. The entire commercial land available with DIAL neither has any immediate commercial value nor can be put to use and therefore cannot be monetized immediately. Thus, just using value of one acre and extrapolating the same for the entire land parcel is at best an arithmetic exercise and not practical.

d. In fact, using the same method of calculation, AAI will receive Rs. 3 to 4 Lakh Crore from DIAL as revenue share over the 54 years.

3. The allegation that Airport Development Fee (ADF) was an afterthought and done only to benefit DIAL is absolutely untrue:

a. ADF is allowed as per section 22 A of AAI Act 1994 as amended in 2003 – long before the bidding process – and hence was known to all bidders

b. AAI Act is the primary governing legislation for the concession as provided in the transaction documents

c. The levy of ADF was upheld by the Hon’ble Supreme Court vide its order dated 26th April 2011

4. The concession period of 30 years with 30 years extension being an unfair advantage to DIAL is also not true:

a. Such long concession periods are quite normal in infrastructure projects where the investment is large and gestation period is long

b. Moreover, as this was a bid condition known to all bidders, they had already considered this condition while quoting the bids

The Indira Gandhi International Airport (IGIA), Delhi is a shining example of the success of PPP model of infrastructure development in India. IGIA is currently rated as the second best airport in the world in the 25-40 million passengers per year category. The current Airport Service Quality (ASQ) rating of IGIA stand at 4.73/5.00 which far exceeds that stipulated in the concession agreement - at 3.75/5.00. It is currently the largest airport in India - catering to 36 million passengers per annum (mppa), handling 600,000 tonnes of cargo and managing over 300,000 aircraft movements every year. According to NCAER, IGIA contributes 0.45 per cent to the national GDP and 13.53 per cent to state GDP of Delhi. It has also created 15,78,000 jobs which is 25.9 per cent of Delhi’s total employment and 0.34 per cent of national total employment.

The Ministry said

Ministry of Civil Aviation has gone through the report of the CAG on Indira Gandhi International Airport, Delhi as tabled in Parliament today and strongly refutes the loss figures and other allegations as made in the report.

The calculation of presumptive gain from the commercial use of land at the Delhi Airport is totally erroneous and misleading as it simply adds the nominal value of the projected revenue, without taking the net present value. In fact the net present value of the figure quoted by CAG is Rs 13795 crores only. CAG has further failed to appreciate that 46% of this amount would be payable to AAI as revenue share.

It is also pointed out that the levy of Development Fee is under Section 22 (A) of AAI Act, 1994 and was in the knowledge of all the bidders prior to the bidding process. Hence, contrary to what the CAG has said, the levy of Development Fee by DIAL was not a post contractual benefit provided to DIAL at the cost of passengers. Further, the levy of the Development Fee has been upheld by the Supreme Court, which has already examined and rejected all the issues now being raised by CAG in its report.

On the issue of lease of Airport land, it is clarified that the land has not been given to DIAL on rental basis. Rs100 is just a token amount for the purpose of the Conveyance Deed. The determining factor for grant of concession to the bidder was the Gross Revenue share quoted by the bidders. As a result, Airports Authority of India (AAI) now receives 45.99% share of Gross Revenues of DIAL and 26% of all Dividends. Benefit to AAI is likely to be more than Rs 3 lakh crores in this process during the entire Concession period. AAI has already got its revenue share of Rs.2936 crores in the last 6 years and likely to get Rs. 1770 crores in the year 2012-13 and Rs. 2287 crores in the year 2013-14. The AAI share of revenue from DIAL is further going to constantly rise every year in the balance concession period.

It may also be noted that the right to use 5% of Airport land for commercial purpose was also defined in the bid and known to all bidders.

The decision to restructure and modernize Delhi and Mumbai Airports was a policy decision of the highest body i.e., the Cabinet following the broad policy formulations of Policy on Airport Infrastructure, 1997. The modalities of modernization/ restructuring were as per the Cabinet decision and were frozen in the Transaction Documents finalized and approved by the Empowered Group of Ministers (EGoM), based on which the bidding process was completed. The issues now being highlighted in the CAG report, viz. Concession Period, Right of First Refusal (ROFR), Upfront Fee, Commercial exploitation of land, and Lease rental of land were part of these documents and were symmetrically known to all bidders before bidding and during the bidding process. These documents were later converted into different agreements, like Operation Management and Development Agreement (OMDA), State Support Agreement (SSA), Shareholders Agreement (SHA), Lease Deed Agreement, CNS-ATM Agreement, and State Government Support Agreement (SGSA), and there has been no change in these documents ever since.

All decisions including the entire bidding process and the approval of the OMDA was monitored by EGoM and subsequently approved by the Union Cabinet. The bidding process has also been upheld by the Supreme Court.

All Aeronautical and Airport assets created by DIAL will be transferred back to AAI as per agreement at the end of the concession period.

It is further stated that the views of Ministry of Civil Aviation and AAI have not been incorporated in the final report of the CAG and there are aspects mentioned in the final report which were neither included in the draft audit report nor were discussed with the Ministry of Civil Aviation at any point in time.

It is pertinent to mention that CAG in its report has itself acknowledged the significant improvement in the services for travelling public, new terminal T-III being completed within the time frame for Common Wealth Games and Delhi Airport being adjudged the second best in the world in the category of 25 to 40 million passengers per annum by the Airports Council International.

India has few world class Airports achieved in a very short span of time. Reports like these would damage the process of PPP and stunt infrastructure development in the country.

The brief parawise comments to the CAG report on IGI Airport are attached as Annexure and are also available on the website of Ministry of Civil Aviation.

Click here to see Annexure

You can download the entire CAG report on DIAL here. Do read it, and share your thoughts.

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New terminal at Lucknow airport found defective

A note from the Press Information Bureau of India about Lucknow airport, which is incidentally named after the father of present civil aviation minister Ajit Singh. The airport is owned and operated by the Airports Authority of India.

Taking a serious note of the complaints of irregularities in the construction of the New Terminal Building of the Chaudhary Charan Singh Airport, Lucknow, Union Minister of Civil Aviation, Shri Ajit Singh has decided to refer the matter to the Chief Technical Examiner’s Wing of the Central Vigilance Commission (CVC) for conducting a detailed enquiry into construction of the building. The decision of Shri Ajit Singh is based on a preliminary enquiry report submitted by a committee which was headed by Shri Samir Sahai, Chief Vigilance Officer, Pawan Hans Helicopters Limited. This committee was constituted by the Minister himself following various complaints received from Members of Parliament and news items published in this regard in newspapers. The report submitted by the enquiry officer has prima facie substantiated various defects in the construction quality, design and maintenance of Lucknow Airport Terminal.

The committee members visited the Airport in Lucknow and found the quality of work of the New Terminal Building below standard. The major defects included leakages from the roof above the check-in counter, in the ceilings near the departure lounge corridor and from some of the thermal expansion joints. The rain water harvesting method was also found prone to leakage as proper drainage system was not in place. The Committee also found that the flooring in the Arrival and Departure Terminal was not proper with granite stone cracking at some places. The electrical fittings were also not properly fixed up at many places. The overall maintenance of the building was found in poor condition, despite the fact that it was inaugurated only about two months back.

As the Committee was of the view that the architectural design as well as construction shortcomings and defects and quality of work need to be verified in detail, it was decided to refer the matter to the CVC. The building was constructed by M/s IPL, Brahmaputra Infrastructure Ltd. (JV) at a cost of about Rs. 90 crore out of which Rs. 85 crore has already been paid to the contractor. This is also noteworthy that the award of the construction was finalized in October 2007 and stipulated date of completion was April 2009. However, the completion was delayed and completed in May 2012. Inauguration of the airport was done on 19th May 2012. The Civil Aviation Minister has taken a serious note of the fact that the airport was inaugurated without ensuring the complete and quality construction. The Minister has clarified to the authorities that stern action will be taken against those found guilty.

The contractor has already received almost all his money. The delay of three years itself would have invoked certain cost escalation clauses in favour of the contractor. What are your views on these developments? Will the true facts ever see the light of day? Will ALL those guilty and culpable face justice?

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NTSB traces Air India Boeing 787 GEnx engine failure to fan mid-shaft fracture

The United States National Transportation Safety Board (NTSB) released an interim report on the progress of its investigation in to the failure of a General Electric GEnx engine on-board a Boeing 787 Dreamliner destined for Air India on July 28th last. The have traced the failure to a fracture on the forward end of the Fan Mid-Shaft.

Bangalore Aviation has exclusive obtained this exemplar image showing approximate location of the failure.

The National Transportation Safety Board continues its investigation of the July 28, 2012 contained engine failure that occurred on a Boeing 787 Dreamliner during a pre-delivery taxi test in Charleston, South Carolina. A contained engine failure is a specific engine design feature in which components might separate inside the engine but either remain within the engine’s cases or exit the engine through the tail pipe. This design feature generally does not pose immediate safety risks.

Last week, the NTSB sent an investigator to the scene to gather information on the incident and subsequently launched a full investigation into the cause of the failure, led by NTSB Investigator-in-Charge, Mr. David Helson.

On August 1, 2012, a team of experts from the NTSB, FAA, Boeing and GE Aviation specializing in engine systems and metallurgy traveled to a GE facility in Cincinnati, OH to disassemble and examine the failed GEnx engine. GE is the manufacturer of the GEnx engine. The parties to the investigation have been extremely cooperative in assisting NTSB personnel in its review and assessment.

As a result of the investigative work to date, the NTSB has determined that a fan mid-shaft on the failed GEnx engine fractured at the forward end of the shaft, rear of the threads where the retaining nut is installed. The fan mid-shaft is undergoing several detailed examinations including dimensional and metallurgical inspections.

GEnx engine cut-away drawing not part of NTSB release.

The GEnx engine is a newly designed aircraft engine. It is a “dual shaft” engine, meaning that one shaft connects the compressor spool at one end to the high pressure turbine spool at the other end. A longer “fan shaft” connects the fan and booster in the front of the engine to the low pressure turbine in the back.

The cockpit voice recorder and flight data recorder, which is a combined unit on the 787 Dreamliner, was transported to the agency's Recorders Laboratory in Washington, DC for processing and readout. Both recordings captured the event and analysis is ongoing.

Moving forward, investigators will continue the detailed examination of the engine and metallurgical analysis of its components. The investigators have also begun reviewing the engine manufacturing and assembly records.

This investigation is ongoing. The information released today is factual in nature and does not include any analysis. Additional factual information may be released as it is developed.

Engine experts in India say that the main component carrying shafts inside an engine are an important part of the engine, but it is too early to say whether this fracture was caused due to materials flaw, a fault in manufacturing, or a design flaw. Depending on the reason for failure, it has the potential to become serious. However, the NTSB has not issued any recommendations yet. Boeing is due to deliver a GEnx powered 787 to Ethiopian Airlines early next week.

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Opinion: DGCA fiasco highlights need to resolve conflicts of interests in civil aviation ministry

The abrupt removal of India's chief civil aviation regulator, the Director General of Civil Aviation, Mr. E.K. Bharat Bhushan, earlier this month, once again brings forth the cross-workings within the ministry of civil aviation, caused by contradictory roles, many of which are driven by political agendas, and the urgent need to re-structure this mammoth ministry to correct the malaise.

Indian civil aviation minister Ajit Singh. PIB Photo.

Mr. Bharat Bhushan, an Indian Administrative Service (IAS) officer of the 1979 batch from Kerala, who took over the role of DGCA from Mr. Syed Nasim Ahmad Zaidi in December 2010. He enjoys the highest levels of respect for his integrity, ethics and generally apolitical decision making.

The reasons behind his sudden dismissal have fuelled speculation on the reasons. Within aviation industry circles, there is a strong sense of certainty that Bharat Bhushan was done in, partially due to a political turf war between the ministry and the Prime Minister's Office (PMO), and in large part due to his strong ethical stand on a variety of issues plaguing the industry.

During his tenure Bharat Bhushan brought in stringent measures to prevent airlines and the DGCA itself, from compromising on safety. He prosecuted a variety of flying schools and government officials in the fake pilots scam, and took on two holy cows, Air India and Kingfisher Airlines. He has repeated told both the financially plagued carriers to shape up and pay employees overdue salaries saying that safety could be adversely affected by a demotivated staff.

Post his departure, news reports have appeared showing his purported note to his successor Prashant Sukul that he had prepared for taking action against cash-strapped Kingfisher Airlines on safety grounds. The cat has been set amongst the pigeons with the ministry saying it cannot find the note and will ask Bhushan for the note.

This wrangling is nothing new. The civil aviation is a behemoth with many departments and entities under it, most of which, have contradictory roles and by the very nature of their function, work at cross purposes to each other. Even in Utopian conditions it is impossible make all these roles co-exist within one ministry and still perform true to their charter, and at optimal levels, and this is the Government of India, one not highly rated on governance.

The ministry itself is a policy maker, but also an airport operator through Airports Authority of India (AAI), and airline operator through Air India (AI). Within AAI, there are airport operations and a monopoly air traffic control, navigation, and communications system which is used for further cross-subsidy.

Global competitiveness have forced aviation operations to operate on extremely high levels of efficiency, not the forte of any government. This naturally demands some concessions for government run operations, and the Indian airline industry is already sick thanks to skewed policies designed to protect AAI and AI.

In its natural role, the ministry is a promoter of air travel which requires easing of regulation, but via the DGCA it is also the regulator and in most cases, also the investigator. You will observe that I have deliberately left out the role of enforcer or prosecutor. The most basic rules of administration demand a separation of policy formulation, operation, regulation, audit, investigation, and enforcement. In all publicly listed companies there is always a separate audit committee within the Board of Directors.

Yet ministry officials are routinely shifted across roles. Let us take the current acting DGCA Mr. Sukul. He is a Joint Secretary in the ministry. In addition to the regulator, auditor, enforcer role at DGCA, Mr. Sukul is also a member of the board of Air India, an airline, the DGCA has to regulate, audit, and enforce the rules on. Similarly, the joint DGCA Mr. Anil Srivastava, is also the Chairman and Managing Director of state owned helicopter operator, Pawan Hans Helicopters. These are conflicts of interest at the most basic level. We have to be delusional not to expect compromises being forced on these and other officials within the ministry.

On these obvious conflicts of interest, the civil aviation ministry seems to be a law unto itself. It has ignored calls from no less a body, than the Appointments Committee of the Cabinet, which is the government's apex body for high level bureaucratic appointments, and headed by the Prime Minister, which had asked the ministry to relieve Anil Srivastava from his leadership of Pawan Hans to resolve the blatant conflict of interest.

A lot of this cross working was exposed in the report on the crash of Air India Express Boeing 737-800 VT-AXV at Mangalore Bajpe airport in 2010.

Despite significant short-comings none of the ministry controlled entities were faulted. AAI, the airport operator, which did not construct frangible buildings at the runway, as required at every major airport in India, nor the DCGA, which conducts the inspections, and ensures these facilities before approval, were both let off with the gentlest of slaps on the wrist, for not performing their duties.

The question before us, is what caused these officers to under-perform? Which of these four C's is most plausible? (in)competence? callousness? corruption? conflict (of interest)?

It is imperative that Indian aviation be protected. Various entities within the ministry need to be made truly independent and taken out of its control.

The recommendation, in the crash report, for an independent investigative board, remains a distant dream. The board may come one day, but we can be certain, that a truly independent board, not reporting within, controlled by, and therefore subservient to the civil aviation ministry, and its political shenanigans, will never be implemented.

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BEA's final report on the crash of Air France AF-447

Image courtesy BEA

France's Bureau of Investigations and Analysis’ (BEA) submitted its final report on the crash of Air France flight AF-447 flying from Rio de Janeiro to Paris, killing all 228 passengers and crew on-board.

The final report essentially re-states what has already been released till date.

The crash commenced with ice crystals blocking the pitot tubes, sending false information to the flight computers and causing the autopilot to shut down while the plane was at cruising altitude, and a reconfiguration of flight controls to alternate law.

A confluence of factors, including a barrage of alarms coupled with inadequate training of the flight crew, and false sensor readings, completely surprised the crew. As per the report "The crew likely never understood that it was faced with a ‘simple’ loss of all three sources of airspeed information.”

In a series of errors, the pilots relying on erroneous readings never recognised they were in a stall and kept nosing the Airbus A330 aircraft upward, rather than downward as was necessary. Chief investigator Alain Bouillard said "The crew was in a state of near-total loss of control". Ironically the flight captain, who was on a rest break, did not return to the cockpit until it was too late.

The BEA has passed the blame all around and its recommendations call for more training of pilots, an improved layout of cockpit instruments and warning systems to help crew better recognise and manage unusual flight situations, and thorough review of the flight director software..

Investigators recommended that the European Aviation Safety Agency (EASA) require the aircraft manufacturer Airbus S.A.S. to review the flight director’s design and to possibly modify the software so that it either disengages permanently in the event of a stall or displays “appropriate orders” when a stall warning is set off.

Read more details at the BEA's page for AF-447.
Read the final report here.
Read the final report summary here.

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DGCA withdraws report on Kingfisher plane crash-cover-up or shoddy investigation?

Post the Air India Express crash at Mangalore, there have been calls across the country for greater transparency within the administration, policy, regulatory, and investigative units of India's civil aviation system.

With the exception of the famous incident involving President Pratibha Patil's helicopters in a near-miss with an Air India aircraft at Mumbai, with a view to increasing transparency, for the first time, India's regulator and investigator the Directorate General of Civil Aviation put up investigation reports on its website which did not involve the loss of life. One was regarding the crash of a Kingfisher Airlines ATR-72-500 aircraft VT-KAC at Mumbai on November 10, 2009, the other was concerning the sudden loss of altitude of an Air India Express Boeing 737-800 aircraft VT-AXJ en-route from Dubai, UAE to Pune, India on May 26 this year.

Yet, before most media in India could react, the DGCA pulled the Kingfisher report of its website. Luckily, the Indian Express reported most of the pertinent parts of the report. As per the Indian Express the DGCA has faulted the crew of the airline and ATC officials.

In its report, the DGCA says that the crew was not qualified to fly into the Mumbai airport during the shortened runway operations as the commander had not been a ‘training captain’. The crew did not take a decision to ‘go around’, despite an unstabilised approach at the time of landing. It adds that there was a breakdown in the ‘crew resource management’ as the commander —a 47-year-old veteran — did not conduct the correct briefing at Mumbai and Bhavnagar and the 34-year-old co-pilot, who was making her first landing on the shortened runway at Mumbai, did not offer the correct feedback to ‘go around’ at a crucial juncture. It has called on the airline to impart corrective training to the crew. DGCA has also pulled up the ATC for not warning the Kingfisher commander that a previous Air India flight had aquaplaned. Aquaplaning is a phenomenon when there is a thin film of water between the aircraft tyres and the runway, which reduces friction. The report says that the ATC officer had admitted to the DGCA team that he had not understood the word ‘aquaplane’, and not passed on the information to the Kingfisher commander.

The very next day, the Times of India reported about the withdrawal of the Kingfisher report, suggesting the report was withdrawn due to excessive technical faults and incorrect information. The paper also suggests that the Kingfisher "incident" was not classified, by thye DGCA, in contravention of ICAO rules an "accident", despite a significant damage to the aircraft hull. The Times of India report goes on to suggest that this was done to benefit Kingfisher Airlines which would have had to pay higher insurance premiums if it had suffered an "accident".

The Air India Express VT-AXJ report can be read here in PDF format. The report concludes the dive and loss of altitude occurred due to the incorrect handling of the flight control column by the co-pilot in automated mode and his lack of knowledge on how to correct the situation.

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