India’s aviation regulator and inspector the Directorate General of Civil Aviation (DGCA) has released its investigative report in the engine fire incident of Air India Boeing 747-400 VT-ESM Konark at Mumbai on September 4, 2009.
As per the DGCA, the primary cause for the accident was
the complete dislodging of No. 1 strut fuel feed line coupling due to dislodging of tie wire from the failed tie wire hole is the cause for heavy fuel leak and leaked fuel falling on hot #1 engine resulted into fire.
In a damning indictment of the lackadaisical “chalta hai” approach of various operations groups including the airline’s engineering, cockpit and cabin crews, and the air traffic control personnel, the DGCA has also opined the contributory factors to include:
- Not tightening the coupling to the proper specification and procedure during maintenance resulting into ductile failure of coupling material is the main contributory causative factor.
- Installation , maintenance or environmental variables.
- Failure of departure AME [aircraft maintenance engineer] in adhering to the standard procedures and his perfunctory function.
- Lapses/failure of the pilots during walk around inspection
- Non-conformance by the pilots [to] company operating procedures
- Failure of ATC-SMC personnel for prompt and effective handling emergency situation.
- Lack of situational awareness and crew coordination.
The DGCA has provided the following safety recommendations:
- Appropriate corrective action as deemed fit should be taken on the involved captain, first officer, all cabin crew and the Departure AME for their deficient performance and lapses.
- Appropriate corrective action as deemed fit should be taken on the SMC controller for his tardy and ineffective handling of the emergency situation.
- Air India shall Review maintenance program, its schedules and maintenance practices for more stringent, effective and frequent inspection and identification of fuel leak from the aircraft.
- The incident may be brought to the knowledge of all concerned.
- AAI [Airports Authority of India] shall introduce, monitor proper training procedure to all ATC personnel for handling emergency situation.
- AAI shall review the Existing System of documenting Departure/arrival register and flight progress strip for inclusion of information of aircraft registration.
- Installation of SMR [Surface Movement Radar] at Mumbai airport shall be done immediately by concerned airport agencies. [Note: Apparently the radar has been installed, but is not used by the ATC since they want all ground vehicles to also be fitted with a radar transponder. I wonder why can they not commence with surface tracking of aircraft first and push for the early implementation of ground vehicle tracking?]
In a reflection of their sensationalism, the mainstream news media which resorted to extreme scaremongering reporting at the time of the incident have not even reported the release of the DGCA findings. The fire is out, and why should they care about the truth.
The full report is embedded below for online viewing or can be downloaded here.