I Mourn for Karthigeyan

Flight Lieutenant Kuke Suresh walked into my office with a grim face. Flight Lieutenant M S Vasudeva walked in just behind him. Kuke was my adjutant and Vasu was the Unit Flight Safety Officer. It was the 29th of September 1969 and I was Archer One. We were at Hindan. ‘There has been an accident in Chandigarh‘, they sang out in unison. A trainee pilot from Eighth Pursuit had crashed on takeoff. The aircraft was a write-off and the pilot was seriously injured. I felt sad. Getting youngsters to convert into high performance aircraft was never easy. Babi Dey (Wing Commander PK Dey) had just taken over the Eighth and I felt sorry for him.

A few minutes later there was a call from the Command HQ. Wingco Man Singh was on the line. There has been an accident in Chandigarh, he repeated the news. I said, yes, I have heard about it. Are any details known? No, he said. We only know that it was a crash on takeoff. We are putting you in as the president of the court of inquiry. Just get to Chandigarh quickly and start the proceedings. I will get the list of your team members shortly. That was that. I went home and packed my bags. Half an hour later an IL-14 came to pick me up and drop me at Chandigarh. A mournful journey began.

On arrival at Chandigarh I first had to sequester all the technical documents pertaining to the aircraft that had crashed as well as all the training documents related to the pilot. This posed no problem. The unit’s flight safety officer had already gathered all the documents in anticipation of my arrival; he now handed these documents over to me. I met Air Commodore E Dhatigara who was the AOC of the Base and his flying and his technical staff. At the unit level I met the flight commander, Squadron Leader Ravi Kumar and the officiating CO Squadron Leader Rodrigues. I could not meet Babi, the commanding officer, as he was out of station. I gathered all the documents and retired to my room in the mess. I had a lot to study.

Karthigeyan, the pilot who had crashed, was in the hospital. He was alive but critically ill. He had multiple internal injuries and was extensively burnt. He was however conscious, and strangely, not in great pain. It seems that his outer skin was so thoroughly burnt that his mechanism for sensing pain was not working any more. I wondered whether I should make an attempt to gather a report from him at first-hand. I spoke to the Senior Medical Officer about it and he vetoed the idea. The poor lad was under heavy sedation and was fighting for his life. No pressure could be allowed on him. Answering questions would be too much of a strain.

Dropping the idea of recording a statement from Karthigeyan, I started examining the documents I had brought down. The very first document I opened was the Form 700 for the aircraft that recorded all details of day to day maintenance activities on the aircraft. It told me that the pre-flight servicing on the aircraft was done as scheduled. Fuel, oil, air and oxygen had been replenished and topped up. The electric accumulators had been checked for adequate voltage. All flight and engine instruments were tested for proper functioning. The airborne interceptor radar and the radio communication sets were checked for serviceability. The aircrafts’ documents had been checked and it was confirmed that all line replaceable parts were left with adequate hours for next inspection. It was also certified that no reported defect investigations were left undone. I leafed back on the document to see what sort of defects had been reported on the aircraft in the recent past and what were the corrective actions taken.

What I found caused me to stop short. Just a couple of days earlier, it had been reported that the afterburner had failed to light up on demand on one occasion! This was a very serious defect report. Horror of horrors! This was not the first occurrence of after-burner malfunction. As I went back on the maintenance log there was yet another report of after-burner not lighting up. And what was the follow-up action on these occasions? On both occasions the aircraft was tested extensively and repeatedly on the ground, but the failure could not be reproduced. The fuel system was then flushed cleaned and put back. The after-burner ignition system was also ‘serviced’: A very clear case of ‘found nothing fixed everything’ maintenance.

There was a knock on the door. Two young pilots walked in. They were the first persons to reach Karthigeyan after the crash. They were standing on the tarmac when the accident took place. As soon as they saw the accident, instinctively they had jumped on to a motorcycle, had driven through the airfield area, had gone through the boundary fence broken at one place, had gone through the drain beyond the fence and had found Karthigeyan on the ground in an extensively burnt but fully conscious condition. They had put out the residual fires on his clothing and were there with him until medical help arrived to take charge of him. These two boys were obviously very important witnesses. I decided to talk to them for some time. What were their first impressions when they had met Karthigeyan? The most unexpected impression these two had was that Karthigeyan was not in pain. He was extensively burnt, but was fully conscious. He was talking normally. And what was he saying to them? Apparently he was fixated on two point; ‘why did I crash?’ and ‘the after burner light was on’. Obviously, he had thought that the after-burner must be working because the after-burner light was on!

Karthigeyan was fighting for his life. In the evening the doctors felt a little hopeful. He was resting well and his routine medication seemed to be effective. We hoped and we prayed. We could do nothing else. Next morning I went down to the technical headquarters of the station and sat down with the Chief Technical Officer (as the Senior Maintenance Officer was known in those days). Wing Commander SS Sehgal was the CTO. A very sincere and hard working officer who was seriously disturbed at the discovery of questionable maintenance practices related to the aircraft destroyed in the accident. We sat down and went minutely through the procedures and practices followed by the second line maintenance organisation of the station.

Some time in the forenoon Karthigeyan breathed his last. The end came rapidly without any warning. One moment he was lying peacefully and in a second he felt wretched and was gone. The information was sent to the Command HQ. I could not continue as the President of the C of I. A court of inquiry on a fatal accident needed to be presided over by an officer at least in the rank of a Group Captain. I was told to carry on as the senior flying member of the C of I. Next morning Group Captain Randhir Singh came and took over the conduct of the C of I. I provided him with a brief of all the information that I had gathered. Groupie Randhir was one of the rising stars of the Air Force at that time. Very sharp and incisive in thought, he was listened to with respect by his seniors and juniors alike. After I finished my briefing we sat together for a long time and decided on our plan of action. It was decided that we would investigate the background of the pilot, the history of the aircraft and the happenings on the immediate environment individually. There after, we would examine the accident itself and try to come to a conclusion about the cause of the accident and our recommendations about preventive measures.

Once we came out of the debriefing, Groupie Randhir went off to meet the AOC while the technical member and I began our individual quests. The tech member had his tasks cut out. The engine had to be salvaged and brought back to the base from the site of the crash. He then would have to devise a method to find a way to determine why the after burner had failed. (There seemed to be overwhelming evidence to indicate that the after burner had indeed failed to light up on take off.) He also had to examine all technical practices in vogue on the station and examine the technical supervisory chain minutely. This was a daunting task and it needed technical officers specially trained to carry out such forensic examination. The air force had just set up an organisation for this purpose. It was called the Aircraft Accident Investigation Board or AAIB. My Technical member was a part of the AAIB.

I had to investigate Karthigeyan as a person; his training, his motivation, his attitude to flying, his abilities as recorded, and his emotional status prior to the accident, all had to be examined. I also had to investigate the flying environment at the time of the accident. The functioning of the Air Traffic Control, the meteorological conditions, the briefing received before the flight, and of course the dynamic of the accident itself, all had to be examined in detail. There was one thing however that was bothering me since the previous day. According to the two young pilots who had reached Karthigeyan first after the accident, Karthi was confused about the cause of his accident. He had seen the ‘Afterburner ON’ light glowing and had concluded that the afterburner was indeed on. That was the root of his confusion. My unease also started from that point. In the MiG21, there are two main indications available to a pilot on the takeoff run to assess whether the afterburner was lit-up properly. The first cue would be the lack of acceleration as the brakes are released. If the pilot fails to perceive the lack of acceleration, he would see a large difference in the rotational speed of the low and high speed turbines. If the afterburner lights up as it should, the two turbines would be turning at almost similar speeds. Both these were mandatory checks to be carried out by the pilot to continue on his takeoff run. Karthi had clearly failed to perceive the situation of afterburner failure on the takeoff run and was confused. This situation could be brought about only by three conditions. Was his ground training about the aircraft and its systems inadequate? Was he temporarily distracted by some other thoughts or concerns? Was he careless by nature and paid inadequate attention to his drills, checks and techniques of flying? What was it? This haze caused me distress. I had to find out the truth. I called for his blue book and immersed myself into it.

The Blue Book is a pilot’s personal flying diary. A fighter pilot is mostly alone in the cockpit. There is no one who can monitor his activities there. For continual progress of his skill and ability, the pilot has to be his own mentor. After every sortie, the pilot is therefore required to write down the details of every manoeuvre carried out while it is still fresh in his memory. All achievements and all failures, all discoveries and all confusions are to be faithfully recorded. The pilot can then, at his leisure, go over the sortie in his mind and decide on corrective action on all failures. The blue book is a personal document and is private to the pilot. It is however open to his immediate superior who reads it to understand what the pilot did in the air. This access also permits the supervisor to peek into the mind of the pilot. The self description often reveals to the supervisor whether the pilot is tending to over-assess or under-assess his own abilities. An ability to acknowledge one’s own failures or faults is an essential attribute to one’s growth of ability and skill. A study of a blue book allows the supervisor to act as a friend and counsellor to the pilot. Maintenance of a detailed blue book is mandatory when a pilot is under training and is highly recommended even when he is fully operational on the type of aircraft in use. During the training period, the blue book entry has to be shown to the leader of the training mission and has to be countersigned by him. It is however not mandatory for supervisors in a unit to maintain their own blue books.

As I waded through Karthi’s blue book many questions arose in my mind. It seemed that Karthi was not a meticulous maintainer of this very important diary. It contained very little introspection. Descriptions of his actions in the cockpit were often perfunctory. For many sorties, there was no analysis at all. I leafed back from his MiG training days to his Mystere operational days. I found that he had actually stopped maintaining the blue book for a long time. I wondered why this was so.
Reading even this patchy record, I discovered a pattern. On many occasions, there was a mention of untidy or delayed joining up after take off with the rest of the formation. These comments were there in both his Mystere and MiG21 periods. Did this constitute a hint of a cause factor for the accident? I asked for his blue book for the earlier period of his life in a Vampire and a Toofani squadron. I also requested the Command HQ to procure his training records of his Cadet Days from the Training Command.

While I was investigating the pilot’s past my technical member worked hard to retrieve the engine from the crash site debris and bring it back to the base. The engine was surprisingly intact and it yielded clear proof that the pilot had engaged the throttle in the afterburner regime and the exhaust was fully open to accommodate the afterburning flow volume of the exhaust gas but the afterburner light-up had not taken place. There was however no direct indication of the cause of this failure. The technical team dismantled the engine and extracted the afterburner torch that ignites the fuel being pumped in to create and sustain the afterburner flame. It was a tough task and it took time. It was possible for us to inspect the opened torch only on the fifth day of the investigation. Even with the pieces opened, it was difficult to find any clear-cut cause for the failure of afterburner light-up. We however did find that the carbon contact panel in the torch wall was some-what eroded. We argued long over this observation and decided that while we could not definitely link the failure of afterburner to the state of the carbon contact, we also could not rule out the possibility of the igniting spark being ‘intermittent’ because of it.

Karthigeyan’s training records arrived on the fourth day of the investigation and it was comprehensive. His total flying training records from his first sortie in an HT2 through the Harvard stage to his last sortie in FTW were neatly bundled. His ground training records were also included. I spent many hours going through this bundle and found what I had expected to find. Karthi had joined the Air Force when it was in the throws of a rapid expansion. The days of massive pruning at the initial flying training days at the Academy were long gone. Unlike my own cadet days (where only 33 cadets reached the stage of completion out of 93 who had commenced) any cadet who could somehow muddle through the flying syllabus was allowed to pass out of the Academy. During the Harvard stage Kathigeyan had some problems with the formation flying stage of flying and needed additional instruction. The problem was repeated in the Vampire stage.

After being commissioned and passing through the FTW, Karthi transited through a Vampire Squadron and reached a Toofani Squadron. By then, the Chinese war had thrown the Air Force into utter confusion. The Training Command was churning out ‘pilots’ at a furious rate. Serviceability State of the operational units was poor. As the units filled up with the pilots produced by the training command, it became difficult to provide enough flying for the young ones to keep them in touch with any kind of flying. Taking them through their operational syllabus quickly became a distant dream for most of the units. A few bright youngsters were selected to undergo operational training with the RAF on Hunter aircraft. Some more were sent off to the USA for an operational training course on the F86. Karthi was not selected for either. He hung on in a Toofani squadron.

In the time frame of 1963/68, the Toofani was the most neglected part of the Air Force’s fighter inventory. Most of its senior pilots were drained off to fill the Mystere units just as the Hunter and Mystere units shed their top lot to fill the growing Mig21 fleet. Slowly, the Toofani units closed down one by one. By then the Mystere fleet had also lost its’ elite status. Most of the pilots from the Toofani squadrons landed up in the newly reorganized Mystere units. Karthi was one of those.
Karthi’s conversion into the Mystere fleet was slow and patchy. There were too many pilots in the queue, the serviceability of the Mystere fleet was not good, the tenures of supervisors were short due to too much of mobility, reasons for his patchy trainig were many. He however managed to complete his operational training syllabus and was declared fully operational by day. Through passage of time he was promoted to the rank of a Flight Lieutenant.

One factor that perhaps played a part in Karthi’s training on the Toofani and the Mystere was something over which Karthi had no control. Neither of these two types had a two seat ‘type trainer’ version. For a period of over five years, Karthi (and all other pilots on these types) never had the opportunity of his cockpit work being scrutinized by a supervisor. Of course his supervisors did fly with him in formation and did watch his aerial performance from outside his aircraft. But here too, in the formative part of his training he did not have the opportunity to fly regularly with the same leader who could judge and then guide him over a period of time. His flying was not perceived as being below ‘acceptable’ levels. He remained unremarked and unmarked. His latent problem, that of being somewhat tentative about his judgement of aerial distances and closing speeds, remained unspotted and uncorrected. The problem however troubled him every time he changed his type of aircraft and found himself in an unfamiliar cockpit.

Number Eight was I think the sixth unit to fly the MiG21. It followed 28, 45, 1, 4 and 47 in the sequence. In other words, it had taken my slot when I moved out of Chandigarh to Hindan with the Archers (47) early in 1969. It was using the same flight-line, offices and hangers that I had vacated. For me it was familiar territory, and I could not help but compare my first six months in Chandigarh with that of Babi Dey and the Eighth Pursuit. I was of course very lucky. I had been given two wonderful fully operational Flight Commanders in Janak Kapur and Vinay Kapila. These two were supported by two wonderful senior Flight Lieutenants in MS Vasudeva and Kuke Suresh. These two, though not fully operational, were fairly close to their fully operational status and were to become supervisors very quickly. The rest of the gang were also handpicked from the cream of the Air Force. I had nothing to complain about manning. I was also left completely alone. I was not disturbed by the Command HQ in any way what so ever. I was thus able to get the unit fully operational in less than one year. By contrast, Babi was having a tough time.

Unlike plain vanilla me, Babi was at that time the star test pilot of the Air Force. For any and every major testing activity, be it for a new acquisition or for unravelling a knotty problem in a development program, Babi seemed to be the first name that came in front of the Plans Branch. Unfortunately, from the perspective of the Personnel Branch, it was time for Babi to command a fighter squadron. He was therefore appointed as the CO of number Eight Squadron. In the first half of 1969, there were many unfinished testing chores awaiting Babi’s attention. Within the first six months of his taking over the squadron, the Air HQ found it fit to call him out for temporary assignments in Bangalore / Delhi / Paris / London / Moscow over and over again. His total absence from the unit exceeded 90 days out of the first 180.

It also seemed to me that he was also kind of short-changed in the supporting staff given to him. Only one of the two flight commanders given to him, Ravi Kumar, was fully operational on type. The other, Rodrigues, was operational under training. He was thus unable to shoulder responsibility of operating as a supervisor for flying training of the young pilots of the unit. In the absence of Babi from the unit due to his other air force tasks, Rodrigues was also required to spend time on the units’ administration. He was thus not available in the flight office. Ravi had to bear the total burden of training a big bunch of young pilots single handed. He was clearly overloaded.
While I was piecing together the operational environment of the unit, the Technical Member investigated the technical ambience existent at that moment. The Air Force at that point of time was practicing a ‘Semi Centralized’ mode of technical administration. In this mode, the responsibility of second line servicing was taken away from the unit commander and was reposed on the CTO (Chief Technical Officer) of the base. The CTO decided on the distribution of manpower between first and second line servicing. At least one out of the four engineer officers (from mechanical/armament/electrical/electronic or signal specialization) was nominated for first line servicing while the rest were merged into the pool of the station’s engineer resources. The engineer in the first line reported to the commanding officer and worked alongside the flight commanders while the other engineers were controlled directly by the CTO. In this arrangement a little fuzziness crept into the chain of command. Legally, the commanding officer continued to be initiating officer for the annual confidential report while the commanding officer seldom had a chance to see his engineers at work.

Chandigarh at that moment of time housed two types of aircraft. The two AN12 squadrons of the Air Force (numbers 25 and 44) were located there. The MiG 21 Type 77 Type Training Squadron (number 45) was also located there. One after another, all the fighter squadrons earmarked for conversion into MiG 21 Type 77 were moved into Chandigarh temporarily and were moved out after they completed their basic conversion under the benign support of number 45 squadron. Currently, number 8 Squadron was located there in the trainee role. From the station point of view, the AN12 fleet was clearly the more demanding technical task. These aircraft were carrying out operational tasks, not the least of which was the air maintenance of Ladakh. Any shortfall in this task affected a huge number of people in the front line. On the other hand, both the fighter units were on a training role. Number 45 Squadron was the type training squadron for the MiG21 fleet for the whole air force. The other squadron located at Chandigarh was invariably a squadron under conversion to MiG21. Operational pressure on these units were less pronounced. It was therefore understandable that the CTO would allocate his resources for the AN12 fleet with greater concern. The engineer appointed by him to the MiG21 R&SS was trained on the type but his experience on the type was not great. The two experienced engineers were located at the first line of the two units.

From a technical point of view, we had to discover why despite two previous failures of after burner engagement, the aircraft was put back on the flight line without the cause of the failures being clearly established. The repair work was clearly symptomatic and not specific. The CTO and all engineers involved in servicing the aircraft were questioned about it. Every one agreed that at some stage, some one should have spotted that the reported problem on the aircraft was not fully addressed by the rectification actions taken. Unfortunately the safety net was weak. The aircraft slipped through with inadequate attention. Of course, with hind sight, we knew that the carbon contacts in the after burner torch was perhaps the source of the problem, but that item was not to be opened up at the first or second line. It should have been removed and sent back to the factory for investigation. Once again, no one realized the gravity of the situation. The sad part was that this was clearly a collective failure rather than an indvidal’s carelessness or oversight.

Having looked at the pilots background and the technical history of the aircraft, we now tried to reconstruct the dynamics of the accident itself. The exercise planned was a two aircraft tactical formation sortie. It was led by Squadron Leader Ravi Kumar who was the flight commander. The pair briefed for the sortie, started up and taxied out normally. The airfield was busy. There was a queue of formations waiting for taking off. This pair had planned to do a stream take off where the two aircraft roll with a short time gap one behind the other to take off individually and then join up to practice tactical formation flying. Ravi Kumar rolled first. Karthi’s followed after a short pause. Ravi Kumar got airborne normally and climbed away. Karthi’s aircraft did not accelerate normally. A plume of black smoke came out of his jet pipe.
Karthi’s luck had apparently deserted him totally that morning. Perhaps he was too tense, afraid of losing sight of his leader on that misty morning, or prheps he had something else occupying his mind. He did not realize that his acceleration was slower than normal. He also did not go through the drill of checking his engine RPM (rotational speed per minute of his high and low speed turbine) or the temperature of his exhaust jet. Had he done so, he would have known that his after burner had not lit up. Or perhaps he saw all this and was confused because of some fatal inadequacy of his ground training? He did not react to the situation. If he had reacted directly, he would have brought the throttle back to the High Pressure Fuel Shut Off position and he would have deployed his breaking tail parachute to slow the aircraft down. It would have been easy thereafter to apply brakes and stop the aircraft. He did none of these. But, had his luck been with him that morning, he might have escaped death even after all these serious lapses. Unfortunately, as I have just said, his luck had deserted him that morning.
Another pair of MiG 21 were waiting for take off at the beginning of the runway. That pair was being led by a senior supervisor from a neighboring squadron. The leader of this pair was watching Karthi’s take off. He realized that Karthi’s had had an afterburner failure as soon as he saw the slow acceleration and the plume of black smoke. He could have called out to Karthi and could have asked him to abandon take off. He did not do so for complex set of reasons. Primarily, it was not his call to interfere into flying of another squadron. There was a properly designated supervisor sitting at the flying control to direct young pilots seen to be erring in any way. It was his call to tell Karthi to abandon take off. This vital radio call could be jammed if some one else tried to transmit on the same frequency at the same time. The supervisior leading the next pair waited for the supervisor at the flying control to call out. That call never came. A window of opportunity was thus lost.
The supervisor on duty at the air traffic control was a very sincere and capable officer. There was no reason for him to fail to come to Karthi’s rescue. But once again, Karthi’s luck played afoul. The air traffic controllers in Chandigarh operated from a large hall with excellent all round view. A number of air traffic controllers were on duty. One controlled the local circuit traffic. Another functioned as the approach controller. A third vetted the flight plans submitted by crews leaving for outstation trips. A fourth coordinated these flights with the air defence set up. A supervisory pilot was on duty keeping an eye on the performance of trainee pilots on the circuit. As luck would have it, just as Karthi was about to roll, one crew came in with a flight plan for clearance. For some reason there was an altercation and the attention of the supervisor pilot on duty was diverted to the source of this distraction for a few seconds. He missed the take-off run of Karthigeyan. The officer on duty for circuit traffic saw the trail of smoke and called out to the supervisor pilot. The supervisor, while looking away from the runway to the altercation taking place elsewhere in the room had dropped his microphone on the table. Unfortunately, now when he picked up the microphone to ask Karthi to abandon take off, he picked up the microphone for the approach frequency instead of the circuit control frequency. Both the microphone were lying on the table side by side. The call to Karthi to abandon takeoff was broadcast on the approach frequency; Karthi was on the circuit frequency and did not hear the call.

Karthi rolled on and mechanically tried to lift the aircraft’s nose for the take off. The Mig 21 has very large control surfaces. Even though Karthi had not reached flying speed, the nose of the aircraft rose above the runway presenting a higher angle of attack to the airflow. This increased angle produced additional drag. In the absence of full power from the engine, the acceleration was hindered further. The end of the runway came up. Desparately Karthi pulled back on the stick. The aircraft staggered into the air, only to fall back to the ground beyond the airfield fence and across a small drain. As he fell towards the ground, a Keekar tree in his path punctured the saddle tank behind the cockpit causing a spray of fuel on the hot engine section and the aircraft caught fire.

As the aircraft contacted ground, the deceleration caused the burning fuel to engulf the cockpit. Karthi was drenched with this burning fuel and was extensively burnt. On contact with the ground the ejection seat fired lifting the burning mass of Karthi’s body and it fell on a steep slope of the drain. Karthi suffered some internal injuries, but he was alive. Because of the extensive burning, all his nerve ends were singed. He felt no pain.

As we went through the reconstruction of the dynamics of the accident, a strange kind of sadness enveloped us. In one way it was easy to find the cause of the accident and to apportion blame. But at the same time we had to recognize the multitude of options that was provided by providence that so many amongst us could have used to save the aircraft and the pilot and did not. How were we to classify this accident? Was it pilot error? Sure. Karthi failed as a pilot on many counts, but could we consider it the primary cause? Was not there a technical failure? Yes indeed! The After burner had failed to light up when selected and there was a good chance that the afterburner failed because of an improper carbon contact of a torch igniter. Was this, seemingly a case of a material failure, then the primary cause? We were not in a position to say so confidently.
What about the two warning shots that the engine had provided? Why were those two reports not followed up with conclusive rectification? If the engine was withdrawn and sent for strip examination after the second incident in the air in the face of our inability to reproduce the failure on the ground, this accident would not have taken place. Was poor technical management then the culprit? In the technical organization, who should we pin the blame on? On the R&SS officer who had very little experience on Mig 21 and this kind of twin spool after burning jet engines? Or should we catch the Engineer in charge of the first line who accepted a ‘found nothing / fixed every thing’ kind of maintenance clearance and allowed the aircraft to come on the flight line? Surely there was an undesirable level of technical mismanagement; but could it be considered as the primary cause? The answer was obviously no.
Step by little step we examined all the possible cause factors to determine the real cause. What about the deficiencies of his immediate training? Very recently Karthi had undergone a period of ground training at the MiG21 MCF specifically designed to impart all necessary technical knowledge about the MiG 21 that a pilot needs to know. And yet, it was evident from Karthi’s actions and words that he was unsure about the information provided by the ‘Afterburner Light’. He evidently thought that the glowing of the light meant that the afterburner was on and functioning. In actual fact the light only indicated that the throttle had been moved through the ‘After Burner Gate’. The light did not reflect that a light up of the afterburner had taken place. This deficiency of his knowledge certainly contributed to the accident, but could we consider it to be the primary cause? We had to admit that it was not.
Karthi’s earlier weaknesses in training that came to our notice were examined and concidered. The only relevant one noticed was his apparant tentetivity of judgement of areal distances when he was new in a cockpit. We could not consider this to be a significant contributory cause. At most, this weakness could have enhanced his level of anxiety, to some extent, on that fateful morning. That this weakness was nott rooted out over the previous 7 years while he moved from a subsonic to transsonic to a supersonic type of aircraft had to be noted with sadness all the same.

We then considered all the environmental causes. The two cases of lost chances to prevent the accident caused us emotional distress. It was so evident that a call from either the officer on duty at the flying control or the supervisor waiting his turn for a take off could have saved Karthi’s life. But, distressful as both the incidents were, could we consider them as primary cause for the accident? We had to agree that these were not the primary cause for the accident. They were merely opportunities lost to save a life. In the case of the officer on duty losing his concentration for a short while due to unexpected cross talk by a visiting crew we examined the situation with greater care. Was the situation as captured by the accident indicative of a lack of discipline at the flying control? We examined the normal functioning of the ATC over a period of time and felt that it would be unfair to impute a general lack of discipline of the ATC because of a momentary situation by an external element.

We were less than satisfied when we examined the impact of the performance of the higher Headquarters on this accident. The newly appointed commanding officer of the unit, Babi Dey, was clearly prevented from performing his required tasks as a squadron commander by the Air HQ. Every one knew that Babi was a valuable asset for the Plans Branch because of his ability as a test pilot and his vast experience in assessing aircraft and weapon systems for procurement. The Personnel Branch however functioned under its own set of rules. Under that set of rules, Babi was now required to command a fighter squadron. The command of an operational unit was a necessary step for one’s progress in the hierarchy of the air force. Windows of opportunity for such appointments were not easy to find. Babi was now due for his command slot. A slot was available. He was therefore appointed as a squadron commander. The Plans branch however had unfinished business on its plate for which Babi’s services were needed. Babi was therefore pulled out of his chair as a squadron commander time and again and was required to go to many corners of the world in performance of his specialist duties as ordained. This conflict of requirement should have been sorted out between the PSOs at the Air Head Quarters, but it was not done. Babi was thus prevented from functioning with his full potential as a commanding officer because of his repeated absence from the unit. He was absent from the unit for 90 days out of his first 180 days in office as a CO. Having known Babi over a long period of time, both Groupi Randhir and I felt that perhaps if Babi was permitted to function normally as a squadron commander, this situation of an aircraft with doubtful maitenance being offered for flying might have been averted. However, regrettable as the situation was, the absence of the squadron commander from the unit could not be considered as a primary cause for the accident.

We struggled hard and debated for long hours to define the primary cause of the accident. There were many patent contibuting factors that we had identified, but none of these factors could be considered as the primary factor by itself. We could of course just call it pilot error and leave it at that; Karthi was not there any more to protest if we did so. We were however not ready to pin this accident solely on his errors. After long cogitation we defined the primary cause of the accident as:
An accumulation of multiple organisational failures spread over a long period of time and attributed to many individuals that permitted a weak pilot, a doubtful aircraft and a unresponsive environment to come together in space and time to cause this accident to take place.
The inquiry made its way up to the highest quarters of Command HQ and Air HQ. A lot of debate ensued. A lot of questions were raised and answered. Finally, our opinion was accepted.

Conducting this court of inquiry was one of the most sobering events of my service life. It taught me how far reaching the effects of our minor or instantenious actions could be. There was nothing that we could do to undo the accident. I however found it even more difficult to formulate concrete plans for preventive actions. The causes were diffused and so difficult to define as an individuals’ failure, I found it difficult to list preventive actions that I could honestly advocate. I carried this dissatisfaction with me as I grew through the service and decided to increase awarenes about the complexity of making aviation a safe occupation through my speech and action. When I became the Director of Flight Safety at the Air HQ, I made an educational film based on this incident. I do not know how much effect that film had on its viewers.

I mourn for Karthigeyan even today.