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                                                                               PREFACE
It is an accepted fact that the rate of helicopter crashes is way to high in the country. Despite numerous committees constituted the rate of crashes has not been arrested.From April 2011 – January 2012 Pawan Hans Helicopter Limited had a total number of 5 crashes. One of the crashes included the fatality of the then incumbent Chief Minister of Arunachal Pradesh,Dorjee Khandu. An independent Inquiry was constituted with the Chairmanship of Air Marshal P.S. Ahluwalia(Retd) PVSM,AVSM & Bar,VM,VSM .One of his recommendations was that the Central Government should set up an independent “Accident Investigation Bureau” in accordance with International Standards for investigations of accidents and serious incidents. Further the Accident Investigation Bureau should have financial and administrative independence.

This document has been made for the eventual realisation of this recommendation. We wish to put a Public Interest Litigation in the Delhi High court stating the importance of consituting just such an Bureau by highlighting the dangers in the present system. According to Civil Aviation Requirements an operator can also conduct an Inquiry into an accident. There are inherent dangers to this as the members of this committee are likely to have a conflict of interest in exposing the negligence of their employers and may be tempted to take the less courageous step of apportioning wrongful blame to the pilots.

This document seeks to expose the fallacy of just such a report that was conducted in the aftermath of the crash of VT-BSH Dhruv. The observations made by the report are contradictory,biased,vague and lacks a comprehensive approach that would improve the flight safety standards in the country.

                                                                               INDEX

  1. Definations
  2. Pawan Hans Helicopter Limited(PHHL)
  3. Navigation through document
  4. Prevailing weather conditions on 19 October 2011
  5. Criticism of Report Findings
    1. Breaking of Rotors from main helicopter structure
    2. Suspicious activity of the engine
    3. Awkward Roll Rate and Bank Angle of Helicopter
    4. Crucial missing evidence
    5. Cyclic Saturation
    6. Not assigning any blame to the operator.
    7. Instrument rating of Pilot-in-command
    8. Criticism of co-pilot inaction during critical phase
    9. Pilots in IMC should have enagaged AFCS upper modes
    10. Pilots displayed inadequate knowledge of the Helcopter systems
    11. Flight crew continuing to fly despite activation of multiple warnings during hover period.
    12. Cockpit Resource Management & Flight Simulator Training
  6. Conclusion
  7. References

 

                                                                              DEFINATIONS
Airworthiness Directives:No person may operate an aircraft to which an Airworthiness Directive applies, except in accordance with the requirements of that Airworthiness Directive unless otherwise agreed with DGCA or the state of registry, as applicable.
Air Traffic Control(ATC):is a service provided by ground-based controller who direct aircraft on the ground and through controlled airspace, and can provide advisory services to aircraft in non-controlled airspace. The primary purpose of ATC worldwide is to prevent collisions, organize and expedite the flow of traffic, and provide information and other support for pilots
Automated Flight Control System(AFCS): is a system which augments the stability,improves handling and provides automatic flying for the helicopter thus relieving the pilot workload and also freeing him/her for other mission related activity
Bank:is a turn or change of direction in which the vehicle banks or inclines, usually towards the inside of the turn.

Cockpit Voice Recorder(CVR):preserves the recent history of the sounds in the cockpit including the conversation of the pilots.
Collective: is normally located on the left side of the pilot’s seat with an adjustable friction control.The collective changes the pitch angle of all the main rotor blades collectively (i.e., all at the same time) and independent of their position. Therefore, if a collective input is made, all the blades change equally, and the result is the helicopter increases or decreases its total lift derived from the rotor. In level flight this would cause a climb or descent, while with the helicopter pitched forward an increase in total lift would produce an acceleration together with a given amount of ascent.
Civil Aviation Requirements(CAR): The Directorate General of Civil Aviation is the regulatory body in the field of Civil Aviation primarily responsible for regulation of air transport services to/from/within India and for enforcement of civil air regulations, air safety and airworthiness standards. The regulations are in the forms of the Aircraft Act, 1934, the Aircraft Rules, the Civil Aviation Requirements, the Aeronautical Information Circulars.  The Advisory and guidance material is in the form of circulars.
Cyclic/Cyclic Stick: The cyclic control is usually located between the pilot’s legs and is commonly called the cyclic stick or just cyclic. On most helicopters, the cyclic is similar in appearance to a joystick in a conventional aircraft. If the pilot pushes the cyclic forward, the rotor disk tilts forward, and the rotor produces a thrust vector in the forward direction. If the pilot pushes the cyclic to the right, the rotor disk tilts to the right and produces thrust in that direction,causing the helicopter to move sideways in a hover or to roll into a right turn during forward flight.

Emergency locator transmitter (ELT):A generic term describing equipment which broadcast distinctive signals on designated frequencies and, depending on application,may be automatically activated by impact or be manually activated

Flight Data Recorder (FDR):is a device that preserves the recent history of the flight through the recording of dozens of parameters collected several times per second.
Flight Simulator: flight simulator which provides an accurate representation of the flight deck of a particular aircraft type to the extent that the mechanical, electrical,electronic, etc. aircraft systems control functions, the normal environment of flight crew members, and the performance and flight characteristics of that type of aircraft are realistically simulated
Instrument Flight Rules(IFR):Rules and regulations under conditions in which flight by outside visual reference is not safe.IFR flight depends upon flying by reference to instruments in the flight deck and navigation is accomplished by reference to electronic signals.
Instrument meteorological conditions (IMC): Descibes weather conditions that require pilots to fly primarily by reference to instruments and therefore under Instrument Flight Rules(IFR)
Instrument Rating(IR): Refers to the qualifications that a pilot must have in order to fly under Instrument Flight Rules(IFR).It requires additional training and instruction beyond what is required for Commercial Pilot certificate, includes rules and procedures specific to instrument flying, additional instruction in meterology and more intensive training in flight solely by reference to instruments
Main Gear Box(MGB): It receives the motion from the engine and transfers it to main rotor, in order to rotate the mainrotor blades. The output from the engine in RPM is very high and of low torque, thus MGB increases the torque by reducing the speed. Simultaneously transmits the motion to the Tail gearbox through the Auxiliary and Intermediate gearboxes.
Operator:A person, organization or enterprise engaged in or offering to engage in an aircraft operation
Pilot-in-command(PIC):The pilot designated by the operator, or in the case of general aviation, the owner, as being in command and charged with the safe conduct of a flight.
Pitch:The angle between the aircraft’s longitudinal axis and the horizontal plane. Also called inclination angle.
Performance Class 1 Helicopter. A helicopter with performance such that, in case of engine failure, it is able to land on the rejected take-off area or safely continue the flight to an appropriate landing area.
Performance Class 2 Helicopter. A helicopter with performance such that, in case of engine failure, it is able to safely continue the flight, except when the failure occurs prior to a defined point after take-off or after a defined point before landing, in which cases a forced landing may be required.
Performance Class 3 Helicopter. A helicopter with performance such that, in case of engine failure at any point in the flight profile, a forced landing must be performed.
Special VFR: When the ground visibility is not less than 1,500 metres, ATC may authorise Special VFR flights provided the helicopter is certified for IFR operations.
Visual Flight Rules(VFR)– Rules and regulations under which a pilot operates an aircraft in weather conditions generally clear enough to allow the pilot to see where the aircraft is going.The pilot must be able to operate the aircraft with visual reference to the ground and by visually avoiding obstructions and other aircraft.
Visual meteorological conditions (VMC)-Condition in which pilots have sufficient visibility to fly the aircraft maintaining visual seperation from terrain and other aircraft. VFR flight is permitted in this condition.
VT-BSH Dhruv: VT-BSH was the registration number of the Dhruv helicopter that crashed on 19 October 2011 in Khunti forest,Jharkhand.The production serial number of the helicopter is DW 63.
VT-BSN Dhruv: VT-BSN was the registration number of the Dhruv helicopter that crashed on 15 January 2012 in Raipur.
VT-PHT Ecureuil: VT-PHT was the registration number of the Ecureuil AS 350 B3 helicopter that crashed on 30th April 2011 near Lubuthang,Arunachal Pradesh.Among the fatalities included the Chief Minister of Arunachal Pradesh.

                                        Pawan Hans Helicopter Limited(PHHL)

Pawan Hans was incorporated on 15 October 1985 as the Helicopter Corporation of India (HCI), the country’s national helicopter company with the objective of providing helicopter support services to the oil sector for its off-shore exploration operations, services in remote areas and charter services for promotion of tourism.

In this document wherever the term “operator” is mentioned it is to be read as PHHL.

 

                                             NAVIGATION THROUGH THIS DOCUMENT
1.// Name of reference Example //VT-BSH Report indicates that the excerpt is from the VT-BSH report
2.Analytical conclusions are in bold
3.Definations are only a brief description of the various technical jargon
4.Red sentences/words are for highlighting purpose only

                                     PREVAILING WEATHER CONDITIONS ON 19 OCTOBER 
// VT-BSH Report

-Co-Pilot had visited Ranchi Met prior to planned departure wherin he was provided only with the current weather of Ranchi.
-Met Officer on duty endorsed the same on the flight plan.
-No trained personnel were available on destination helipads to provide accurate weather inputs.Crew had been getting generic weather picture of destination helipad telephonically.
-ATC informed that visibility was 1500m and all operations under VFR had been suspended.
-Crew Obtained ATC approval to operate under Special VFR.
-The clouding reported by Ranchi Met was ‘few’ at 1500 feet

INSAT 3A picture of Ranchi Area on 19 Oct 2011

INSAT 3A picture of Ranchi Area on 19 Oct 2011

However,
-During Flight Co-pilot selected weather Radar ON and pilot called out “Yahan clouding kafi hai” indicating en-route clouding
-Search and Rescue Helicopter flying over crash site reported significant clouding 5 Nautical miles out of Ranchi and at the crash site.

From the above points it is clear that the crew had been misinformed about the prevailing weather condition which was not in the parameters of Special VFR but IMC which is a potentially dangerous situation and flight in such inclement weather can only be performed by helicopters with IFR equipment and Pilots who have been Instrument Rated.

// VT PHT Report

As per CAR Section 3, series C, Part III, para 7.1.3, the organization shall have an operations office with adequate management and operations personnel. Among the operations personnel, there shall be an Operations Officer/ Flight Despatcher responsible for the functions stated in para 4.6 of CAR section 2, Series O, part II & IV. There were no operational personnel at Tawang to brief the flight crew about the weather condition prevailing enroute or at destination. In all probability, the pilots did not obtain the weather at destination

//CAR Section 8 Series O Part I (3)

Special VFR flights shall be operated by only those pilots who have:-
1.Instrument Rating
2.Examinership on type of helicopter flown
3.Flight Instructor rating/ Assisstant Flight Instructor Rating
4.Special training in accordance to CAR

                                                       CRITICISM OF REPORT FINDINGS

1. Breaking of Rotors from main helicopter structure: This has been attributed to the large input controls(rearward movement of cyclic in particular) by the PIC in the final stages.The report seems to stress on this point as can be seen from the below.

//VT BSH Report

1.11.3.4.4. Phase III – Loss of Control (02:54:20 to 02:54:25.5).. Realisation of the steep nose down attitude (-74°) and bank to the left (105°), the Pilot applied large cyclic inputs to the rear and right. The cyclic was moved rearwards by 35.4% and to the right by 22.9% along with raising the collective by 10% (83% to 93%). These large control inputs were applied with helicopter air speed in excess of 170 kts, which is greater than the VNE for the ambient conditions

1.11.3.4.4.1. Main Rotor RPM (NR) and Longitudinal Acceleration (NZ). As a result of large rearward cyclic input, the helicopter experienced a flare effect wherein the NR increased to 109.7%. Due to the rearward cyclic application, the longitudinal acceleration (NZ) as recorded, increased from 1.4 g to 3.3 g. Immediately after the cyclic input to the rear, at time 02:54:22.5, the NR reduced from 109.7% to 76% in 0.5 sec and continued to wind down, becoming zero, thereafter, in the next one second. This rapid deceleration in NR implies damage to the rotor system.

1.11.3.6. Analysis of the above flight parameters and control inputs, indicate that most probably, the Pilot had regained visual references at a very late stage whereon he had applied large control inputs in an attempt to recover the helicopter. The control application was done at a stage where the helicopter was already beyond its cleared flight envelope. The large application of controls further aggravated the situation, taking the helicopter well beyond its structural limit resulting in damage to the rotor system.

The disorientation of the Pilot resulted in the helicopter entering into an unusual steep nose down attitude with bank angle of 105°. With the helicopter close to ground, the Pilot applied abrupt and large control inputs resulting in the helicopter exceeding its structural limits, and thereby causing damage to the main rotor system.

3.1.4. Restoration of visual references was significantly delayed as seen from flight parameters and control inputs. On regaining visual reference, the Pilot applied large control inputs, to recover the helicopter in a frantic attempt but the inputs were grossly delayed to such an extent that the helicopter had already gone beyond the cleared flight envelope by then. These unfavourable conditions aggravated the situation further such that the helicopter crossed the structural limits resulting in damage to the rotor system.
3.2.2.4. Piloting. The large and sudden control applications by the Pilot at the time when the helicopter was beyond its cleared flight envelope led to exceedance of structural limits and subsequent failure of the rotor system.

Note: The CVR and FDR stop recording at 02:54:25.5 most probably due to impacting the ground.

Rotor distance

According to the report the damage to the rotor system took place at 02:54:22.5 due to rearward movement of cyclic by PIC.In other words 3 seconds before impact the PIC made a last ditch attempt to gain control.

As has been mentioned the Helicopter was in excess of 170 knots. Taking the speed of the Helicopter even at 200 knots the rate of descent would have been 100m/s (approx) showing that the Helicopter rotor system failed at about 300 meters(approx) above ground level. The green blade at this juncture defied the laws of physics and landed 1.2 kilometers away from the helicopter. The red,blue and yellow blades decided to make more sense and seperated within a radius of less than 150 m from the main wrekage. Common sense dictates that in all probability the green blade must have separated much before the report indicates.The reports refusal to acknowledge this fact has put a question mark on the credibility of the report.

Recovered 1.2 km from main wreakage

Green blade recovered 1.2 km from main wreakage

2. Suspicious activity of the engine

//VT-BSH Report

CVR Data:

Power used during the hover was suspected to be marginally higher as made out from crew conversation but the discussion was based on approximation, as power required had most likely not been calculated before the flight. On calculating the Torque (Q) required for hovering from the Flight Manual and comparing the same with FDR recording, it was seen that the actual Q being used at hover was within the limits as given in the Flight Manual.

At 2:54:08, the Audio Warning System (AWS) and Audio Alarm for Torque came on, indicating that the Torque had exceeded 91% on one or both engines.

FDR data:

At 02:54:10 for a duration of 3.5 seconds Master Warning, MCR Engine 1& 2 Warning & MGB Pr#1 was activated
The pilot rapidly raised the collective to arrest the descent, resulting in Main Rotor RPM (NR) dropping to 95%. This was accompanied by activation of MW and Low Rotor RPM & MCR audio warnings.

//Airworthiness Directive 023 

Engine Controls – Power Control – Inspection of collective pitch anticipator
During a sortie on one of the military Dhruv helicopter, at hover, prior to take off, low rotor warning was observed. Helicopter carried out a safe precautionary landing. On further investigation, it was noticed that the fixed eye‐end of the collective pitch anticipator (CPA), p/n 34LL03C502W3290 was detached from the body of CPA. Such failure may affect handling qualities of helicopter adversely.

//VT-BSH Report (25)

1.11.3.7. Engine Parameters. The engine parameters as recorded in the FDR were analysed to check for functioning of the engines. The engine operation had been normal till time 02:54:21.5 where after in the last 04 sec of FDR recording, the NF, NG, Q and TGT values of both engines were found to wind down. The reason for this could not be ascertained. However, this does not have relevance since the rotor system had already been damaged by this time.

 

Turboméca_Makila_cutaway

Turbomeca Engine used in ALH Dhruv

Unfortunately their own calculations have gone wrong as the report says that the rotor system was damaged at 02:54:22.5 and thus both engines began failing a full second before the rotor system was damaged.

1.6.4. Engine power check was being carried out at regular interval as recommended by the manufacturer i.e., every 25 Hrs inspection. The number of cycles completed by the engine and percentage of creep had also been downloaded from FADEC during these inspections. Scrutiny of Engine log book revealed that recording of Cycles and creep data was irregular

1.6.5. Record of operation for the last few days was not available as the engineering department had failed to remove the required copy of the Technical Log Book for preservation and the whole Tech Log Book placed in the helicopter was destroyed by the post-crash fire.

3. Awkward Roll Rate and Bank Angle of Helicopter

//VT BSH Report

1.11.3.4.4.2.2. Roll Rate and Bank Angle. At time 02:54:21.5, the cyclic was moved to right by 15.3%, which resulted in the roll rate changing from -15.4°/sec to 20.2°/sec (change of 35.6°/sec in 1.5 sec) and the bank angle from -102.7° to -32.1°. However, at time 02:54:23, the roll rate was found to change abruptly from 20.2°/sec to – 83.7°/sec (change in roll rate of 100°/sec to the left) in 0.5 sec. Since the NR during this period was reducing from 109% to 76% (below the normal operating range), there would have been no control power available to generate such a high roll rate.
This sudden change in roll rate during the last 2.5 seconds without any rotor system to maneuver the helicopter indicates that the information on the roll rate & Bank Angle extracted from the FDR is unreliable.

4. Crucial evidence missing which gives an incomplete/distorted picture to the events that took place

//VT BSH Report 

1.Recording of AFCS Data. The data recording was scrutinised and it was found that Gp 7 and Gp 8 parameters, which were supposed to record the AFCS status had not been recording the same.
On enquiring, it was revealed that the fault had been observed by HAL during scheduled FDR data review at its facility and was communicated to PHHL through routine reports on FDR analysis.
The deficiency, was missed out at PHHL and no corrective action was initiated. HAL also did not initiate any corrective action to rectify the fault either as manufacturer or maintenancecontractor. The matter was also not communicated to BSF. Absence of AFCS data impeded the investigation in determining the sequence of actions taken by the Pilot.

The helicopter FDR was not recording the AFCS status. The fault had been observed by the HAL during the routine analysis of ALH FDR data. The same had been intimated through routine reportsto PHHL, who missed the anomaly. No intimation of the same was given to BSF, the owner of the helicopter. HAL as manufacturer and maintenance contractor, did not take any action to rectify the fault.

The report though fails to mention CAR Section 5 Series F Part I which puts the onus of FDR monitoring on the operator which should have taken corrective action.

// CAR Section 5 Series F Part I 

The value of data retrieved from the Cockpit Voice Recorders (CVR) and Digital Flight Data recorders (DFDR) has been proven. Periodic monitoring of CVR and DFDR must be carried out by all operators. As the DFDR systems are enhanced with greater recorder capacity, they will become even more valuable tools not only for accident investigation but also accident prevention. The recorded data can be analysed for the purpose of checking deviations in flight parameters beyond acceptable limits which are critical to flight safety.
The operator should develop suitable computer software to determine the deviations of different flight parameters beyond acceptable limits.

//VT BSH Report 

2.Record of operation for the last few days was not available as the engineering department had failed to remove the required copy of the Technical Log Book for preservation and the whole Tech Log Book placed in the helicopter was destroyed by the post-crash fire.

5.Cyclic Saturation

The report has also been critical of the inability of the PIC to return the Helicopter to arrest the bank rate after executing a tight left turn. What it fails to mention is that the Helicopter has a manufacturing defect which is Generic to ALH Dhruv called Cyclic Saturation

//CAG Report to Parliament 

Loss of control, caused by the aerodynamic environment that resulted due to the combination of control inputs leading to the air crew running out of right cyclic to roll out of the left turn. This behavior of ALH is generic to type, and not a specific case attributable only to this accident.

The very limitation of control saturation of ALH led to non-receipt (July 2007) of a potential export order from Chile though Rs. 10 crore was spent for demonstration and certification of ALH at Chile

6.The Committee has done a great disservice by blaming the pilots and not assigning any blame to the operator.

A reading of a more comprehensive report on a Mi-172 crash in comparison to the VT-BSH report gives the impression that the members of the committee had a prejudiced mindset.The former report while studying the actions performed by the pilots also went into organisational failures that precipitated the conditions for reduced air safety.

//Kaushik Committee Report

In most of the cases, where the investigations are over, the pilots are blamed for the accident by the Board of Investigation; a conclusion easily drawn from the available evidence. Interestingly, no accountability on the part of operator was assigned, not even indirectly. The operating conditions and other external factors were also not considered that resulted in these accidents. Suspecting the capability of the pilot and blaming him for the accident may not be incorrect but the operator cannot evade his responsibility for not ensuring proper conduct of recurrent training, maintenance of proficiency and competency of the pilot for the task. It is possible that commercial interest may have forced an operator to overlook or circumvent rules, thereby directly affecting the flight safety, which could contribute as a major factor towards an accident, but may not be detectable during an investigation. It is the view of the committee that operators need to follow the laid down rules judiciously and be conscientious of their responsibilities and accountability.

7.Instrument rating of Pilot-in-command

//VT-BSH Report 

The Captain had undergone 5 hrs of Instrument Flying (IF) training as required for issue of IR in the year 2009. As per Aircraft Act 1937 for issue of Initial IR, the Pilot needs to be examined by two independent examiners. In case of the Captain, record of only one IR test for initial issue could be found.

//CAR Section 8 Series O Part IV 

7.4.3 Pilot Proficiency checks

An operator shall ensure that piloting technique and the ability to execute emergency procedures is checked in such a way as to demonstrate the pilot’s competence on each type or a variant of type of helicopter.In addition where the operation may be conducted under instrument flight rules, an operator shall ensure that the pilot’s competence to comply with such rules is demonstrated to either a DGCA approved instructor or examiner or to a DGCA Flight Inspector.Such checks shall be performed twice within any period of one year.Any two such checks which are similar and which occur within a period of four consecutive months shall not alone satisfy this requirement.

//VT-BSH Report 

For the year 2010, no IF training record could be found in the logbook. For the year 2011, the Pilot had logged adequate Actual/Simulated IF.

It was observed that Simulated (Sim) IF had been logged in number of revenue sorties where the PIC had logged Sim flying while flying with a 2nd Pilot who was not an Instructor.

This is in contravention to the DGCA instructions wherein training flying cannot be conducted with passengers on board

//CAR Section 8 Series O Part IV 

2.2.5 In flight simulation of emergency situations
The operator shall ensure that when passengers or cargo are being carried, no emergency or abnormal situation shall be simulated.

//CAR Section 5 Series F Part I 

Flight Operations
Flight operations offices at the main base and sub-bases are adequately manned and equipped with communication and other assisting equipments. The operator should have sub-bases at stations where there are night halts. The flight despatchers shall be approved by DGCA. Company doctors and proper medical equipments are available at the main base and at sub-bases for carrying out preflight medical check. The flight operations offices shall maintain the records of FDTL, validity of licence/IR, medical check, proficiency check, refresher and flight safety courses which shall be updated regularly.

//VT-BSH Report 

Pilot holding IR Rating are required to undergo 05 hrs of IF training in two years on type specific flight simulator or in case the simulator for the type is not available,the training can be carried out on the type of helicopter. (This had not been done)

While all this is highlighted the report puts the blame on the DGCA despite CAR Section 8 Series O Part IV which clearly puts the onus of training the pilots on the operator.The report has also underscored the negligence of training and expects the PIC to perform in IMC conditions when the training & testing of skills was substandard/non existent. The lack of records available for IR 2009 & 2010 has not been criticised. Furthermore as the PIC in actuality was not supposed to possess an IR, the flight on 19 October 2011 should not have taken place as the operation would not have been cleared by the ATC as the PIC was in fact not IR. Thus negligence on the part of Pawan Hans Helicopter Limited in giving an IR to the PIC without following the procedures laid down by DGCA had resulted in the premature death of Colonel S.P. Singh(Retd), Lt.Colonel K.V. Thomas(Retd) & Manoj Swain

8. Criticism of co-pilot inaction during critical phase:

The report while mentioning that the co-pilot had not received Instrument Flying training or being instrument rated expects the co-pilot to provide assistance when he has not received training to perform under IMC. This is a bogus claim and the motives of the report behind making such a claim are questionable.

//Kaushik Committee Report

One of the most skilled tasks of a pilot is to maintain control of a helicopter without outside visual reference and sometimes under inclement weather conditions solely with reference to the instruments in the cockpit. Such skill is not a natural attribute and can only be acquired by through training, constant practice and systematic approach.

The Committee is of the view that proper training and proficiency of helicopter pilots to fly under IMC is to be ensured by proper training and monitored periodically by Operators/Supervisor.CAR Series O, part IV stipulates that only performance class I & II helicopters are permitted to operate under IFR and pilots operating such helicopters must be instrument rated.

9. Pilots in IMC should have enagaged AFCS upper modes

One wonders how they can make such a claim with such authority when it is also mentioned that one of the possible reasons for activation of Master Warning could have been due to a failure in the AFCS. Though it cannot be conclusively proven that the AFCS was functional they make this claim as a way to assign blame to the Pilots.

//VT-BSH Report 

1.11.3.3.3. As can be seen from Table 2, the MW was activated repetitively after TGB Hot warning. Specific reason for its activation, on some of the instances could not be determined, in absence of associated warning in FDR and CVR. Possible causes of the MW activation for these instances are listed below:

Failure of AFCS. This could not be determined, as FDR was not recording AFCS status in Gp 7 and Gp 8.
Degradation of AFCS. Minor degradation in AFCS could also have resulted in the MW activation.
-TGB Hot Wx. TGB Hot Wx could have been intermittent that would have activated the MW.

10. Pilots displayed inadequate knowledge of the Helcopter systems:The syallabus for the Dhruv has been vague or lacking on many aspects of the helicopter.

Examples:

//VT-BSN Report 

1.Recommendation- “Information neccessary for flight crew such as automatic disengagement of Hover Height (H.HT) hold due to excessive deviation needs to be incorporated into the flight manual.(It must be noted that H.HT comprises one of the uppermode functions.)

//A Unique Situation of Cyclic Saturation in a Helicopter during an Aerobatic Display : Human Factors Perspective – Tripathy NK, Joshi VV 

2.The problem of cyclic saturation to right has been observed as long as 10 years back by the test pilots when the helicopter did not respond to right cyclic input while in a step turn to left. One year later similar problem was experienced once again by the test pilots. Both the incidences had been projected and the Manufacturer has been asked to document the condition and correct the problem. However, this problem has not been addressed adequately by the Manufacturer. Documentation pertaining to saturation of right cyclic in a left turn is grossly inadequate in Flight Manual in spite of repeated reported incidences. There has been no quantification in terms of entry or recovery parameters during sucha situation. Also it was observed that the flight manual has not been certified by the concerned certifying agencies and there is a failure in the part of IAF to monitor adequately the progress on the subject matter.

//VT-BSH Report

3.It was observed that though the helicopter is equipped with the Emergency Locator Transmitter (ELT) ELT 503, which has a G switch for activation, the same had not operated in the crashed helicopter. The procedure of arming the ELT and the G switch before take-off was checked. It was found that the Pilots were not checking the ELT status as they were under the impression that the ELT and the G switch was always kept armed. Also, no check for the same was mentioned in the Flight Reference Cards provided by HAL. Flight Manual para 4.8.10 provides the checks to be carried out for arming of ELT and the G switch. The Flight reference card needs to be suitably amended and also, the check for ELT must be included in section 4.1.2 Pre-flight Checks of the Flight Manual.

//Ground training notes for ALH Dhruv pilots provided by HAL

4.In the ground training notes for pilots provided by HAL the corrective action for TGB HOT warning does not mention any reduction in speed.

IMG_20151210_184936

Corrective action for TGB Hot Warning in HAL textbook for ALH Dhruv

11.Flight crew continuing to fly despite activation of Main Gear Box Pressure(MGB PR) #1 Warning & Master Warning(MW) during hover period.

//VT-BSH Report 

The MW and MGB PR#1 warning (Wx) had been activated on multiple occasions while the helicopter was at hover. In spite of noticing these transient warnings, the crew however, decided to continue with the flight.

The report has admitted that the activation of MW & MGB as transient warnings. While criticising the crew, the report itself has neglected the cause of the activation of MGB PR#1 Wx.

ALH Dhruv MGB

Main Gear Box of ALH Dhruv

12.Cockpit Resource Management & Flight Simulator Training

//VT-BSH Report 

3.1.10. The Cockpit Resource Management by the crew was found to be lacking. Inadequate use of available helicopter resources and Co-Pilot’s inability to render assistance to the pilot in the critical phase of flight aggravated the situation.

3.2.2.3. Cockpit Resource Management. Crew coordination was found lacking during handling of the emergency. The Co-Pilot did not render any assistance during the critical phase of flight. The AFCS and available avionics onboard were not appropriately utilized for negotiating the marginal weather.

3.1.12. Simulator training for IF and Critical emergency training along with the ground refresher had not been undertaken.
3.1.17. The use of flight simulators needs to be made mandatory so that the pilots can be trained for all emergencies, which cannot be practiced on the actual helicopter. Also they can be given practice in actual IFR flying.

The report has made a note of the fact that both pilots had not been given simulator training. The report is lacking in criticism of Pawan Hans in this regard. Flight simulators are widely recognised as an important element in training not just in handling emergency situations but also in improving CRM.

//Operations circular 6 of 2009 DGCA 

The use of flight training devices and flight simulators has become increasingly important in training flight crew members. As the level of sophistication in simulators increased, air operators have come to rely on
simulators for part or all of their flight training programs. LOFT is training in a simulator with a complete crew using representative flight segments which contain normal, abnormal, and emergency procedures that may be expected in line operations.

LOFT is a useful training method because it gives crew members the opportunity to practice line operations (e.g., maneuvers, operating skills,systems operations, and the operator’s procedures) with a full crew in a
realistic environment. Crew members learn to handle a variety of scripted real-time scenarios which include routine, abnormal, and emergency situations. They also learn and practice cockpit resource management
skills, including crew coordination, judgment, decision making, and communication skills. The overall objective of LOFT is to improve total flight crew performance, thereby preventing incidents and accidents during operational flying.

Special Purpose Operational Training is designed for training crew members in a
flight simulator or flight training device. Special Purpose Operational Training is
useful whenever coordinated crew performance is required.

 CONCLUSION

The information presented in this document is vast and technical to say the least. The civil society of India or any informed citizens can make a difference by providing their support or atleast being informed on some of the problems of the aviation industry.Too many pilots have died due to complacency on the part of the regulatory bodies such as the DGCA in implementing sweeping reforms that can make a difference.A special mention goes to Kamlesh Kumar Joshi,IAS and pilots M S Brar & Rajeev Hoskote who died on 4th August 2015.

As the legislative route can be cumbersome and may not bear fruit considering the tamasha in parliament, the judiciary can be used by the civil society to implement administrative reforms. This can be in the form of a writ petition, more specifically a mandamus meaning command. The Constitution of India allows courts to give orders to the Government of India if it feels the need to do so.The term for it is judicial activism.Though in the long term reforms in the form of judicial activism may erode the democratic nature of legislation an urgent order is needed in implementing an independent accident and investigation Bureau on the lines of National Safety Transport Board(NSTB) of the United States of America. The difficulty in getting an important bill such as the Goods and Services Tax Bill only reinforces the idea that judicial activism is the best way to set up the Independent Investigative Bureau.

 

References:

1.CAG Report on ALH Dhruv 

2.Crash Investigation Reports

3.Civil Aviation Requirements

4.Kaushik Committee report

5.Airworthiness Directives

6.Cyclic Saturation

 

Comments (2)

  • vijesh . 16th February 2017 . Reply

    great job…

    • (Author) George Kottakal . 16th February 2017 . Reply

      thanks!!

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