Expert-speak on how to prevent aviation disasters...

Consider this. An aircraft is a machine at the end of the day so some air accidents are beyond human control. A part or a number of parts of any machine can malfunction, leading to fatalities as does happen every once in a way. 

Years and years of honing and perfecting standard operating procedures (SOPs), regulations, norms and systems under the monitoring of the International Civil Aviation Organisation (ICAO), the apex global body on airline safety have ensured that air travel is considered one of the safest modes of travel today. Accidents are rare in aviation. There were five fatal accidents among 32.2 million flights in 2022, making it among the safest activities in which a person can engage. Airlines, pilots and crew the world over are encouraged to follow the checklists and set-down guidelines to a tee. That is in a nutshell the best they can do to ensure an accident does not occur. 

In 2019-2020, there were a series of technical snags and many incidents and a few incidents that were serious enough to be classified as accidents that spooked fliers in India. This ensured the director general for civil aviation (DGCA) and others in charge pulled up their socks and tightened the checks and inspections system. The good news is that in a November 2022 audit by ICAO, India’s safety oversight capability ranking climbed from 112 to 55 out of 193-odd member countries. In a majority of the areas, the protocols followed were found satisfactory, thanks to a tightening in the last four years. While this is great news, it doesn’t mean things cannot be better. Even as this article went live, an AirAsia India flight made an emergency landing due to a sudden technical snag. 

In a country where airlines routinely go through mini financial slumps and where there is a tendency to find loopholes and take shortcuts, every few weeks some gap or shortcomings in one of the airline’s functioning and operations are uncovered. While in 99% of the cases, these gaps are unintentional, it is equally critical that Indian authorities remain vigilant and keep a close eye on each operator. 

This was more recently demonstrated by Tata run low fare airline AirAsia India (recently renamed AIX Connect), which received a rap on the knuckles from the DGCA after the authority found it was not fulfilling ICAO requirements in pilot training, transgressions that the authorities felt were serious and compromised safety. In particular, it was found during the regular surveillance audit that the examiners and trainers of the airline were certifying the pilots and clearing them for flights without  adequate training on how to handle the aircraft if the weather radar is malfunctioning and without simulator training on GPS warning for ground proximity and so on. The transgressions were significant and serious enough for DGCA to penalise the airline and the trainers concerned. 

So how does one ensure that airline safety is kept paramount and above all else in a chaotic aviation scenario with dizzying growth in the number of fliers, commanders and crew and additions to fleet and capacity? Fortune India spoke to a range of commanders, crew, industry experts, past and present DGCA officials and those vested in the sector to find out. Here’s what they advise. 

Don’t Exercise Your Mind, Only Skill

There is one aspect of piloting an aircraft that sets it apart from most other sectors, industries or jobs. In a majority of assignments, originality, innovativeness and using your own mind or being creative is highly appreciated. Thinking out of the box will usually win you accolades, rewards or if nothing else, a pat on the back from your boss.

Pilots and flying an aircraft is one massive exception to this rule. This is one field where SOP (standard operating procedure) is “God” or sacrosanct and using your own mind is not only discouraged but could be dangerous.

Industry sources say that problems arise when commanders or first officers decide to exercise their own mind and give in to their overconfidence that “they can pull it off”. In a SpiceJet accident in 2019, the aircraft landed beyond the “lakshman rekha” so to speak, his braking action was poor as well and the aircraft went out of control and overshot the runway. The nose landing gear of the aircraft collapsed, the tyres sunk in and the passengers had to be evacuated after getting the fright of their lives. All in all, the incident was serious enough to be classified as an “accident” by the authorities. After the event, the pilot told his own management that breaching the landing line was business as usual : he’d done it several times before, as did his colleagues. 

Then there is the urgency to get it “over and done with” that afflicts certain commanders, in particular those who do many take-offs and landings in a single day and the landing is back to their home base. This is particularly true when it comes to aircraft stabilisation prior to landing. No matter which airline one considers, pilots tend to take chances and fail to go around as required if all parameters are not stable. A senior commander says that often, even when aircraft are not stabilised or landing conditions are not quite perfect and require the pilot to go around, stabilise the approach and come in again for landing, they don’t. These pilots choose not to err on the side of caution as they have a bad case of “get-home-itis”. They’re fed up with the flight, want to get it over and done with and go home. This is a fatigue of sorts, which is quite common with low fare airlines both in India and globally.

These situations and this kind of laxity, over confidence or even brazenness on behalf of the captain often leads to hard or long landings and runway excursions as India saw in the Calicut in August 2020 which took the lives of 19 passengers and the two pilots.

Penny Wise Pound Foolish

Since flying is generally safe, a certain laxity can creep into the airline’s training and operations departments. “There is a simple sentence in aviation about flight safety: If you think safety is expensive, try an accident. Sounds harsh but covers the whole truth”, says Gustav Baldauf, an aviation industry expert who was director for safety responsible for the International Aviation Safety Audits (IOSA) during his stint with IATA and holds a degree in accident investigations from the University of Southern California.

In India, where flying is still considered a luxury by many and where airlines are under constant pressure to offer lower and lower fares, often below cost, there is a tendency to delay regular mandatory checks to cut costs including on maintenance and spares. “This can play havoc with airline safety since a serious accident is usually a build up or a series of negligent acts that lead up to it”, says a former DGCA on condition of anonymity.

Airlines run on wafer-thin margins and the focus remains on cutting costs. At times, this can compromise safety. Take, for instance, the mad rush that often ensues when a low-fare airline flight lands. In a bid to minimise turnaround time, passengers can be seen boarding even as passengers from the earlier flight are yet to alight. “This mad rush can have more serious consequences if the engineers and other safety protocols are equally rushed”, says a former aviation secretary.

Pilot training is another critical area where airlines could pull up their socks. Most airlines tend to outsource the basic CPL license training and hire pilots who are both type rated and have some experience. This implies that to some extent the airline has no real quality control over the skills and competence of the pilot. 

Baldauf argues that “if an airline wants full control, it must set up its own flight training academy and training centers like the big players including Emirates , Singapore Airlines , Qantas, Lufthansa do”. In India, even the largest player IndiGo has not so far set up its own training academy; it does however have a cadet pilot programme with around six flying schools that produces around 500 pilots a year including the largest player in the segment Chimes, which produces around 100 pilots a year for the airline.

Moreover, training is not a static state but needs continuous retraining and upgradation to stay current and up to date with the latest technologies, be it in the air or the ground. Licensed pilots have to undergo trainings  like route and airport qualification trainings , Type rating trainings , captains training , technical refresher training, special safety trainings like human factor training aso

In the past, many first officers (across airlines) who get their command usually on completion of 3,000 hours of flying have very little practice of real time landings in poor weather conditions. So it’s the first officer who suddenly finds himself in the hot seat (read: commander) one day with a relatively inexperienced colleague in the next seat and he’s told to land out of the blue in the most adverse of weather conditions especially in Mumbai rains. A recent Airline Pilots Association of India (ALPA) note on safety points out that a DGCA circular on supervised take-off and landing disallows a captain from allowing his co-pilot to perform take-offs and landings if the runway is wet, if there are tailwinds and in certain other conditions. This effectively prevents co-pilots from getting hands-on experience in handling adverse weather. “The co-pilot finds himself thrown in at the deep end when he becomes a commander,” says former Jet commander and APLA president Sam Thomas. He says that operating in India during the monsoon is highly challenging and many youngsters are ill-equipped to handle adverse weather situations, and simply just call in sick to avoid flying. It is in fact to everyone’s benefit that they choose to err on the side of caution and were not cocky and overconfident as many of their brethren tend to be.

Other Performers In The Ballet

Of course, there are other actors that play a part. Airports need to be far more focused on enhancing safety features of both the runway and airside operations. Commaders, crew and pilot associations argue that while private players are involved in developing airports in metros, these are limited to glossy terminal buildings with eateries and stores. The runways, their lighting and instrument landing facilities leave a lot to be desired. They point out that even today out of three of the busiest airports, Mumbai, Delhi and Bengaluru, only Delhi has CAT3 ILS – technology that helps aircraft land in poor visibility conditions -- while the latter two have the older CAT1 ILS. “Enhancing safety features of airports is and should always remain a work in progress”, says a former Air India CMD. He says that globally technology constantly brings in improvements and it is incumbent on the airport operators to integrate new technologies and features.

Pilots and industry observers also argue that there is a marked reluctance to shut down operations even when extreme adverse weather conditions prevail. The reluctance owes to commercial reasons and the pressure exerted by airline operators. Pilots point out that most Indian airports lack critical disabled aircraft retrieval kits (DARK) leading to extended periods of closure for the smallest of incidents of disabled aircraft.

Commanders and pilots say that a report published and accepted by the government in the early nineties mandates airport authorities to provide accurate friction coefficients of runways, to enable the pilot to accurately judge the level of braking required. This hasn’t happened. Pilots are often left to their own devices and past incidents have shown that some were unable to judge properly.

Keeping Your Eye On the Ball

Flying is a sport where keeping your eye on the ball cannot be overemphasised. India’s safety regulator and watchdog DGCA has traditionally suffered from both a lack of funds and expertise. Required to keep tabs on no less than 40,000 individuals – pilots, co-pilots, engineers and cabin crew,  not only has the organisation been traditionally understaffed, it is usually headed by non-technical IAS officers. No matter which government has been in power, the aviation  sector experts - both in India and outside - have argued that the DGCA simply does not have the expertise and pays too poorly to attract the right talent. This has led to a situation where the organisation has been beset with petty corruption at all levels of seniority for decades and has historically underperformed.

One single statistic highlights why. The US Federal Aviation Authority has an annual budget of US $17 billion (in 2019) whereas the DGCA annual budget has hovered around a fraction of that. This despite the fact that air traffic growth in India is among the highest in the world, crossing double digits most years.

Sources say that most of the changes DGCA tries to make are made redundant by the fact that the man at the top keeps changing and the next office-bearer often negates the work done by his predecessor. Moreover, issuing circulars is one thing and enforcement quite another. Shakti Lumba, former head of operation for IndiGo and an outspoken critic of the body, has famously said, “DGCA can issue all the circulars in the world but unless they are enforced they are as good as the paper they are printed on.”

A senior Air India commander argues that DGCA just conveniently transfers the onus onto everyone else by issuing circulars while they themselves are not even in a position to judge whether the circulars are being enforced. While there may be more than a grain of truth in his words, this may not be any individuals or even the organisation’s fault as much as the system which has contrived to keep the organisation both financially tight, poorly equipped and manned over the last several years.

Systemic Reforms Might Be One Answer

In 2021 and 2022, following a series of incidents in the air, the DGCA was strengthened by the government and new posts were created. The organization has been strengthened but there remains massive scope for further improvement including in accident investigation and follow up action, the weakest spot in India’s aviation sector. Reports and recommendations based on past accidents usually only gather dust in the DGCA offices. In 2022, it launched eGCA, a single window e-governance platform aimed to provide transparency, accountability and ease of doing business to all its stakeholders. Many argued that this is a welcome beginning although as usual with anything launched by bureaucratic initiative, it has a long way to go (more on this later).

Another systemic change that is urgently required in India is how the DGCA is picked. For many years, aviation industry experts and analysts have been pointing out that instead of having a bureaucrat with no aviation expertise, the DGCA needs to be someone with fairly deep expertise in the sector. In the US for instance the recently appointed chief Phil Washington of the Federal Aviation Authority (FAA) was asked to publicly defend his credentials to run the organization. Not only does the chief need to be well versed with aviation safety, he needs to be familiar with the challenges faced by commanders and crew and have some knowledge of accident investigations. “Either way, moving away from the practice of putting an IAS officer in charge would greatly help”, says a former Jet commander with 25 years of experience of working with DGCAs.

In a country like India where commercial considerations seem to always override all other considerations, the DGCA should consider making the CEO or the founder and face of the airline the accountable manager (accountable managers are the ones held responsible by the authorities for safety). When major policy changes that affect commercials are discussed with the government, it is these people who either represent or lobby at some level and they, many argue, should be held responsible for the lives they ferry. “Let the promoter or the CEO be held responsible if anything goes wrong on the safety front and you’ll have much more alacrity in the system. In an airline like SpiceJet, this would be Ajay Singh and in IndiGo, it would be Rahul Bhatia.” says a former aviation secretary. He argues that this makes sense since an air accident can often lead to bankruptcy for the airline.

The more recent peeing incident on an Air India non-stop flights has brought up another systemic reform that the authorities need to consider. The question the industry is asking is whether in cases of medical emergency or unruly incidents the commander and cockpit should be kept insulated so that they can focus on the main task of ferrying fliers safely. “It might make sense for the crew supervisor to relay happenings to some authority on the ground competent to advise on next steps and how to proceed”, says a MOCA official. Instructions based on informed opinion and judgment can then be conveyed to the cockpit to follow through. Many commanders this writer spoke to post the Air India November incident were of the view that the system needs a serious relook.

At the end of the day however even if all these systemic reforms are introduced and take shape as desired, an aircraft remains a machine and machines malfunction at times. The best humans can do is to minimise scope for error in their own functioning and remain humble.

Arun Kumar, DGCA since June 2019 who recently stepped down, spoke to Anjuli Bhargava on his mantras for safety. Excerpts from a detailed conversation:

Q1: Recurring snags, technical hitches and incidents like we saw in 2019 and 2020 are all usually build ups to a more serious accident. How in your view can the Indian skies be made safer?

Ans 1: Many of the checks and balances in the system have a certain periodicity. Certain checks and retrainings have to be carried out again in 3, 6 months or even once in 3 years - since things are going smoothly, some of these tend to be overlooked. Airlines, inspectors and examiners at times tend to be lax about these. It is human nature. But in aviation with the interplay of men and machines, this cannot be allowed to happen.

Q2: Based on your tenure, what would you advise airlines and other stakeholders to do to prevent any major accident from occurring?

Ans 2: The period I have been there was marked by the COVID pandemic and many airlines were under severe financial stress. After a halt in operations for a certain time, there are many protocols that need to be met. We found some operators skipping the maintenance schedule or wanting to bring the aircraft or pilot back into operation without meeting all the required protocols. I won’t say anything is deliberate but there are lapses and a certain laxity. The key takeaway is that there is a constant need for supervision. Somebody has to be a whistleblower and somebody has to keep a check. Perhaps the greatest takeaway is that even with the best intentions, constant surveillance is necessary.

It is important that the designated examiners remain vigilant and it is equally critical that the authorities keep a strict watch over the examiners. There are almost 11,000 pilots and only 170-odd examiners. It is an industry, a machine and those who man it have to be constantly monitored and deficiencies and gaps have to be promptly identified and fixed.

Q3: But if one was to ask what the airlines should treat as the highest priority?

Ans 4: There is no single mantra. This is an SOP driven industry. Everything is by the book and driven by checklists. If the airlines, the pilot, engineers and all others involved in dispatching a flight follow the laid down process, things usually work.

There is the flight dispatch reliability data that airlines keep close to their chests but this is a good indicator. For instance if the weather radar on a flight is functioning, the pilot is required to abort the flight and come back, get it rectified and then take off again. For commanders, I would say any application of mind can be serious and even disastrous. Do not apply your mind or try to be innovative.

Q4: I recall a few incidents of hard landings and the runway being overshot. Why does this happen and what can be done to prevent it?

Ans 4: One has to monitor exceedances. What does this mean? Anything that is being exceeded - hard or long landings. On the runway, there is a marker before which you should touchdown. If the pilot sees that he is exceeding that, he should do a go around and then come in again. Some tend to feel they can manage but the runway is a predefined length and that’s why runway excursions happen.

Q5: Airline managements say some commanders are overconfident, some feel they can manage somehow and at times they are even brazen…

Ans 5: There is a homecoming syndrome that afflicts many. Take for instance if a pilot is Mumbai based and is coming back home but there are strong tailwinds or poor visibility, he ideally needs to divert the aircraft to Nagpur. Or say in Calicut, go to Coimbatore and then come back when the landing conditions are better. But this is when many pilots are tempted and take their chances as we have seen with grave consequences for all.

Airlines need to monitor exceedances very very seriously - in fact we have recently issued a circular on this - and wherever it calls for intervention, they must intervene and insist that the set SOPs are followed. They should not hesitate to check errant pilots. I have been chanting this like a mantra during my entire tenure : follow SOP, follow SOP and don’t exercise your own mind.