Bangalore air crash :1990
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The entire
‘Report on The Accident to Indian Airlines Airbus A320 Aircraft VT-EPN on 14 th February, 1990 at Bangalore'
By The Court of Inquiry Hon’ble Mr . Justice K. Shivashankar Bhat,
Judge, High Court of Karnataka
for
The Government of India, Ministry of Civil Aviation
can be read at the link given above.
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This is a collection of articles archived for the excellence of their content. |
Contents |
The highlights
Shivaniii, Friday, January 26, 2007, The Bangalore Air crash – 1990
Description
Controlled flight into terrain during approach. Aircraft hit about 400 meters short of the runway. Four of the seven crew members and 88 of the 139 passengers were killed.
Location and date of the crash
Date 14/02/1990
Time 13:03
Location Bangalore, India
Plane information
Serial number 79
Type 320-231
Engine manufacturer IAE
Engine type V2500-A1
Delivery year 1989
Flight Information
Flight Number 605
Départure airport : Mumbai , Santa Cruz Sahar Int'l - India (BOM / VAAB)
Arrival airport : Bangalore, Hindustan - India (BLR / BLR)
Bangalore crash :1990
REVISITING THE HORROR
Crash that shook Bangalore in 1990
Vinay Madhav | TNN
Bangalore: On a bright Valentine’s Day afternoon in 1990, an A-320 Boeing aircraft which had taken off from Mumbai at 11.58 am, started descending to HAL Airport in Bangalore. At 1.03 pm, the aircraft was on its final approach and descended well below the normal approach. It kept descending until it struck Karnataka Golf Club’s boundaries.
The aircraft, delivered to Indian Airlines in December 1989, was 2,300 ft short of the runway and 200 ft right of the extended centreline. It rolled for 80 feet and lifted off again for about 230 ft and came down on the golf course’s 17th green. The aircraft’s gears and engines sheared off as it continued to move before coming to a halt in nearby Challaghatta Lake’s marshy and rocky area.
It was Karnataka’s worst air crash and left 92 people dead, including four crew. Fifty-four passengers survived with injuries. The bodies were badly charred, forcing the police to go for a mass funeral.
One of the crash theories was that the pilot tried to use auto-landing system and misjudged the precise point of landing. Foreigners and VIPs, including three Birla family members, were among the victims and survivors. By the time rescuers reached the place, many survivors were walking away from the crash site.
Former IGP and then DCP, T Jayaprakash, who was at the airport to see off Bangalore police commissioner, recalls the harrowing day:
When we heard about the crash, the commissioner cancelled his Delhi meeting and without realising there was a wall separating the crash site and the airport, we set off on the runway. Once we hit the dead-end, we turned back and reached a jam-packed main road. Realising we would be stuck in the jam, we got out of the car and started walking. When we reached the site, we saw some survivors limping out of the water.
In 1990, wireless sets were the only means of communication and we roped in the entire Bangalore police force for the rescue. After moving the injured to hospitals, we recovered over 50 bodies and shifted them to Victoria H spital.
Since there were no facilities to preserve the bodies, the rule was that we couldn’t conduct post mortem till the relatives identified the bodies. Most relatives had to travel a long distance. By early next morning, the bodies started decomposing. We ordered for a large quantity of ice to help preserve the bodies. It helped for some time, but by afternoon, the ice melted and the bodies started swelling. By evening, we decided to have a mass funeral. We called for a priest, a maulvi and guru from the gurdwara. After a prayer for the departed souls, we held a mass funeral.
The New York Times’ report
NEW DELHI, Feb. 14— A new Indian Airlines plane, flying for less than two months in this country, crashed today in the southern city of Bangalore, killing at least 89 people. About 50 survivors were reported taken to hospitals from the fiery crash site.
The plane, an Airbus 320 delivered to the national domestic carrier on Dec. 24, 1989, was carrying 135 passengers, 4 additional passengers who were infants not assigned seats and a crew of 7, an airline spokesman here said. It was about to land after a flight from Bombay when it undershot the runway in Bangalore by about 1,000 feet just after noon, under clear skies. It hit an empty reservoir.
When the final death toll is known, the crash could be nearly as bad as an Indian Airlines accident on Oct. 19, 1988, in the western city of Ahmadabad that killed 133 people. That crash, involving an old Boeing 737, was apparently caused by pilot error. On the same day, a small Fokker Friendship plane belonging to the feeder airline Vayudoot also crashed in the Indian northeast, killing 34 people.
The accident today came as India's domestic airline, which has a virtual monopoly on internal flights, is under intense criticism and strain, unable to meet the needs of at least 30,000 travelers daily. Planes often fly 18-hour days with multiple take-offs and landings. Delays and cancellations, along with the worst cabin service in Asia outside China and Vietnam, have become legendary. Strikes, walkouts and the occasional sitdown protest by enraged passengers have added to the airline's problems.
In 1988, when the first of the Airbus 320's, built by a European consortium, were about to be delivered to India, pilots at Indian Airlines threatened to refuse to fly them, saying the sophisticated planes could not be properly maintained in India.
Engineers later went on strike demanding to be sent to France to be trained to look after the planes, whose operations Indians describe as fly by wire.
Nineeteen of the planes were purchased in 1986, and additional orders were made later. As they began to enter Indian Airlines service, they encountered peculiar local conditions: dust, severe monsoon rains and flocks of vultures that live on illegal trash dumps and slums that have encroached on airport lands.
Issue of Advanced Technology
The Airbus 320, the plane that crashed during the Paris air show in June 1988, has such advanced computer technology that Indian aviation experts questioned whether it would deprive pilots of the power of quick response in an emergency.
Capt. S. S. Gopchujakar, the pilot of today's flight, IC 605, was reported to be one of the airline's most experienced. A survivor told an Indian news agency reporter in Bangalore tonight that the quick reaction of the crew in opening aircraft doors immediately after the crash saved the lives of many passengers.
But this survivor, Hem Chand, who was identified as a bank officer, said it appeared that the pilot had misjudged the landing. Both the pilot and copilot were killed.
India has seen a series of bizarre accidents over the last several years, including one in which pilots forgot to lower the plane's wheels and another in which the plane hit a wandering bull crossing the runway. Crews have flown on the authorization of unqualified examiners. Passengers have sacked airline offices or commandeered planes.
Delays Are Long
Indian airports have outdated equipment, forcing long delays and unannounced rerouting in fog or heavy rain. Ground staff members are often careless. Hardly anyone traveling in India is without stories of near-disaster in the skies or unbelievable management on the ground.
On a flight in October from New Delhi to Goa, an aircraft was more than an hour late taking off because someone had parked another plane too close behind it, and to start the engines of the first aircraft would have destroyed the second, the pilot said. Passengers had to wait for a change of shift when someone would be authorized to move the other aircraft.
Cause
Ministry: ‘failure of pilots to monitor speed’
Pilot error caused 1990 Bangalore air crash: report, The Hindu Bangalore, May 24, 2010
Even as the speculations are on about the cause for the crash of Air India Express IX-812 near Mangalore, an official of the Ministry of Civil Aviation has pointed out that “failure of pilots to monitor speed” had resulted in crash of Airbus 320 of Indian Airlines (IC-605/VT-EPN) near Bangalore's HAL Airport in 1990. In all, 92 persons on board, including two pilots and two cabin crew, died in that accident.
Capt. S.S. Gopujkar was in command of the flight CI-605 and Capt. C.A. Fernandez was the second pilot operating under his supervision. Like Capt. Z. Glusica (who commanded the IX-812), Capt. Gopujkar too had flying experience of over 10,000 flying hours.
The official, referring to the report of investigation conducted by the Directorate-General of Civil Aviation, pointed out that the aircraft (IC-605/VT-EPN) during approach to HAL airport never went to the speed mode which is the proper mode for landing and one of the Flight Directors remained engaged till the time the aircraft crashed.
“If Capt. Gopujkar would have also disengaged his Flight Director when Capt. Fernandez disengaged his Flight Director 21 seconds prior to the crash, the speed mode would have been activated and engine power would have started building up from that instant to restore the speed and the accident could have possibly been averted,” the official said quoting the investigation report.
The investigation report stated that the crash would not have happened if the pilots had taken any of the following actions:
- If the vertical speed of 700 feet as asked for by Capt. Fernandez at about DFRD (Digital Flight Director Recorder) 294 seconds had been selected and aircraft had continued in speed/vertical speed mode.
- If both the Flight Directors has been switched off between DFDR seconds 312 and 317.
- If taking over manual control of the thrust, that is disconnecting auto-thrust system and manually pushing the thrust levers to TOGA (Take Off-Go Around) position at or before DFDR 320 seconds (prior to 9 seconds to first impact on golf course).
- If the go around altitude of 6,000 feet had been selected on flight control unit in accordance with the standard procedure at the time it was asked for by Capt. Fernandez.
Data
The conversation between Capt. Gopujkar and Capt. Fernandez recorded in the cockpit voice recorder (CVR) played a major role in ascertaining the actions prior to the crash during 1990, said the officer while pointing out that CVR data will be crucial to arrive at reason for crash at aircraft as no clear picture is emerging at present.
As per the investigation report, IC-605/VT-EPN first contacted the ground within the boundary of Karnataka Golf Association (situated next to HAL airport) approximately 2,300 ft prior to the beginning of runway.
The aircraft had gone up into the air for a very short duration after which it again contacted the ground on all three gears and then hit an embankment at the boundary of the golf course. The aircraft finally came to rest outside the boundary wall of the HAL airport.
Monitoring speed
The investigation report further stated that “failure of the pilots to monitor speed during final approach, probably because they diverted their attention to find out the reason for aircraft going into idle/open descent mode rather than realising the gravity of the situation and responding immediately towards proper action.”
Disputed findings
Dispute over findings Raj Chengappa, India Today June 15, 1990 |
On February 14, as Indian Airlines' Flight IC 605 came into make its fatal landing, Captain V.S. Sathaye was sitting in the cockpit of another A 320 waiting to take off from Bangalore airport. When he looked out of his windscreen, he noticed a cloud of dust beyond the runway boundary and saw the aircraft bounce before bursting into flames. He immediately informed the control tower of the crash and rushed to the spot.
Yet when Sathaye narrated his experience to the four-member Court of Inquiry into the IC 605 crash at Bangalore last week, the poignancy of the occasion seemed lost. Inside the spacious high court hall, the gripping details of the crash were soon reduced to cold facts as each statement was quizzed by a battery of lawyers representing Indian Airlines, the Pilots Association, Airbus Industrie, International Aero-engines and a consumers' forum.
The crash site
As the court, chaired by Justice Shivashankar Bhat, heard the evidence, jurors and counsels were constantly foxed by technical jargon like FCU, ECAM, PFD and ALT STAR frequently used by the experts. Sensing that a quick verdict would be difficult, Bhat informed the Ministry of Civil Aviation that the inquiry would not be completed by the May 31 deadline and sought a two-month extension.
The ministry, which was banking on the court's judgement to decide the fate of Indian Airlines' grounded fleet of 14 A 320s, took alternative measures. The Union Cabinet last fortnight approved its proposal to sell four aircraft that Airbus Industrie was to deliver. And it also decided to indefinitely lease the remaining 14 to other international airlines. That was done to cut down the mounting losses estimated at Rs 2.5 crore a week to keep these aircraft grounded.
The mild-mannered Bhat is piqued by the fact that his court's verdict would also be a judgement on the world's most advanced passenger aircraft in the world. As he told INDIA TODAY: "It is really putting a heavy responsibility on me for deciding such a highly technical matter. I am only looking at what caused the crash."
However, even that is going to prove difficult. Three months after the Bangalore crash that killed 91 people, its cause is hotly disputed.
The inspector of accidents, appointed by the Director General of Civil Aviation, in his report submitted to the court, puts the blame squarely on the pilots.
Airbus Industrie gleefully supports it and provides more evidence to establish that fact. But the Indian Commercial Pilots Association says that it was a clear case of failure of the sophisticated systems of the aircraft and adds that it has evidence to prove that the pilots struggled bravely to avert the crash.
As the various counsels presented their arguments, it was clear that the action or the lack of it by captain S. Gopujkar and co-pilot Cyril Fernandes in the last 35 seconds before the crash is what proved most crucial.
In that half a minute several things happened that finally led to Flight IC 605 landing prematurely on a golf course, before hitting a bundh and bursting into flames. Fernandes was, in fact, on his first route-check for his command ratings and was piloting the aircraft.
According to Satendra Singh, the inspector of accidents, it was a series of mistakes by the two pilots that caused the crash. It began when the more experienced Gopujkar made a faulty altitude setting in his flight control unit. That reading led to the aircraft's automatic thrust control systems go on the 'Open Descent' Mode. This mode keeps the engines idling and reduces the aeroplane's speed.
That error was compounded when Gopujkar failed to disengage his flight director, a requirement before landing. If he had shut his director, then the aircraft's flight control systems, sensing that speed was dropping, would have automatically given the engines more power. Worse, even though the two pilots noticed these errors, Singh opines they failed to take corrective measures. Airbus says they made the mistake of not checking the aircraft's speed in those vital 35 seconds, even when it had dropped far below the critical minimum of 132 knots.
The pilots realised they were falling short just six seconds before the crash when they were only 135 ft above the ground. Although they did take evasive measures, Singh's report concludes that if it had been done just two seconds earlier, the accident may have been averted.
He does point to the fact that the engines did not build up the specified power after corrective action was taken. But he seems satisfied with Airbus Industrie's explanation that there is always a 0.5 second time lag for a command to the aircraft's thrust control to act.
The Pilots Association, however, fiercely refutes the findings. In its affidavit, it points to several conversations indicating that the pilots were not fouling up. It argues it is unlikely that a senior pilot like Gopujkar would commit such a series of mistakes? There was no proof to show that he made a faulty setting in the first place as the data recorders do not register it.
The association also believes that the engines went into idle power because of a major systems defect. Even when Gopujkar tried to shut his director off, it didn't respond. And that the time lag of 0.5 seconds for the auto-thrust controls to act proved to be disastrous.
Hearings have been suspended till June-end and when the Court of Inquiry reconvenes, it will be faced with ambiguities in several key clues. For instance, the vital conversation describing the altitude setting is lost in a garble of tower control transmissions. Then again at one point the pilots' conversation about the flight director not being off, could also point to a systems malfunction.
The battle over whether the aircraft's engines responded according to parameters is likely to be long drawn. Certainly, deciding what happened in the last 35 seconds of Flight IC 605 will take the court not just hours but months.
What caused the crash?
Shivashankar Bhat: A difficult judgement
Inspector of Accidents Directorate
General of Civil Aviation
...Pilots made a faulty altitude setting, bringing engines to idle.
...As a flight director remained on, the auto-thrust did not work.
...They then failed to monitor speed even when it fell too low.
...Their measures to avert the crash were taken too late.
Airbus Industrie
...Agrees substantially with the inspector of accidents' report.
...Pilots should have put off the flight director as per procedure.
...Failure to monitor air speed was a serious lapse.
...Aircraft control systems performed satisfactorily.
Pilots Association
...No real proof that the pilots had made a faulty altitude setting.
...Although they shut the flight director, the system failed to do so.
...Silent about why the air speed was not monitored by the pilots.
...Cause of the crash was a major aircraft systems failure.
The victims
Ashok Birla - industrialist, He was on his way to cut the ribbon for the inauguration of the Birla-3M factory when the fatal accident happened.
