Monday Accident Lessons and Learned: A review of the Mangalore Air India Crash.. when do you reopen an investigation?
158 lives were lost on May 22nd, 2011, when Air India Express Flight 812 crashed after not aborting a landing. According to an article by Indian Aviation News,
“The court of Inquiry determines that the cause of the accident was Captain’s failure to discontinue an “Un-stabilised approach” and his persistence to continue with the landing, despite three calls from the First Officer to “go-around” and a number of warnings from the EGPWS”
According to the article being reviewed, the Government of India had inserted vide GSR No. 168(E) a very important rule to ‘The Aircraft Rules 1937′, which govern everything aviation in this country On 2009 March 13.
75A. Reopening of Investigation – Where it appears to the Central Government that any new and material evidence has become available after completion of the investigation under rule 71, 74 or 75, as the case may be, it may, by order, direct the reopening of the same.
The article then references the findings that should reopen the case:
Here is a list of new and material evidence:
1. The fact that a huge portion of the wreckage was taken away from the crash site by locals and was sold as scrap metal. What the Court of Inquiry was inspected and studied (if at all they had done any study) was the remaining wreckage.
2. The reconstruction of the wreckage was never actually done by the CoI. The image of the reconstructed wreckage included in the report was a computer generated one.
3. While testifying before the court of Inquiry at Mangalore airport, Six survivors of the crash were made to answer a totally biased and misleading question by the CoI. The question was, “Do you think the accident occurred because of the fault of the pilot?” This was in plain violation of Rule 7.2.1 of the Manual of Accident/ incident investigation: ‘ The investigation of aircraft accidents and incidents has to be strictly objective and totally impartial and must also be perceived to be so’.
4. The “Hard Landing” circular issued by Air India is a major contributor to the accident. The CoI had chosen to ignore this vital fact.
Of course some of the issues from the article’s author stem from the investigation itself and are items that we teach our clients to avoid:
1. Spoliation of Evidence
2. Interviewing in a less effective manner which could have induced bias…. (leading the interviewee)
3. Focusing on what TapRooT® would define as a Causal Factor only and not the root causes for the Causal Factors
So the question for today’s Monday Lessons Learned is when would you, or when have you reopened an Investigation?
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