The Joint Investigation team constituted on February 19, 2009 to investigate the serious incident of a near miss between the Presidential Indian Air Force (IAF) helicopter and a Air India flight IC-866 on February 9, 2009 at Mumbai airport has submitted it report to the Ministry of Civil Aviation.
To translate the official findings (shown below), the Presidential formation called Pratap (comprising of three helicopters Pratap 1, Pratap 2 and Pratap 3) landed on the active runway without reference to or permission from the Air Traffic Controllers causing the Air India Airbus A321 VT-PPV to perform a high speed take-off reject.
As in this article by 737 instructor pilot Captain A. Ranganathan, the team has also criticised the lack of modern recording and safety equipment like DFDR (Digital Flight Data Recorder), CVR (Cockpit Voice Recorder), GPWS (Ground Proximity Warning System), TCAS (Traffic Collision Avoidance System) on many Indian Air Force equipment.
The lack of such equipment on many official government aircraft is widespread and was also considered responsible for another near miss between an Ilyushin IL-76MD and an Air India flight just two days after the Mumbai incident. It was later discovered that the IL-76 did not belong to the Indian Air Force but the Aviation Research Centre which is directly under the Prime Minister’s Office. There is no release of information on that incident.
With apologies in advance for the plethora of acronyms, the findings of the Committee were:
- Pilot of IC-866 were appropriately licensed and aircraft was airworthy and maintained as per the Regulations of DGCA.
- Pilots of the IAF helicopter were authorized as per Indian Air Force Regulations and Helicopter was maintained as per Regulations and was airworthy.
- Air Traffic Control Officers (ATCOs) on duty had proper expertise and rating of their units.
- Weather at Mumbai airport at the time of incident was not suitable for VFR [Visual Flight Rules] Operations but it is not considered as a contributory factor.
- The coordination among various agencies was unsatisfactory and coordination meeting was not carried out as per the existing instructions.
- There is no common SOP [Standard Operating Procedure] between the Indian Air Force [IAF] and Airports Authority of India [AAI] for VVIP [Very Very Important Persons] operations.
- RT reporting procedure for formation is not satisfactorily documented. There was a difference of opinion between Airports Authority of India [AAI] and Indian Air Force [IAF] on procedure to be followed.
- Transfer of control from approach to Tower should have been earlier.
- Helicopter was given direct routing from INS Shikra (Kunjali) to Mumbai which was as per the regulations.
- There was a difference of opinion and understanding about the VFR circuit to be followed especially for Helicopters between Indian Air Force and Airports Authority of India.
- No closure of airport is required for VVIP flights at present as per the instructions of Home Ministry. VVIP flights are however to be given priority landing. There was a lack of common understanding on the concept of priority landing between AAI and IAF.
- IC-866 rejected take off at high speed after sighting Helicopter on the side of Runway and turned to taxi track ‘W’ to avoid direct collision with the Helicopter which was in front of him at distance of 30-40 meters.
- MI-8 and MI-17 Helicopters are not equipped with FDR and other safety equipments which are installed on civil version of these Helicopters.
- Pratap formation (all three helicopters) landed without landing clearance from ATC.
- According to the Committee the following factors can be attributed to the serious incident. These factors are listed according to sequence of events and not in terms of gravity:
- Unsatisfactory coordination among various agencies, involved in the incident.
- The late transfer of control of aircraft from approach to tower.
- Landing of Pratap 2 directly at the place of landing on Runway 27 by making a very short circuit.
- Landing of Pratap 2 without landing clearance from ATC even before Pratap formation reported the finals.
- Landing Pratap 1 and Pratap 3 without landing clearance.
In typical bureaucratic form the recommendations of the Committee are wide-spread, with no central agency responsible, and no fixed time frame for implementation.
- The instructions given in the Home Ministry’s Bluebook for coordination procedure should be strictly followed and all Members be invited for Coordination Meetings. The minutes of meeting should be documented and circulated to all concerned for compliance.
- Last minute local changes, if required, can be carried out after consultations among Aerodrome Operator, ATC, IAF and Security Agencies which should be documented and should be duly informed to Protocol Department of State Government.
- Airport Level coordination Meeting should be conducted to discuss the operational issues between AAI, IAF, DGCA [Directorate General of Civil Aviation] and Security agencies.
- Ministry of Home Affairs should send a copy of Bluebook to AAI in case it is not done at present. Based on the same, AAI will make internal confidential circulars for use of their own officers.
- AAI and Indian Air Force shall designate senior level officers for effective coordination for VVIP movements.
- AAI shall issue a Standard Operating Procedure for handling of VVIP flights incorporating all instructions already issued, to make a comprehensive document. IAF and AAI will mutually share SOPs.
- An Airport specific Standard Operating Procedure for VVIP movement in case of AAI managed airports be prepared by AAI and will be approved by AAI headquarters. In respect of IAF airfields, the Standard Operating Procedure shall be prepared and approved by IAF. For private airports, the Standard Operating Procedure for VVIP movement will be prepared by aerodrome Operator and shall be approved by DGCA. The standard operating procedure so prepared will be used by Indian Air Force, Airports Authority of India and Aerodrome operator jointly, covering all phases of operations. This task may be accomplished at the earliest.
- The two organizations namely IAF and AAI should exchange, documents in connection with VVIP flights whenever required.
- Priority landing and privileges attached with it may be defined and documented.
- Issue regarding routing, special VFR, position reporting etc. should be discussed and resolved at Airport Level Committee 24-48 hours before commencement of VVIP flights.
- The formation shall report position of lead Helicopter even during entering the aerodrome circuit or for asking permission for landing. However, vacation report of runway etc. will be that of last Helicopter. This procedure should be documented by Indian Air Force and Airports Authority of India in respective Standard Operating Procedures and in common Standard Operating Procedure, for correct understanding of procedure.
- Helicopters and aircraft used for VVIP flights must have a DFDR, CVR with multi channels, GPWS, TCAS and other safety equipments used on similar civil aircraft/helicopters, once these equipments are installed, regular monitoring of these flights be carried out on the lines of FOQA (Flight operations quality assurance), by other airlines for safety oversight.
- The Helicopter Committee set up by MOCA/DGCA [Ministry of Civil Aviation/Directorate General of Civil Aviation] should expedite identification of landing places for Helicopter at Delhi and Mumbai and to work out the traffic circuit for Helicopters.
- Till the time the above recommendation is implemented, all Helicopters will report finals at the beginning of Runway and thereafter land at desired spot on the runway. This should be immediately documented and circulated by both Indian Air Force and Airports Authority of India.
- Three minutes before and after ETA/ETD of VVIP operations, airspace should be closed. This closure should be informed by issuing a NOTAM.
- Existing Regulations of aircraft landing only after obtaining permission from ATC units should be strictly enforced and circulated to all concerned including pilots of VVIP flights.
- The Airport Committee comprising AAI, IAF and Aerodrome Operator should work out airport specific operational issues 24-48 hours before actual operations of VVIP flights.
- The existing laid down procedure for missed approach will remain in-force. However, the consequences of missed approach on the security, health and other aspect of VVIP on board need separate examination. In this regard MOCA in consultation with MHA may examine this aspect to asses whether any other procedure can be evolved in such an eventuality of missed approach.
- The committee re-emphasizes that Transfer of control from Approach to Tower and vice versa, should be followed strictly as per ICAO [International Civil Aviation Organisation] DOC 4444.
- Visual surveillance before landing, especially for VFR flights should be re-emphasized on all aircrew members and ATCO.
The report has been accepted by the Ministry of Civil Aviation.