Mangalore air-crash-report

SANDEEP UDUPA
Mangalore Air Crash
Report

Mangalore Crash Report
1
Table of Contents
1. Introduction ……………………………………………………………………………. 2
2. Flight Trivia …………………………………………………………….……….…….. 2
3. The Crash ………………………………………………………..…………………… 3
4. The Victims & The Survivors …………………………………………………………………….……… 4
5. Rescue and Response …………………………………………………………………………..… 5
6. The Investigation ………….…………………………………………………………………. 5
7. The Investigation Report ………….…………………………………………………………….…… 6
8. Court of Inquiry ………….……………………………………………………………….… 7
9. The Fire Department ………..………………………………………………………………..…. 8
10. Compensation ……….………………………………………………………………….… 9
11. Violation of Mandatory Procedures ………………………………………………………………………….... 9
12. The Politics …………………………………………………………………………... 12
13. Current Scenario …………………………………………………………………………... 13

2
Introduction:
In what could be one of India’s most catastrophic air disaster in over a decade (and third most
horrible in the past fifty years), the Mangalore air crash tragedy turned out to be a life altering
experience for all of the 166 persons that were on board.
On22 May 2010, the Air India Express Flight 812, a scheduled passenger service from
Dubai to Mangalore overshot the runway on landingat around 01:00 UTC, fell over a cliff and
caught fire, spreading wreckage across the surrounding hillside. Ofthe 160 passengers and 6
crew members on board, only eight passengers survived.
With its 158 fatalities, the accident was the third deadliest aviation disaster in India
(after the 1996 Charkhi Dadri mid-air collision which killed 349 and the 1978 crash of Air India
Flight 855, which killed 213). The crash caused the highest number of aviation fatalities in 2010
and was the second of the year to involve a 737–800. It was also the second time that an
aircraft had overshot the runway at Mangalore.
The deceased crew on board VT–AXV Of 22 May 2010 (IX -812)

3
Flight Trivia:
The aircraft registration was VT–AXV, a Boeing 737-8NG, one of Boeing's 737 Next
Generation series with the manufacturer's serial number being 36333 and line number
2481.The aircraft was delivered to Air India on 18 January 2008.
Commanded by Captain Zlatko Glušica, the remaining crew consisted of First Officer H.
S. Ahluwalia and four cabin attendants. Glušica was a British and Serbian national with over
10,000 hours of flying and over 7,500 hours of command experience. He was a former
employee of Jet Airways. Ahluwalia, the first officer, was also a former employee of Jet Airways
who joined Air India in April 2009. They were both based in Mangalore and both were killed in
the incident.
Following its scheduled departure time of 22:35 UTC from Dubai International Airport in
Dubai, the plane crashed upon landing on the 8,033 feet (2,448 m) runway number 06/24 at
Mangalore International Airport at around 01:00 UTC. Situated in a hilly area, the airport is one
of the seven Indian airports designated as a "critical airfield" by the Directorate General of Civil
Aviation (DGCA), wherein such airfields prohibit "supervised take offs and landings", so that
only the captain (not the first officer) may pilot an aircraft during take-off and landing. The
airport is one of three airports in India having table top runwaysthat require a very precise
landing approach.
The Crash:
After touching down, Air India Express Flight 812overran the runway and crashed down
the hill at its far end. The final conversations between Air Traffic Control (ATC) and the pilot
prior to landing showed no indications of distress.
Images available from shortly after the crash showed the remains of the aircraft on fire
and lying on its belly with smoke rising from the wreckage.

4
Picture of the plane soon after the crash
The then Civil Aviation Minister, Praful Patel said that the aircraft was following an
Instrument Landing System (ILS) approach for landing on the newer runway, which was
commissioned in 2006. Sequence of specifics before the crash is as follows:
The pilot reported to ATC that an ILS approach was 'established' about 4.3 miles
(6.9 km) from touchdown
Landingclearance was then given at 2,000 feet (610 m) from touchdown
The airplane concluded its ILS approach on runway 24, touching down 300 feet
(91 m) past the touch down zone
It then overran the runway and ploughed through a 90 meters (300 ft) sand arrestor
bed which did not stop it
As the aircraft passed the arrestor bed, its starboard wing collided with the concrete
socket of the ILS localizer antenna
It eventually plunged over the cliff and on to the hillside, coming to a stop 660 to
980 feet(200 to 300m ) past the top of the slope.

5
The minister also stated that weather conditions were normal with a visibility of 3.7
miles (6.0 km) and said wind conditions were calm and there was no rain at the time of the
crash. A drizzle started only after the accident.
The Victims&The Survivors:
Apart from the six crew members, a total of 160 passengers were on board at the time
of the crash. Although there were 169 names on the original passenger list, 9 did not board the
flight. All the bodies were recovered from the wreckage.
Initial reports from survivors suggested a tyre burst as the aircraft attempted a go-
around. Some other recollections from the survivors also indicated the plane breaking into two
parts, followed by dense black smoke invading the cabin. Some passengers who were able to
jump out through an opening in the window were essentially the survivors. Withthe help of the
inhabitants of the nearby village, these survivors were able to escape.

6
Rescue and Response:
Members of the public services were assisted by local
volunteers in a joint rescue operation at the scene of the crash
Local villagers were among the first on the
scene to help while an estimated 15 fire trucks,
20 ambulances and 100 rescue workers were
immediately allocated to rescue operations.
The Karnataka Police force, bomb squad,
Karnataka Fire & Emergency Services,
Karnataka State Reserve Police and all hospitals were working together to help out. The Central
Industrial Security Force (CISF) sent 150 personnel to Mangalore to help in the relief and rescue
operations. Bodies of all of the deceased were recovered from the crash site on the day of the
crash, with relatives of the deceased receiving 87 of the bodies.
The Investigation:
Initial investigations revealed that the plane landed about 2,000 feet (610 m) beyond
the usual touch down point on Mangalore's new 8,040 feet (2,450 m) runway 24. A team of
airline officials and staff from the Airports Authority of India were rushed to the scene to
investigate the incident and assist with rescue efforts. Boeing also announced that a team
would be sent to provide technical assistance following a request from Indian authorities.
The Directorate General of Civil Aviation ordered an inquiry into the crash, which began
the same day. The National Transportation Safety Board (NTSB) also assisted the investigation
by sending a team of specialists including a senior air safety investigator, a flight operations

7
specialist, an aircraft systems specialist and technical advisers for Boeing and the Federal
Aviation Administration.
In direct response to the accident, the Government of India decided to set up an
independent air accident enquiry board called the Civil Aviation Authority that would function
independently of the DGCA. Effectively this meant that the DGCA would be the regulator and
the CAA the investigator. The Director General of the DGCA said that it would be set up through
legislation and would comply with the recommendations of the International Civil Aviation
Organization.
The Investigation Report:
According to audio transcripts obtained from ATC, Serbian pilot ZlatkoGlušica, aged 55,
was given clearance to land however,he suddenly aborted the attempted landing. The aircraft's
throttle handle was reportedly found in the forward position, suggesting that the pilot had
attempted to abort the landing and take-off again. According to unnamed ATC sources at
Mangalore, the co-pilot Ahluwalia was said to have warned his commander more than once to
go around instead of landing, and that this warning had come at a height of 800 feet (240 m),
well before the aircraft made a touchdown.
The Cockpit Voice Recorder (CVR) was recovered on 23 May, and the Flight Data
Recorder (FDR) two days later. The recorders were sent to New Delhi by the Directorate
General of Civil Aviation for data acquisition and analysis and subsequently to The American
National Transportation Safety Boardfor investigation.
The enquiry report submitted by the Civil Aviation Ministry claimed that Glusica slept for
over 90 minutes during the flight. The American National Transportation Safety Board says it
was the first instance of snoring recorded on a Cockpit Voice Recorder (CVR). Analysis of the
accident revealed that had the pilot "deployed détente reverse thrust and applied maximum
manual braking at touchdown", the aircraft could have been stopped within the paved overrun

8
area of the runway. The captain had aggravated the long landing by attempting a go-around
following deployment of the thrust reversers.
Court of Inquiry:
On 17 August 2010, the Court of Inquiry began a three day public hearing in Mangalore
to interview airport officials and witnesses. On day one, airport and airline officials overthrew
that the aircraft had approached at an altitude higher than usual, and that it had landed beyond
the landing zone (LDZ). They also mentioned that the airport's radar was operational from
20 May 2010. The airport chief fire officer testified that crash tenders had taken four minutes to
reach the aircraftbecause the road leading away from the airport perimeter to the crash site
was very narrow and undulating. This was followed by day two transcript of the cockpit
conversation to ATC.
Doctors who conducted post mortems on the bodies recovered recorded that most
victims had died of burns. On day four, Air India's flight safety officer informed the inquiry that
the aircraft's thrust lever and thrust reverse levers were both in the forward position, possibly
indicating that the pilot intended to go around.
On 8 September 2010, details from the Cockpit Voice Recorder (CVR) and Flight Data
Recorder (FDR) were presented to the Court of Inquiry. The CVR analysis revealed that one of
the pilots was asleep in the cockpit. For 110 minutes the CVR had picked up no conversation
from the pilots, with the report adding that the sound of nasal snoring and deep breathing
could be heard during this recording. The FDR analysis indicated that the flight started its
descent at an altitude of 4,400 feet (1,300 m), instead of the normal 2,000 feet (610 m). The
aircraft also touched down at the 4,638 feet (1,414 m) mark on the runway instead of the 1,000
feet (300 m) mark, whereupon the pilot then tried to take off with just 800 feet (240 m) of the
runway remaining which resulted in the crash.

9
Both pilots had been aware of the wrong flight path since they are both heard saying
"Flight is taking wrong path and wrong side", while the aircraft's instruments gave repeated
warnings of this.
On 16 November 2010, five months after the Court of Inquiry was constituted, it submitted its
report with input from the NTSB and Boeing, and stated that pilot error was the cause of the
accident since the flight path was incorrect.
The Fire Department:
The investigation report stated that the fire services reached the site within 4
minutes.However, the truth was disclosed by the Chief of Fire services at Mangalore,
Mr.H.S.Varadarajan. He quoted; “After every fire, people conveniently forget the firemen who
rescued them, by risking their own necks. The heroic efforts of firemen in the Air India Express
IX 812 crash too have gone unsung. After nearly a year, their efforts were labeled as ‘nothing
extraordinary’. The fireman’s manual on aircraft disasters and fires depicts a burning aircraft as
a bomb waiting to explode. The oxygen tubes, the helium-filled gadgets, and the hydraulic
systems are full of highly combustible material which gives firemen only 160 seconds to carry
out any rescue operation”. It is called ‘2.5 minute window’. Within this time, the fire will travel
through the tubular structure of the plane engulfing the entire passenger area. Attempts to
save lives will have to be made within that time, and the IX 812 crash happened in a valley
where approach was difficult but our vehicle reached there in eight to nine minutes of the
crash. The first gush of aqua film forming foam was administered within 13 to 15 minutes of the
crash. But by that time, fire had engulfed the entire plane and the broken parts of the belly had
strewn around in three different places and had turned into mounds of fire.”
The fire department was also criticised for using the AFFF. But that was the only
material that could have extinguished the high intensity fire ignited by highly volatile material
like aviation turbine fuel (ATF). Any water sprayed on the burning plane would have just
evaporated even before it reached the target area.

10
Compensation:
The Prime Minister of India, Manmohan Singh announced 2 lakh for the families of the
dead and 50,000 for the injured to be allocated from the Prime Minister's National Relief
Fund. Karnataka Chief Minister Yeddyurappa has also announced compensation of 2lakh to
the families of the dead. In addition to this, the Civil Aviation Ministry advised that the Airline
will provide up to 72 lakh to family members of each victim as per the provisions of the Indian
Carriage by Air (Amendment) Act which follows the Montreal Convention.
The Airline announced interim compensation of 10 lakh for passengers above 12 years
of age, 5 lakh for passengers below 12 years of age and 2 lakh for every injured passenger.
This compensation was over and above the ex-gratia payment announced by the Prime
Minister. Additionally, Air India had said it would offer jobs to the survivors.
As of 11 June 2010, an amount of 170 million had been distributed as compensation to
the families of the victims and to the eight survivors. Victims' families had become increasingly
vocal as to the inequitable nature of compensation paid out by Air India and also of the alleged
hostile attitude of the airline's counsel.
Violationof Mandatory Procedures:
When Air India’s Jumbo Jet Emperor Kanishka exploded mid-flight and got scattered in
Atlantic near Ireland coast on June 23 1985, the investigators had a gigantic task at hand. The
Royal Canadian Mounted Police of Canada organized dives in excess of 7000 feet not only
immediately after the crash, but in 1989 and 1991 also to collect wreckage from the ocean floor

11
and to pick up the aircraft debris scattered across the ocean floor.The numerous parts
recovered from the thousands of square meters beneath the sea were all cleaned, numbered
and shipped to a facility in Ireland where they were all kept for more than two decades. The
recovered parts were later arranged to re-create the shape of the aircraft as a part of the
investigation and also to find out how the explosion happened and what exactly caused it.
In case of Pan American World Airways’ Pan Am Flight 103 that was disintegrated in an
explosion many thousands of feet above southern Scotland, on 21 December 1988, the same
procedure repeated. More than 10,000 pieces of debris were retrieved, tagged and entered
into a computer tracking system. The fuselage of the aircraft was reconstructed by air accident
investigators, revealing a 20-inch (510 mm) hole consistent with an explosion in the forward
cargo hold.
As per Rule 9.7.2:
Here in India too, the air crash investigators are obliged to conduct the same exercise.
As per the Procedure Manualof Accident / Incident investigation published by DGCA (Issue I rev
2 dated 5.10.2006), the reconstruction of the aircraft with all the debris collected carefully from
the crash is mandatory, irrespective of the circumstances in which the crash occurred.
However, in case of the Mangalore crash, for forty days on a stretch the debris had
remained in the crash site soaked in dust and mud enduring heavy rain and sun. This negligence
on the part of Air India, the owner, and the Court of Inquiry that investigated the crash was
bound to be subjected to a great deal of criticism.
The clearing process was initiated by Fiza, a local construction firm, which was hired to
do the job and they heaped the picked up parts in Lorries and then dumped them on an open
platform near the new terminal of Mangalore airport. According to an official of Fiza, the total
weight of the debris recovered from the crash site was just 16 tons, as compared to 41 tons of
metal and fire resistant composites which make up the total empty weight of a Boeing 737-800.

12
The unfortunate episode continued even after the removal of debris was officially
complete and the police men were withdrawn from the site. Hoardsof scrap metal collectors
descended on the crash site and for three continuous days that the ‘metal scavengers’ looted
the site with the metal remains shipped to various scrap dealers in Mangalore city.
As per Rule 6.5.2:
As per the Procedure Manualof Accident / Incident investigation published by DGCA
(Issue I rev 2 dated 5.10.2006), whenever an accident occurs, the Owner, Operator, Pilot-in-
Command, Co-pilot of the aircraft shall take all reasonable measures to protect the evidence
and to maintain safe custody of the aircraft and its contents for such a period as may be
necessary for the purposes of an investigation subject to the Indian Aircraft Rules 1937. Safe
custody shall include protection against further damage, access by unauthorized persons.
The Court of Inquiry involved in the Mangalore crash calamity had done a scientific
examination of the ‘reconstructed’ aircraft. It was while examining these 16 tons of salvaged
aircraft pieces that a member of the Court of Inquiry team noticed the downward position of
the flap locator, a finger sized metallic switch in cockpit used to move the flaps in the wings.
The reason for the aircraft to generate not enough lift to take off in the last moment was
becoming clear then.
The panicked pilots must have forgotten to push up the switch.If a finger sized metallic part
could have spoken so much about the crash, the act of shame was the loss in precise
investigation due to the sheer volume of the precious evidential scrap metal that was sold in
numerous shops scattered across the city.
To carry out effective rescue and recovery operations in an emergency situation, it is necessary
to cordon off 500 meters around the crash area with no unauthorized person being allowed
inside. In the case of Mangalore crash, everybody and anybody entered the site. Indeed, some
of them tried to help the victims, but most of them only added to the confusion. The narrow

13
road between Kenjar and Adyapady was blocked with all kinds of vehicles including private cars
and two wheelers, not allowing the emergency vehicles to operate freely. The victims’ bodies
were damaged so badly that it was hard to identify them. The disaster management machinery
had no clue about a procedure called ‘Triage Area (TA)’ where the fireman on duty will deposit
the recovered body. This facility was missing at the crash site.
The Politics:
The post investigation indications were clear that the objective was not to find out the
truth and come out with procedures to prevent another tragedy, but it was a single minded
objective to blame the captain and give a fairy tale ending to all the others who are equally
responsible for the fatal tragedy.
In November 2007, the DGCA safety oversight audit on Air India Express had found
several deficiencies and the management was notified to make the corrections. The findings
included the fact that the airline did not have a Head of Safety and Chief of Training as per the
DGCA regulations. In June 2010, when a fresh audit was carried out on the airline, the same
deficiencies were found. Yet, the conclusion in the report neither blames the airline nor the
DGCA for permitting the continued operation by an airline which did not confirm to basic safety
norms.
The Head of safety should have been held responsible for the wrong circular that was
issued about hard landings. The captain had been counseled earlier for a “hard landing” which
fell into that category but which was well within the manufacturer’s limit. The fatal flight which
was descending at a very high rate was corrected to make a smooth landing. The circular would
have been at the back of the captain’s mind. Yet, this was covered up by the Court of Inquiry.
The most serious aspect is the failure of the COI in not indicting the Airports Authority of India.
The report covers up the dangerous rigid concrete structure that holds the Instrument Landing
System Localiser antenna. This is completely against the ICAO Standards which prohibits

14
anything other than a frangible structure in that area. The report clearly states that the right
wing broke when it struck the concrete structure and the post-accident fire is evident in the
slope beyond the boundary wall. The illegal structure was rebuilt and operations continue with
this dangerous structure remaining.
Current Scenario:
Twenty two months after the horrific crash of Air IndiaBoeing IX 812, which resulted in
the death of 158 passengers, the legal counsel for Air India – Mulla & Mulla - Mumbai, has
settled 114 cases, eight of them partially. Kapi lAseri, chief finance officer, Air India, said a total
of 96 cases have been settled on full and final basis and eight in part for an overall amount of
83 crore, including the survivors.
The airport manager at Mangalore, Peter Abraham confirmed that after the crash, the
rescue operators had difficulties when trying to reach the plane.The concrete structure still
remains and so do the narrow roads which make the area beyond the runway difficult to reach.
The current condition is such that any other tragedy will result in the same kind of tragedy.
Although the officials in AAI and the airline claim to have completed the necessary formalities
and liabilities, it is essential that people wake up to the apparent danger at airports like
Mangalore, otherwise we are not far from another catastrophe.

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REFERENCES:
 Mangalore crash report – The “truth blanket” Decision Height_files
 Catastrophic Air India Plane Crash in Mangalore (Report)
arkarthick.com_files
 Mangalore air crash 114 cases settled for Rs 83 crore - Times Of
India_files
 Massive Cover Up In Mangalore Air Crash Investigation By Jacob K
Philip_files
 articles.economictimes.indiatimes.com
 www.hindustantimes.com/.../Mangalore-crash...
 www.pprune.org › ... › South Asia and the Far East
 www.indianaviationnews.net/.../mangalore-crash-report-–-the-
“truth
 realityviews.blogspot.com/.../mangalore-air-india-crash-
complete.htm

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