CIVIL AVIATION AIRCRAFT ACCIDENT SUMMARY FOR THE 1. INTRODUCTION The information contained in the publication is 60 th in the series. "Notifiable accidents", which took place in India during the year 2009, have been listed in a classified chronological order along with the summary and the cause of the accidents. There have been five accidents during the year. Four accidents have been investigated by Inspector of Accidents, and remaining one by Committee of Inquery. Four of the accidents proved fatal wherein six crew members, three passengers and one other received fatal injuries. Incidents such as precautionary landings, forced landings, aborted takeoff, air misses, bird strikes etc. are not listed in this publication, although all these have been investigated. The recommendations emanating from all such investigations of accidents and incidents are being implemented for enhancing the level of air safety. Statistical data of accidents and fatalities in respect of airlines operations including flying clubs and aerial operations is given in table 1 to 16. NOTE: All timings given in this publication are in IST (Indian Standard Time). 1
i) Accident 2. Definitions An occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, in which a) A person is fatally or seriously injured as a result of being in the aircraft, or direct contact with any part of the aircraft, including parts which have become detached from the aircraft, or direct exposure to jet blast, except when the injuries are from natural causes, selfinflicted or inflicted by other persons, or when the injuries are to stowaways hiding outside the areas normally available to the passengers and crew; or b) The aircraft sustains damage or structural failure which adversely affects the structural strength, performance or flight characteristics of the aircraft, and would normally require major repair or replacement of the affected components, except for engine failure or damage, when the damage is limited to the engine, its cowlings or accessories, or for damage limited to propellers, wing tips, antennas, Tyres, brakes, fairings, small dents or puncture holes in the aircrafts skin; or c) The aircraft is missing or is completely inaccessible. NOTE: An aircraft is considered to be missing when the official search has been terminated and the wreckage has not been located. ii) Serious Injury: An injury which is sustained by a person in an accident and which: (a) Require hospitalization for more than 48 hours, commencing within seven days from the date the injury was received; or (b) Results in a fracture of any bone (except simple fractures of fingers, toes or nose); or (c) Involves lacerations which cause severe haemorrhage nerve, muscle or tendon damage; or (d) Involves injury to any internal organ; or (e) Involves second or third degree burns, or any burns affecting more than five percent of the body surface; or (f) Involves verified exposure to infectious substances or injurious radiation. 2
Rule 71 - Inspector's Investigation: 3. INVESTIGATION OF ACCIDENTS (Aircraft Rules, 1937) The Director General may order the investigation of any accident involving an aircraft whether such accident is required to be notified under Rule 68 or not, and may, by general or special order, appoint any person (hereinafter referred to as an "Inspector of Accidents") for the purpose of carrying out such investigation. Rule 74 - Committee of Inquiry: The Central Government may, at its discretion, appoint a committee of Inquiry composed of two or more persons to hold an inquiry into an accident in which an aircraft is involved, and such a committee shall have the same powers as an Inspector of Accidents. Rule 75 - Formal Investigations: Where it appears to the Central Government that it is expedient to hold a formal investigation of an accident it may, whether or not an investigation or an inquiry has been made under Rule 71 or 74, by order direct a formal investigation to be held. The Central Government shall appoint a competent person (referred as Court), to hold the investigation, and may appoint one or more persons possessing legal, aeronautical engineering or other special knowledge to act as accessory to the Court. The Court shall hold the investigation in open Court in such manner and such conditions as the Court may think fit for ascertaining the causes and circumstances of the accident and for enabling it to make the report hereinafter mentioned: Provided that where the Court is of opinion that holding the investigation is likely a) To be prejudicial to the interests of any country; or b) To jeopardize the personal safety of a person who is willing to make any statement or give evidence, the Court may hold in camera, the whole or part of the investigation. 3
4. TYPES OF FLYING i) Airline Operation: The operation include all scheduled, non-scheduled and non-revenue flying by Air India, Air India Express, Indian Airlines, Alliance Air, Jet Airways, Jetlite, MDLR, Kingfisher, Go Air, Spicejet, Paramount and Indigo. ii) Non- Operations: The operation includes all non-scheduled ferry; non-revenue, charter and test flying by other operators holding non-scheduled operators permit and engaged primarily in such operations. iii) Flying Training: Includes all flights for the purpose of initial issue of a flying licence, for conversion and practice flying or qualifying for renewal / endorsement of pilots licence and test and ferry flying by organization engaged primarily in flying training. iv) Aerial Work: Includes aerial survey, aerial, mustering on a commercial basis, aerial ambulance, aerial agricultural operations etc. and test and ferry flying by organisation engaged principally in aerial work operations. v) Private and Business: Includes private, pleasure and business flying and practice flying when the flying is not directly connected with the purposes of obtaining a higher licence qualifications. 4
EXPERIMENTAL OPERATION-01 01. Aircraft Type Saras PT2 Registration VT-XRM 02. Date and Time 06-03-2009 03. Location Bidadi, Bangalore 04. Persons on Board Crew 03 Passengers -- 05. Injury Index Fatal Serious Minor/None Crew 03 Passenger Others 06. Damage to Aircraft Destroyed 07. Pilot-in- Command License Age 35 Total Hrs 2414 Hrs SUMMARY Test Pilot, IAF Saras PT2 aircraft VT-XRM manufactured and owned by National Aerospace Laboratories, Bangalore was scheduled on 06.03.2009 for carrying out its test flight including in-flight engine shut down and relight procedure at 10000 AMSL. Chief test pilot was in command. Another test pilot and a Flight test engineer were also on board. Aircraft took-off at 0925 UTC and thereafter changed over to radar. There was no event. After climbing to about 9000 AMSL in sector Southwest aircraft reported 15 miles and FL 90 at about 0948 UTC and reported turning around. But HAL radar as well BIAL radar was showing level 72 for which aircraft replied that it has descended and climbing back to 9000 AMSL. At about 0956 UTC aircraft reported OPS NORMAL at 20Nm in sector Southwest 2. This was the last contact of aircraft with radar but was in contact with FTD telemetry desk of ASTE, Bangalore. After successful left engine shut down and its securing procedure, at about 1001UTC left engine relight procedure was initiated at about 9200 AMSL. During the relighting of left engine, FTD desk also lost contact with aircraft about 37 seconds prior to crash. After extensive search efforts, at about 1100 UTC it was finally established that the aircraft crashed at about 1004 UTC at a village called Sehsagirihalli near Bidadi, 37km by road southwest of HAL airport, Bangalore. All the three persons on board were charred death. There was post impact fire. Aircraft was completely destroyed due impact and fire. The Probable cause of the accident: Incorrect relight procedure devised by the designer and adopted by the crew at insufficient height leading to rapid loss of altitude and abnormal behavior of aircraft resulted into accident. Contributory factors: a) Lack of crew coordination and cockpit procedures b) Handling of the controls c) Non-aborting of flight by the crew in coordination with the flight test Director after failure of first relight attempt. d) Devising engine relight procedures by NAL without consulting the propeller manufacturer. Factors: 1. Lack of crew co-ordination & cockpit procedures 2. Incorrect relight procedure design 5
TRAINING OPERATION-01 01. Aircraft Type Cessna 172-R Registration VT-CAI 02. Date and Time 06-04-2009 03. Location Bargi Dam, Jabalpur(M.P.) 04. Persons on Board Crew 01 Passengers -- 05. Injury Index Fatal Serious Minor/None Crew 01 Passenger Others 06. Damage to Aircraft Destroyed 07. Pilot-in- Command License CAA/D/113 Age 19 Total Hrs 103:45 Hrs SUMMARY Cessna 172R, VT-CAI aircraft was owned and operated by M/s Chimes Aviation Academy, Dhana, Sagar MP. The aircraft was used for flying training purpose for PPL and CPL courses for VFR operations only. On 06 th April 2009 the aircraft took off at 0815 UTC for the non stop cross -country flying on the sector Dhana Umeria Baihar-Dhana. The student pilot during his last leg went to the right of his track approximately 10 KM over the Bargi dam. He approached the water body from 090 (easterly) direction and made a low pass. Thereafter he again approach at the same location were the local fishermen were available and just went into the water. The local fisher men immediately put a buoy in water for identifying the location of crash and informed the district administration. The district administration made an attempt to recover the aircraft through navy divers but failed however the parents continued the search with private divers/villagers and got the aircraft wreckage with body on 29/05/2009. The aircraft got damaged with engine hanging and propeller facing down. The body was recovered by cutting open the fuselage. The Probable cause of the accident: The probable cause of the accident is carrying out very low flying over water in cruise configuration at high speed & touching the water causing the aircraft to crash into the dam. Factors : Pilot- low flying 6
NON-SCHEDULED OPERATION-01 01. Aircraft Type Lama SA315B Helicopter Registration VT-WEX 02. Date and Time 09-07-2009 03. Location Near Amarnath Cave, J & K 04. Persons on Board Crew 01 Passengers 04 05. Injury Index Fatal Serious Minor/None Crew 01 Passenger 02 02 Others 01 06. Damage to Aircraft Substantial 07. Pilot-in- Command License CHPL Age 48 Total Hrs 2785:35 hrs SUMMARY The helicopter was engaged in the carriage of the pilgrims from Baltal Helipad to Sh. Amarnathji Helipad. It started the operation at 6:05 IST and had made five trips. During the sixth trip, while landing at Sh. Amarnathji helipad, helicopter experienced sudden sink and crashed at 500 meters away from the cave helipad. The pilot had made a steeper approach for helipad, but did not apply correct technique for the steeper approach. Due to this, on the short finals of the approach, he felt the helicopter sinking with a high rate of descent. He pulled full collective to get a quick recovery and took a right turn. He tried to build up speed to gain transition lift and then decided to make an emergency landing in the middle of the valley instead of going forward to avoid hitting the tents further down the valley. Accordingly, he turned 180 o right, across the width of the valley and in the process it passed over a hill of height 11800 ft. on the left side (out going route) of the valley. He initiated flaring to check the speed. While approaching the valley from the hill, the skid of the helicopter hit a female pilgrim on the pedestrian road flanking the valley, at the back of her head. Thereafter helicopter approached the accident site in a pitch up attitude and crashed in the middle of the valley. Due to impact helicopter was substantially damaged and there was no fire. The pilgrim on the road died, while passengers and crew sustained minor to serious injuries. The Probable cause of the accident: Accident occurred due to the sudden sink experienced by the pilot during landing at helipad and his inability to recover from it. Contributory Factors: (1) Improper technique used for the steep approach. (2) Approaching the landing site at an angle from the left and making steep bank during the recovery process. Factors: Pilot- improper handling 7
NON-SCHEDULED OPERATION-02 01. Aircraft Type Bell 430 Helicopter Registration VT-APG 02. Date and Time 02-09-2009 03. Location Rudrakodru hill, Kulnoor, Andhra Pradesh 04. Persons on Board Crew 02 Passengers 03 05. Injury Index Fatal Serious Minor/None Crew 02 Passenger 03 Others 06. Damage to Aircraft Destroyed 07. Pilot-in- Command License Age Total Hrs CHPL 47 Yrs 6204:30 Hrs SUMMARY The helicopter took off from Begumpet Airport, Hyderabad at 08:38 IST and was cleared for altitude of 5500 ft en-route. At 09:10:50 IST and at a distance of 64 nm the helicopter entered the clouds. As per CVR readout, helicopter weather radar was painting red. Last radio contact with Approach Hyderabad was made at 09:12:52 IST. At 09:13:17 IST due to weather they decided to be slightly on the left of the track and they cleared the red zone, however they continued to fly through the clouds. At 09:21:07 IST they encountered the snag of transmission oil pressure.09:27:24 IST onwards, there were repeated callouts from co-pilot to Go Around. The Engine Control Unit (ECU) readout shows that during the last 14 seconds the rate of descent was in excess of ten thousand feet/minute. Thereafter helicopter crashed in hills of Nallamalla forest range and all occupants on board died. The Probable cause of the accident: Accident occurred due to loss of control resulting in uncontrolled descent in the terrain at a very high rate of descent due to entry into severe downdraught. Contributory Factors: (1) Crew noticed a snag and was engrossed for more than vital six minutes before the impact in searching for relevant information in the emergency checklist and the Flight Manual. This distracted their attention from the prevailing weather conditions which led to loss of situational awareness. (2) The Crew was flying in Instrument Meteorological Conditions (IMC) whereas the flight plan was cleared for VFR flying. (3) They had no intention either to divert or return back to base. Factors: Bad Weather 8
SCHEDULED OPERATION-01 01. Aircraft Type ATR 72-212 Registration VT-KAC 02. Date and Time 19-11-2009 1640 IST 03. Location Mumbai Airport 04. Persons on Board Crew 04 Passengers 36+2 05. Injury Index Fatal Serious Minor/None Crew Passenger Others 06. Damage to Aircraft Substantial 07. Pilot-in- Command License Age Total Hrs ATPL 47 Years 7160 hrs SUMMARY Kingfisher Airlines ATR-72-212 aircraft VT-KAC was schedule to operate IT-4124 (Bhavnagar Mumbai) on 10.11.2010. Aircraft took off from Bhavnagar at 15:36 hrs. and came in contact with ATC Approach, Mumbai around 17NM to touchdown. The ATC instructed IT-4124 to continue approach. On the day of accident, secondary runway 14/32 was under maintenance and the primary runway 09/27 was available after runway intersection as 27A. The crew on the accident flight was not meeting the cockpit qualification required to operate the flight on runway 09/27. During approach the aircraft was high and fast, the touchdown was delayed. The runway available after touchdown was around 1000 meters which was just sufficient to stop the aircraft on the runway. The aircraft rolled into unpaved wet area. After the aircraft stopped, the right engine kept on running though the Condition Lever was selected to shutoff. The cockpit crew then pulled the right emergency handle followed by the left emergency handle but the engine failed to shutoff. The pilot evacuated from the emergency exit and then assisted co-pilot to evacuate. The cockpit crew then went to the left side forward cabin emergency exit and assisted the cabin crew with the evacuation of passengers. All the passengers including crew evacuated safely without any injuries. There was no fire. The Probable cause of the accident: The accident occurred due to un-stabilized approach and decision of crew not to carry out a Go-around. Contributory Factors: i) Water patches on the R/w 27A ii) Inability of the ATCO to communicate the aircraft about aquaplaning of the previous aircraft iii) Lack of input from the co-pilot. Factors: Pilot-Unstabilised Approach 9
TABLE 1 ` CLASSIFICATION OF ACCIDENTS (POWERED AIRCRAFT) BY NATURE OF FLIGHT FOR THE Nature of Flight No. of Accidents No. of Fatal Accidents Crew Passengers Others Aircraft Damage Killed Seriously Killed Seriously Killed Seriously Destroyed Substantial Minor Injured Injured Injured 1 2 3 4 5 6 7 8 9 10 11 12 Airlines Operation 01 01 Non Operation 02 02 02 01 03 02 01 01 01 Aerial Work Flying Training Private & Business Total 01 01 03 01 01 01 01 01 05 04 06 01 03 02 01 03 02 10
TABLE 2 ACCIDENT STATISTICS AND FATALITY RATE OF AIR INDIA FOR THE Hours Flown (No.) 16182 / 128636 Passengers carried (No.) 474776 / 2845130 Kilometers flown (in thousand) 8653 / 96416 Passenger Kilometers flown (in thousand) 423774 / 17007737 TABLE 3 ACCIDENT STATISTICS AND FATALITY RATE OF AIR INDIA EXPRESS FOR THE Hours Flown (No.) 7052 / 62928 Passengers carried (No.) 236135 / 1980174 Kilometers flown (in thousand) 2910 / 42332 Passenger Kilometers flown (in thousand) 191327 / 5123563 11
TABLE 4 ACCIDENT STATISTICS AND FATALITY RATE OF INDIAN AIRLINES FOR THE Hours Flown (No.) 128262 / 67570 Passengers carried (No.) 6073124 / 1961775 Kilometers flown (in thousand) 65052 / 45140 Passenger Kilometers flown (in thousand) 6249946 / 4483323 TABLE 5 ACCIDENT STATISTICS AND FATALITY RATE OF ALLIANCE AIR FOR THE Hours Flown (No.) 20352 Passengers carried (No.) 419979 Kilometers flown (in thousand) 8606 Passenger Kilometers flown (in thousand) 276686 12
TABLE 6 ACCIDENT STATISTICS AND FATALITY RATE OF JET AIRWAYS FOR THE Hours Flown (No.) 171841 / 133272 Passengers carried (No.) 7790827 / 3490075 Kilometers flown (in thousand) 76859 / 93594 Passenger Kilometers flown (in thousand) 6694066 / 14839465 TABLE 7 ACCIDENT STATISTICS AND FATALITY RATE OF JET LITE FOR THE Hours Flown (No.) 67649 / 2140 Passengers carried (No.) 3275960 / 206784 Kilometers flown (in thousand) 35213 / 1024 Passenger Kilometers flown (in thousand) 3653119 / 151709 13
TABLE 8 ACCIDENT STATISTICS AND FATALITY RATE OF KINGFISHER AIRLINES FOR THE Hours Flown (No.) 196264 / 20891 Passengers carried (No.) 10509104 / 445712 Kilometers flown (in thousand) 92003 / 13457 Passenger Kilometers flown (in thousand) 8644480 / 1879065 01 0.95 0.46 TABLE 9 ACCIDENT STATISTICS AND FATALITY RATE OF SPICEJET FOR THE Hours Flown (No.) 74135 Passengers carried (No.) 5447802 Kilometers flown (in thousand) 44259 Passenger Kilometers flown (in thousand) 6443925 14
TABLE 10 ACCIDENT STATISTICS AND FATALITY RATE OF INDIGO AIRLINE FOR THE Hours Flown (No.) 87085 Passengers carried (No.) 6101548 Kilometers flown (in thousand) 47923 Passenger Kilometers flown (in thousand) 6798346 TABLE 11 ACCIDENT STATISTICS AND FATALITY RATE OF GO AIR FOR THE Hours Flown (No.) 24380 Passengers carried (No.) 2060260 Kilometers flown (in thousand) 15541 Passenger Kilometers flown (in thousand) 2002289 15
TABLE 12 ACCIDENT STATISTICS AND FATALITY RATE OF MDLR FOR THE Hours Flown (No.) 3095 Passengers carried (No.) 114512 Kilometers flown (in thousand) 1510 Passenger Kilometers flown (in thousand) 89753 TABLE 13 ACCIDENT STATISTICS AND FATALITY RATE OF PARAMOUNT AIRWAYS FOR THE Hours Flown (No.) 15513 Passengers carried (No.) 831822 Kilometers flown (in thousand) 8179 Passenger Kilometers flown (in thousand) 498870 16
TABLE 14 ACCIDENT STATISTICS AND FATALITY RATE OF AIRLINES OPERATORS FOR THE Hours Flown (No.) 811810 / 421773 Passengers carried (No.) 43335849 / 1128096 Kilometers flown (in thousand) 406668 / 296182 Passenger Kilometers flown (in thousand) 41966581 / 43986088 0.14 0.081 17
TABLE 15 POWERED AIRCRAFT ACCIDENTS BY CLASS OF PILOTS LICENCE (PIC) FOR THE CLASS OF LICENCE HELD TOTAL ACCIDENTS FATAL ACCIDENTS SPL 01 01 PPL CPL/CHPL 02 02 ATPL 01 OTHERS 01 01 TOTAL 05 04 TABLE 16 AIRCRAFT ACCIDENTS BY PHASE OF OPERATION FOR THE PHASE OF OPERATION TOTAL INVOLVEMENT PERCENTAGE OF TOTAL ACCIDENTS STATIC 00 TAXI 00 TAKE-OFF 00 IN FLIGHT 03 60% LANDING 02 40% 18