A joint investigation team, set up by the government to inquire into the near-miss at Mumbai airport on February 19 this year involving an Air India flight and a helicopter from the Presidential fleet, has in its report listed the "unsatisfactory coordination" among various agencies involved as one of the prime factors that led to the incident.
Apart from this, the committee has cited the late transfer of control of the helicopters from approach to the air traffic control (ATC) tower and the landing of the three-helicopter formation without clearance from the ATC as the factors that could be attributed to the incident.
The report has listed the factors according to sequence of events and not in terms of gravity.
It said Pratap 2, one of the helicopters, had landed directly at the place on landing on runway 27 by making a very short circuit. It said Pratap 2 had landed without landing clearance from ATC even before the Pratap formation had reported the finals. It said Pratap 1 and Pratap 3 also landed without landing clearance.
President Pratibha Patil and her entourage, who were on a visit to Maharashtra, were returning to Mumbai by three helicopters when the near-miss occurred.
One of the helicopters landed on the same runway which a Delhi-bound Air India flight, IC 866 being operated with an Airbus A-321 aircraft, was using for take-off. The Air India pilot, Capt S K Kohli, aborted take off at high speed and applied the emergency brakes when he saw the helicopter landing just some metres ahead. The aircraft had 150 passengers on board. The President was not in that helicopter.
The Director General of Civil Aviation (DGCA) appointed a five-member high-level team, led by Joint Director General (Investigation) of the DGCA, Mr A K Chopra, to probe the entire sequence of events.
The committee has, in its report, also made a series of recommendations, especially in the procedures to be followed for VVIP flights, to prevent the recurrence of such incidents.
The Ministry of Civil Aviation said in a statement that it had accepted the report.
According to the report, the Air India pilot and the Indian Air Force (IAF) pilot of the helicopter were appropriately licensed and authorised to fly the respective aircraft. It also said the plane and the helicopter were both airworthy and had been maintained as per regulations.
It said the Air Traffic Control Officers (ATCOs) on duty also had proper expertise and rating of their units.
The report said the weather at the Mumbai airport was not suitable for Visual Flight Rules (VFR) operations but it was not considered as a contributory factor as far as the incident was concerned.
The report said the coordination among various agencies was unsatisfactory and the coordination meeting was not carried as per the existing instructions. It said there is no common Standard Operating Procedure (SOP) between the IAF and the Airports Authority of India (AAI) for VVIP flights.
According to the report, the radio telephony (RT) reporting procedure for the helicopter formation was not satisfactorily documented. It said there was a difference of opinion between the AAI and the IAF on the procedure to be followed.
The committee felt the transfer of control from approach to the ATC tower should have been earlier. The 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 the IAF and the AAI.
At present, as per instructions of the Home Ministry, no closure of airport is required for VVIP flights, but they are given priority landing. The report said there was a lack of common understanding on the concept of priority landing between AAI and IAF.
The committee noted that the Air India pilot had rejected take-off at high speed after sighting the helicopter on the side of the runway and turned to taxi track W to avoid direct collision with the chopper which was in front of him at a distance of 30-40 metres.
The report highlighted the fact that the IAF's MI-8 and MI-17 helicopters are not equipped with flight data recorder (FDR) and other safety equipment which are installed on the civil version of these helicopters.
The committee recommended that 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.
It said 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 the State Government.
The report said airport-level coordination meeting should be conducted to discuss the operational issues between AAI, IAF, DGCA and security agencies.
The committee said the Home Ministry 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.
The committee said the AAI and IAF should designate senior level officers for effective coordination for VVIP movements.
It said the AAI should issue an SOP for handling of VVIP flights incorporating all instructions already issued, to make a comprehensive document. IAF and AAI will mutually share SOPs.
It said an airport-specific SOP for VVIP movement in case of AAI-managed airports should be prepared by AAI and will be approved by AAI Headquarters. In respect of IAF airfields, the SOP shall be prepared and approved by IAF. For private airports, the SOP for VVIP movement will be prepared by the aerodrome operator and shall be approved by DGCA.
The standard operating procedure so prepared will be used by IAF, AAI and aerodrome operator jointly, covering all phases of operations. This task may be accomplished at the earliest.
The committee said 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. Issues regarding routing, special VFR, position reporting etc. should be discussed and resolved at Airport Level Committee 24-48 hours before commencement of VVIP flights, it said.
According to the report, the VVIP flight 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 IAF and AAI in respective SOPs and in common SOP for correct understanding of procedure.
Helicopters and aircraft used for VVIP flights must have a digital flight data recorder (DFDR), cockpit voice recorder (CVR) with multi channels, ground proximity warning system (GPWS), Traffic Alert & Collision Avoidance System (TCAS) and other safety equipments used on similar civil aircraft/helicopters.
Once these equipments are installed, regular monitoring of these flights should be carried out on the lines of FOQA (Flight operations quality assurance) by other airlines for safety oversight, the report said.
According to it, the Helicopter Committee set up by the Civil Aviation Ministry/DGCA should expedite identification of landing places for helicopters at Delhi and Mumbai and to work out the traffic circuit for them.
Till the time this is implemented, all helicopters should 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 IAF and AAI.
Three minutes before and after the estimated time of arrival and estimated time of departure of VVIP operations, air operations, airspace should be closed. This closure should be informed by issuing a Notice to Airmen (NOTAM), the report said.
It said the 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 committee said 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.
It said 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, the Civil Aviation Ministry in consultation with Home Ministry may examine this aspect to asses whether any other procedure can be evolved in such an eventuality of missed approach.
The committee re-emphasized that transfer of control from Approach to Tower and vice versa, should be followed strictly as per ICAO DOC 4444.
Visual surveillance before landing, especially for VFR flights, should be re-emphasized on all aircrew members and ATCO, the report added.