AIR SAFETY
by Capt. G A Fernando-December 19, 2019,gafplane@sltnet.lk
Former Member Accident Investigation team CAASL
Today, Air travel is the safest mode of travel in the world. It didn’t happen overnight. The main reason for achieving this status was the ability of the Industry to learn from mistakes, in a non-punitive environment. By the very definition of an accident, it is an unexpected event and unintentional. The results of all accident investigations were published for the benefit of all and not intended to apportion blame. We in Ceylon/ Sri Lanka have had our share of air accidents. On 15th November 1961, a rainy afternoon in Ratmalana, an Indian Airlines Vickers Viscount aircraft, inbound from Madras (now Chennai) was making an approach to land on Runway 22 (from the Attidiya end). At the controls were two experienced Captains. One occupying the Captain’s left hand seat while the other occupied the right hand one, carrying out the duties and the functions of the First Officer (Co-Pilot). Although equally experienced, the acting First Officer had more experience on Viscounts. The aircraft was only three years old, powered by four Rolls Royce Dart engines. Named after the Dart River and very successful. The Flight had six crew members and 36 passengers. The registration of the aircraft was VT-DIH. The Viscount was the first Turboprop Airliner in the world and was popular worldwide. Turbine engines are smooth and do not vibrate like Piston Engines. Therefore gave a more comfortable ride to the passengers.
Plane 1
The aircraft was observed to be high on the approach path, probably being pushed by the prevalent Northeast Monsoon. (Wind direction is defined from where it blows and not to where it goes) The projected touchdown point was about one third of the way into the runway. Normally, the pilots aim to land about 1000 feet beyond the runway threshold. Some eye witnesses say that it was raining heavily. Then suddenly, at very low altitude, the more experienced on type, right hand seat co-pilot, initiated go around action, without informing the Captain, by opening up the throttles and selecting the Landing Gear (Wheels) up.. Unfortunately, on this occasion the other pilot (LH seat) was intent in landing. The turbine engines have a lag between throttle and power known as the ‘spooling up time’. There is also drag created by the gear doors opening up to receive the retracting wheels. As a result momentum, drag and slow engines, the aircraft to continue its descent had landed on its belly. The large propellers touched the ground and the aircraft veered to the left out of control, all the way towards the New Airport road and smashed through the fence. The aircraft was badly damaged by the concrete fence posts and hit the Bata board, coming to rest across the airport road, facing Attidiya again. Fortunately there was no resulting fire.
None of the 42 occupants were injured. The aircraft was damaged beyond repair and subsequently scrapped. The official International Civil Aviation Organisation (ICAO) accident report stated that the pilot in the right hand Seat (First Officer) had interfered with the controls without instructions from the Captain. The actions of the co-pilot, however well-meant was both "unauthorised and unwarranted". Obviously there had been a huge communication gap between the two pilots.
Plane 2
It took many more high profile air accidents all over the world, for the safety experts to acknowledge that there were serious behavioural problem between cockpit crew members that need to be addressed including the ‘Intra Cockpit Authority Gradient’ between Captains and Co-pilots
The first person to identify these ‘Human Factors’ in aircraft accidents was a Ceylon born, WWII pilot, David Beaty, who flew for BOAC as a Captain and then qualified in Psychology at Oxford. When he propounded his theories for causation of air accidents and that there was a ‘cause behind the cause’ of accidents, many, especially the Airline Pilots didn’t like their human problems going public, as Airline Pilots at that time were considered to be ‘supermen’ and thought to be infallible. David Beaty was a prolific writer of airline stories. ‘The Cone of Silence’, ‘The Heart of the Storm’, ‘The Naked Pilot’ and ‘The Temple Tree were some of his many books. Now there are other researchers like Roger Green, Mica Ensley, Prof Tony Kern and Prof James Reason to name a few, who are continuing the studies to reduce air accidents and improve air safety. Essentially, while equipment is getting more and more reliable the human element is still in the Stone Age. As they say a chain is as strong as its weakest link.
The time we were flying school trainees, in the late sixties the best place to buy aviation related books was at K V G de Silva & Sons at the YMBA, Fort. We didn’t have Amazon.com then. Whenever we, Ratmalana types visited the Directorate of Civil Aviation, at Lotus Road, Fort, we never failed to drop in at the McCallum’s book Depot to pick up the latest Air Progress Magazine (Rs.10/-) and then before taking the bus home, check K V G de Silva & Sons out. Here is the strange part. The gentleman in charge was Mr K V N de Silva and had been a passenger in that Indian Airlines Viscount flight in November 1961 and lived to tell the tale. He could exercise his discretion on what books to order. That was how we could pick up interesting books pertaining to aircraft accidents there. In fact I picked up a copy of the ‘Human Factors in Aircraft Accidents’ by David Beaty there (didn’t know the Ceylonese connection then)
That sparked off my initial interest in human factors in aircraft accidents. Now after over fifty years in the aviation industry, organizing the first ever Crew Resource Management workshop (CRM) in AirLanka, being trained as a CRM Facilitator in Singapore Airlines, serving in the Air Accident Investigation Panel in the Civil Aviation Authority Sri Lanka (CAASL) and serving as a Designated Flight Operations Inspector at the CAASL, I think I am qualified to comment on the Viscount Crash at Ratmalana on 15th November 1961, as we now have established many procedures, checklists and alternative positive behaviours which are common place and are taken for granted by all and sundry in the Industry. All reforms were made after blood was spilt somewhere.
So let us start at the beginning. Was it a good idea to have two equally experienced Captains in the Flight Deck on a scheduled flight? Unless the person on the left seat was undergoing training or was under supervision for a routine check flight, it is not a good idea. During a training or Check flight, the Instructor Captain sits on the right and is designated officially as Captain of the flight. There can be only one Captain. There are pre-flight briefings now in place to remove any ambiguity as to who is in authority. In most airlines, unless they are trained to fly from the right seat the Captains are prohibited from handling the controls from an unfamiliar (right hand) seat. There is something now identified by the safety experts as ‘Intra Cockpit Authority Gradient’. Having similar experience (11,000plus hours each) the authority gradient would have been flat. The co-pilot, having more experience on the type (Viscounts) than the Captain, the perceived authority gradient would have even gone the other way and given a sense of greater authority to the co-pilot. That is where the designated Captain sets the tone at the pre-flight briefing, by saying something like "If you see something unsafe happening, please say it out loud, even at the risk of being embarrassed" Believe me it works!
Then there is something called the ‘Support Process’ which is now becoming a standard airline practise. Only one pilot should handle the aircraft at all times. He shall be called the ‘Flying Pilot’. The non-flying pilot, now called the ‘Monitoring Pilot’ should in the case of an undesired situation, like what happened in the Ratmalana accident, where the aircraft ended up high on the final approach, should verbally show his concern. If no corrective action is taken by the ‘Flying Pilot’, then the Monitoring pilot should suggest a solution. For instance when the aircraft was observed to be high on approach, he could come up with a solution statement "Shall we extend our Landing Gear?" or "Shall we apply more Flap?" Both these actions create more drag and help the aircraft to get down quickly. If the flying pilot does not give a rational answer or does not respond, the monitoring Pilot is expected to use the flying pilot’s rank and name and say "Capt …, you have to go around" with a sense of urgency. If this does not trigger the Flying Pilot into action, then the Monitoring pilot assumes that the Flying Pilot is incapacitated and takes over control. In case the Monitoring Pilot takes over control, he is supposed to announce "I have control" and the former Flying Pilot acknowledges that by saying "You have control" As to whether it was mutiny or self-preservation could be sorted out later on ground. In this case, the two Captains were well experienced and could have easily noticed that an undesirable situation was building up. The ‘Support Process’ could have helped.
In the present day, in case of a go around (aborted landing), the Flying pilot has to wait for a positive climb indicated on the altimeter before calling for the Monitoring pilot to select the landing gear up. The Monitoring Pilot will confirm a "positive climb" and then select the gear up. That was introduced to the procedures later (in the seventies), to prevent accidents such as this. If the wheels were still down when the aircraft touched down, it would have been a non-event. Since the aircraft had full power, it would have bounced back into the air and prevented a belly landing. And when it climbed out safely, the gear could have been retracted. A matter of announcing a "go around" and getting the sequence right. The pilots now have to demonstrate this drill every six months in the simulator, to a CAASL designated Examiner, over and over again.
Unlike other conventional aircraft, where the lever to raise and lower the Landing Gear, is situated in the forward instrument panel, the Vickers Viscount had an electric switch in the centre pedestal between the pilots. The Flying pilot couldn’t have observed the Monitoring Pilot, interfering with the undercarriage, even with his peripheral vision, until it was too late. That could have some implication too. The switch design should be error proof. Usually the aircraft would have had a geometric or electric lock to prevent the gear being retracted once the aircraft is firmly on ground. The aircraft would have been still in the air when the ‘Gear up’ button was pushed by the co-pilot. Now by regulation, all Air Crew must undergo Crew Resource Management (CRM), sometimes known as Team Resource Management (TRM) training once in every two years. The studies involve New Accidents/ Incidents, Communication Skills, Team Building, Briefing techniques, Use of Checklists, Situational Awareness, Automatic Flight, Personality Types and Conflict Resolution among other interesting topics.
The aircraft crashed through a perimeter barbed wire fence with concrete posts which ripped the wings and the fuselage and wrote off the aircraft. The same type of perimeter fences are still there at Ratmalana. The recommendations contained in the Annex 14 to the ICAO Convention is to have all perimeter fencing to be frangible (Breaking on impact) have been ignored. There are also other obstacles such as metal security watch towers and mounds of earth on either side of the runway, within the perimeter of the airport, introduced by the SLAF during the almost thirty year war. There is also a hazardous concrete wall at the Galle Road end of the runway.
For certain, if the pilots were aware of what the airline pilots know today, this accident need not have happened.
