Fatal Roll-Over

My story today is a sad one as it normally is when I talk of aircraft accidents. It is an old tale but the lessons that we can draw from this accident or rather a series of accidents is eternal.

A fatal accident took place in Bhuj.   I was then the director flight safety. Air Marshal Latif  was the Vice Chief – my direct super-boss.  Air Chief Marshal Mulgaonkar was the CAS.  I was required to brief the CAS immediately of any serious accident. Chief held the DFS directly responsible for such happenings. Fortunately for me, on that day the CAS was away to Europe for a week. I reported the happening to the VCAS and went back to my office.

There was a second fatal accident in the same Squadron within the week. The nature of both the accidents were similar.  In a low-level training mission in level flights the aircraft just rolled over and went into the ground .   There was no call on the radio and there was no perceived reason why any pilot would crash in such a way. A high powered Court of Inquiry was ordered for the two accidents clubbed together.

A couple of days later the CAS returned. There was a hushed silence on the fifth floor of Vayu Bhawan. The Chief was angry.  A little later we got called into a conference. All PSOs, ACsAs, all Directors, Joint Directors, And Deputy Directors of the Operations Branch were to attend. 

As soon as we convened, we received a blast from the Chief. We were all useless – unable to perform our duties. So much so that as soon as his back was turned we had allowed two fatal accident to take place. Having had his outburst the Chief cooled down. He then looked at the Director Personnel (Officers) and gave out a series of directions. The Officer Commanding of the defaulting Squadron was to be sacked immediately. Three or four other  placements were also to be done. He would issue other directions shortly.

I was confused.   For the previous six or eight months, my focus was on restoring the confidence of the field staff about the top brass.  Removing the CO for accidents that had not been investigated as yet would destroy organisational trust at the ground level.  Fortunately, the CAS 

then asked whether any one had any question. He put his finger out and pointed to each one by turn.  There were no doubts. His finger point marked me last.  I was in a sort of daze.

I stood up and told him that as his Director of Flight Safety it was incumbent upon me to advise him to with-hold the directions he had just given till the Court of Inquiry was complete.

There was stunned silence in the hall. The CAS got visibly upset.  He looked at me and started to say something. Then he changed his mind and huffed out of the conference hall by himself without waiting for his staff to catch-up.  His staff officer ran after him.     All the senior staff hung around in confusion for some time.  I went up to the DP(O) and asked him what his interpretation of the decision was.  He told me that he would action the Chief’s directions immediately.   I begged him to give me some time to react.  He agreed not to issue any orders till the evening.

By now it was lunch time, but I was not hungry. I locked my self in my room to address the CAS directly on this issue.   Two or three drafts of the note that I was trying to compose had to be trashed, but I was finally ready with my note by about two thirty.  It was written in my long hand and ran to over three pages.

I took the note to the ACAS (FS&I).   He read it through without a pause, crossed his address and readdressed to the VCAS. I found the VCAS alone. As I entered his room he raised his questioning eyes. I looked down to the file in my hand, and offered it without a word. The VCAS also read the note through nonstop and marked it to the CAS.

I now took the file with the note to the Chief’s office and gave it to the SO. Aggarwal, the SO, took it in and placed it on his table. I sat in the guest enclosure. And I sat there.  After about an hour Aggarwal told me that the Chief had read the file and had put it aside.  I continued to wait. Then, about four o’clock the CAS called me in. 

Normally the Chief always asked me to sit down before he spoke to me. However, on that day he let me stand. For about fifteen minutes he spoke his heart out full of frustration.  Flight Safety was his field of special interest.  If the safety record was not upto his expectation he was upset.  He was however a man of reason. He did not change a single letter in the note.

Out of the CAS’s office I ran to the DP(O) and gave him the file duly marked for him. The immediate problem was solved. I could now pay full attention to the CoI .

The CoI examined the case of both the aircraft rolling while going down. Unfortunately, both aircraft had disintegrated and had burnt down.  The recovered servo-dynes could not give any clue for the aircraft’s behaviour.  No training or operational mistakes came to light.  Thus these two aircraft also joined the list of ‘unresolved’ cases of accidents.

Once the CoI proceedings were approved I decided to launch a second level inquiry within the directorate.  Files of all Hunter accidents that were unresolved or had reports of rolling while going down were segregated. Between 1962 and 1978 there were more than ten cases.  Then we started investigating technical health of each of these aircraft. Slowly it emerged that a particular technical instruction regarding the hydraulic system leading to the aileron servo dynes had not been implemented. It was strange that an  instruction related to the control system was on concession on all Hunters throughout the Airforce for about fifteen years without raising a stink.

We went deeper. Logistically the mod kits had been received from the UK and had been distributed to the bases.   In the base, the instructions were not carried out because the kits appeared to be incomplete, some parts could not be found/identified. We could not trace any activity to rectify this logistic/technical  situation.

We enlarged our enquiry to technical training.  It was discovered that the manufacturer had considered this instruction to be of critical importance and had offered to train one fitter for installing this instruction. A smart Sergeant was selected and sent.  He completed his training and was complimented for his performance .

On return, the SNCO was posted to a non Hunter station far away because he had spent many years in the North: the rules demanded that he must share his time in the South or East. For the next fifteen years he never worked on a Hunter.

These accidents happened off many bases and on many exercises. One happened in the East: a young lad was practising dummy dives over the airfield. In one of the dives as he rolled in, the aircraft continued to roll and went into ground. There was one off Ambala.  A pilot in his early training days was practising parallel quarter attacks with his flight commander in the lead aircraft. The Flight Commander saw the aircraft turning into him but instead of reversing the turn for the attack he kept on rolling and dived into the ground from 20000 feet. Many more accidents are  there  that I cannot  recollect details of after these forty odd years.

We ferreted out that SNCO from his non-Hunter appointment. By then he had become a JWO. A team was formed under his leadership. The team visited all Hunter stations and installed the instructions on all aircraft. 

This story stands in the calendar year of 1977 or 1978. We flew the Hunter for more than another decade there after.  Thankfully we did not have any further incidents of uncontrolled rolling.

The story gives me shivers even now. Why did so many of us senior guys fail our juniors over fifteen years and indirectly cause so many young deaths? If any of you young tech managers go through this story now and try to find parallels in the present environment, you might find some things that you have never imagined; who knows? You might end up with the satisfaction of saving some lives from accidents that get prevented by your actions.

I shall not spell out the lessons from this story. My readers are smart. They will find the lessons for themselves.

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