Fatal Roll-Over

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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.

14 responses »

  1. Sir, Good to see you back after a long time.
    Question. During your tenure after 1962, was there any occasion when Fighters had to be scrambled towards our eastern border.

  2. Sir, as usual a thought-proving post, always a pleasure to read your postings.

    A Sgt was trained abroad and then posted out to non-Hunter units without letting him complete the mission for which he was sent. It just shows a gross lack of coordination between AFRO/Engg Directorate at Air HQs/C Eng O of the base/ CO of the Sqn concerned? Should not all these stake holders have interacted? I find the lack of interaction the only reason why we lost valuable lives and equipment. I hope these shortcomings have been overcome in the IAF today.

  3. It’s great to find you writing/posting again. Had missed your posts for very long.
    As for this current post, comments are, I feel, quite unnecessary. It’s more of a lesson everyone must learn.

    I hope you are in good health. How’s Kakima?

    I’m sure you know of Baba’s passing away on 25 June.
    The shradh is actually going on in the next room.

    Please take care.
    Pronam.

  4. Thanks sir and glad to see you back. First, I would like to endorse the remarks made by S Mukherjee.

    The CAS you mention was well known for removing officers from command as an universal solution to all accidents. No surprise that his tenure saw an increase in the accident rate.

  5. Sad, but great tale. In these days of Corona/China virus sad tales of missed diagnosis and misdiagnosis ring ironically across domains. Thank you

    shiv

  6. Dear Shankar da,

    Very painful lesson.

    Dipu

    Dipankar (Doug) Dasgupta

    Minneapolis, MN USA

    Cell 612 599 5631
    WhatsApp +1 6125995631

    ________________________________

  7. Dear Sir, what a pleasure to read this narrative of the mistakes made. It sure is an eye opener. Well thanks to you we flew the Hunter at OCU in 1979 without the threat of the unknown !!
    Regards

  8. I thank my readers for the great enthusiasm with which they have hailed my return from hibernation.

    Air Marshal Shashi Ramdas in a separate mail has queried about the technical details of the accident that evoked the probe. In my write up I did not elaborate on the tech details as I am not fully sure of my memory. I will now try to put down what I remember.

    The servicing instruction was initiated by the RAF following two or three roll-over crashes where the servo dynes were found fully fit after the accident. The reason of issuing a servicing instruction was a suspicion that the hydraulic pipeline might have sagged under G loads leading to a permanent bend somewhere permitting a temporary vapour-lock to form. As a precaution, the SI demanded the lines to be taken down, flushed, And fitted back with a larger number of clits.

    The most amazing aspect of this series of accident was in every case the rolling of the aircraft were noted and in every case the ‘lateral control system’ was given a clean chit because the servo dynes were found serviceable. Though 13 or 14 accidents could be suspected to be in this class, no CoI connected its own investigation with the investigations into other accidents.

    The DFS is tasked with second third and fourth level enquiries like the one in this instant.

  9. sir
    By chance, I read this article on social media and which led me to your blog. I read many articles of yours. It gives a historical perspective of how our Air Force has evolved and grown.
    The articles should be combined together and published as a book some publisher and books should be purchased by Air Hqrs to be supplied to all Air Force units.

    Let the new generation know how we reached this stage.
    My salute to you sir
    Ex-Wo Bhupal Singh

  10. I had a similar incident on a Gnat Mk 1 but fortunately survived. There had been many similar accidents on Gnats in the early days of aircraft rolling and crashing on the takeoff roll, on downwind etc.
    In my case, I was on an air test when I felt a momentary slight lateral jerk on my control column when passing through 20,000 feet. Everything appeared normal including hydraulics. Since it was a control issue and not being sure as to what could be wrong, I discontinued the air test which required me to climb to 48000 feet and told ATC I was returning.
    Trying to figure out what could be wrong and suspecting a hydraulic issue, I decided to lower my undercarriage fearing that it may be an impending hydraulic failure. The moment I did that all hell broke loose. The control column was snatched out of my hands and the aircraft rolled violently and entered a steep rolling dive. My first reaction was to eject and since it could be a spin in which case I would have to jettison the canopy first, I looked inside to locate the canopy jettison handle. When I did that I saw the gear lever was down and remembered that my last action before the loss of control was lowering the gear. Since I found I was still passing through 14000 feet and I had till 10000 feet to eject I decided to try and see if raising the landing gear would help. Sure enough on raising the gear, the aircraft recovered and I was able to get it wings level. I had lost a few thousand feet in the bargain and was pretty shaken up.
    To make a long story short, various procedures were tried out to see what could be done including lowering the gear, but as soon as the gear began to descend, the aircraft would begin to roll and go out of control. Even partial lowering of gear (to “airbrake” position) still did not correct the aircraft from flying one wing low. Even depleting the hydraulics and lowering the gear on manual was considered but given up as if the problem persisted, the gear could not be raised again and ejection would be inevitable under less than ideal conditions. Finally, I was asked to eject but instead opted for a somewhat risky belly landing as this would be the first time a fully wheels-up belly landing was being attempted. The landing was uneventful even though the drop tanks and subsequently the tail caught fire in spite of laying foam on the runway.
    The recovery of the aircraft intact helped isolate the fault to one aileron going into manual while one remained in power due to a clogged filter in the line. Subsequently, modifications were made whereby, I am sure, many lives were saved.
    It was just providence that I decided to lower the gear at 20000 feet as, if I had chosen to lower it on downwind, I would not have lived to tell the tale.

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