A proper system is always a joke for this late CM of Andhra Pradesh. He laughed at the system while having his good times. But one can not have those days forever.
* He wants some Reddy (Brahmananda Reddy?) as the chief of APACL.
* He wants Pilot Bhatia and he had him.
* He wants SSP YADAV as DGP and he had him in that place.
Like this, the list is endless, He ruined every system. What he wants is a rule. He made all the exemptions and exceptions for his friends and followers. At the end, these same actions cost him his LIFE, which one can not bring back. All those unfit to the job candidates couldn't stop YSR from dying.
Read just a few findings from DGCA report by Tyagi and team and you will know that No Reliance group or Maoist group involved in his death, but he dug his own graveyard by ruining the systems.
4.4 APACL functioning
4.4.1 The performance and capability of various MDs of APACL who headed the organization definitely lacked the knowledge of aviation related issues. This resulted into certain issues not being undertaken and certain actions not being initiated due to lack of their professional knowledge/sufficient tenure. It is proposed that a separate technical audit on the functioning of APACL be conducted. It will be better if appropriate qualification requirement (QR) for senior officials like MD/CEO are laid down. CEO / Head of Operations should have adequate knowledge / experience of regulatory, O&M and other aeronautical issues. The lapses by the AME concerned also need to be addressed suitably by the Regulatory Agencies.
4.4.2 The Committee while examining the technical cause of the present accident also briefly reviewed the reasons of non-availability of AW-139 helicopter (procured by the APACL one year back). It was found that the helicopter was not serviceable on that day and that is why Bell 430 was assigned the flight. The procurement, contract administration and O&M of AW-139 helicopter seem to lack professionalism. It is recommended that an independent audit be conducted to look into the manner in which this helicopter was selected & procured, the processes involved in training, selections and the contract administration of present O&M services. The circumstances leading to the extension of two years period to a five years plus period in case of the then Chief Operating Officer Capt. Jagan Manthena and also his role into the above aspects need a thorough examination by the State.
2.4 Management Issues and System of Maintenance &
Operation
On 31.03.2006 the Government of Andhra Pradesh promoted the A.P.
Aviation Corporation Limited (a Public Limited company) with objectives of
developing aviation sector in Andhra Pradesh by setting of training
academy, acquiring aircraft and helicopters to serve the commitments of
various departments of the state government and private parties.
Accordingly it appointed full time Managing Director. However during this
period the managing director was changed three times and no system had
been evolved for coordinated working of the organisation.
The organisation changed its name to APACL. However it continues to
hold organisation approval in the name The Aviation Division, Helicopter
Wing (GAD). It is holding approval in Category “C”. The approval of the
organisation is valid up to 31.12.2009. As per the QC cum Assurance
Manual, Maintenance organisation will be headed by Quality Control
Manager assisted by Deputy QCM and AME. .The Organisation entered in
to contract with M/s OSS management services to provide maintenance
for the Bell 430 helicopter along with AW-139 helicopter. After the contract
materialized, M/s OSS expressed its inability to take care of the
maintenance of Bell 430 helicopter. Apparently no careful assessment of
service provider was carried out before entering into the contract.
Thereafter the organisation partially revived its maintenance setup for the
Bell 430 Helicopter. Prior to the contract the Helicopter wing had three
AMEs, and the supporting staff. However post contract it was left with only
one AME who also performed the duties of the Dy. Quality Control
Manager (QCM). There was no approved QCM. This put all the
responsibilities on the AME and his working was not supervised / crosschecked
for any deviation from the standard maintenance practices.
The operation wing is headed by Chief Pilot/Pilot Coordinator/Chief
operating officer. For the operation of the Bell 430 one pilot was taken
under contract from M/s OSS Management services. Earlier the other two
pilots were in the employment of the State Government on deputation
basis from the Indian Air Force. Though at all time organisation had
licensed crew, however no attempt was made to revise the operation
manual of the organisation in line with new Civil Aviation Requirements
and the changes in the operational policy of the organisation. The
operations manual was made in 2004 and never revised thereafter.
Organisation has not prescribed any minimum flying experience
requirements in the operation manual before permitting a newly endorsed
crew on Bell 430 helicopter to fly as PIC. Records reveal that organization
did not encourage its pilots to undergo recurrent simulator training. Many
of the reportable incidents / snags were not reported to regulatory
authorities.
Record reveals that earlier both the pilots on deputation from Indian Air
Force were engaged in the act of one up manship and despite the adverse
entries, were able to prolong their stay in the organisation beyond the
permitted deputation period. They were able to influence the decision
making process even at the highest level in the State. They were also
involved in various procurements and also like helicopter procurements
without adequate knowledge about the subject. Even selection of AMEs
for the training on new helicopter was not appropriate as the AMEs under
state were overlooked.
This did not promote a healthy culture in the organisation and indicates
lack of involvement and poor knowledge of personnel in-charge of State
Aviation set up.
YSR is the one who setup this and he is the one brought Brahmananda Reddy as APACL chief.
2.6 Was any explosive device detonated?
Wreckage examination was carried out at the site of the accident to look
out for evidence to determine if any explosion had taken place on board at
the accident flight. Wreckage did not reveal damage due to splinters nor
the splinters were observed. Curling of metal on edges of broken parts
was absent. No damage due to impact of high pressure gases was
109
observed. Seat cushion were recovered and examined in details to find
out if there were embedded splinters or associated damages. However,
nothing was observed.
Post mortem report has not recorded any impact of/embedded splinters in
soft tissues of dead bodies nor there is evidence of affect of high pressure
waves on lungs, etc.
Opinion on the issue was taken from NAL, Bangalore who also ruled out
the possibility of any explosive material in the wreckage.
So, No Reliance or Paritala Ravi Family killed YSR.
3.1 Findings:
3.1.1 Certificate of Airworthiness of the helicopter was current and valid.
3.1.2 The organisation did not maintain any snag register to allow analysis of the
defects. The action of the maintenance organisation was in violation of the
procedure specified in the QC manual.
3.1.3 Engine S/N: CAE-844104 was removed from helicopter on 01/11/2007
from No.2 position at 2160:05 hrs and installed on 30/05/2009 at No: 1
position. Reason for removal was not recorded in the logbook. There is no
preservation/de-preservation entry for the storage period. Reason for
removal of any other component is also not recorded. This indicates
casual attitude of the maintenance personnel.
3.1.4 In APACL only one AME is performing the job of certifying staff, QCM and
Quality assurance personnel. The organisation once engaged outside
personnel for the audit. The report submitted by him did not mention any
deficiency despite many deficiencies as mentioned above. Therefore
quality assurance function of the organisation was not performed as per
the laid down practices/ directives.
3.1.5 ECU data indicated that on No.1 engine during some previous flight two
minutes OEI event had occurred. The event lasted for 14.208 seconds
and was due to MGT exceeding the limit of 1468ºF for more than 12
seconds continuously. The cumulative MGT exceedance is recorded for
44.256 seconds. The data also indicates that during the event, torque
exceeded its two minute OEI limit of 102.5% for 4.224 seconds. “it would
have resulted in an advisory indication to the pilot, displayed as a white ‘1
M/OEI’ on the IIDS prior to and during the final flight.” This requires
maintenance action prior to release for the next flight. AME and flight
crew ignored this advisory before operation of the flight on 2.09.2009.
Thus the helicopter was probably not airworthy when it was released for
flight on 02.09.2009 even though it was not a contributory factor to the
accident.
3.1.6 Both engines were operating normally and capable of producing power at
the time of impact.
3.1.7 The Main Gear Box, gears were found to be in good condition. No
evidence of degradation due to lack of oil pressure was observed. No sign
of overheating was observed. The gears in the transmission were capable
of smooth transmission of power. Observed snag could not be established.
3.1.8 The installed ELT had 121.5 MHZ and 243 MHZ as operating frequencies.
As per CAR of Section 2, Series O Part V and ICAO’s recommendations in
Annex 10, all ELT must have three frequencies including 406 MHZ as
operating frequencies. This requirement is effective from 01 January
2005, however, was not implemented by APACL on this helicopter.
3.1.9 At the accident site severe down draught existed and was encountered by
the helicopter.
3.1.10 Both the crew held valid license and were qualified on type. Their ratings
were current. They met the requirements of Air safety Circular 2 of 1981,
Para 3.2 regarding carriage of VIPs.
3.1.11 Following were the discrepancies regarding license of Pilot –In-
Command:-
For the Endorsement on Bell 430 helicopters only one instrument
rating test was carried out against the requirement of two Instrument
rating tests with two different examiners for as per Schedule 2,
Section P, Subpara E of Aircraft Rules 1937.
Flying hours during training sorties have been reflected as PIC flying
in the personal log book whereas it should be in Training Column.
The instructor who conducted the night flying and instrument flying
training has also undertaken night skill test and instrument rating test
as well. Only day skill test by the training instructor was carried out
with FOI (H) DGCA on board as observer.
This indicates lack of knowledge/disregard to the rules by the PIC and
supervisory staff. The above discrepancies also went unnoticed during the
check by Instructor/examiner and endorsement process on his license.
3.1.12 Recurrent simulator training for PIC became due in the month of June
2009 on completion of two years from the date of endorsement viz.
5.06.2007 and was not carried out. This is non-compliance of Civil Aviation
Requirements. The organization also did not encourage its pilots to
undergo recurrent simulator training.
3.1.13 Crew was aware of the poor weather conditions on the route and before
departure did not again review the weather situation The Crew continued
to proceed ahead inspite of inclement weather which was continuously
aggravating and was becoming more and more difficult to negotiate. The
Co-pilot also did not advise the PIC to return back or divert to nearest
location.
3.1.14 The crew encountered a snag of transmission oil pressure prior to the
accident. Crew got engrossed in locating the appropriate procedure in
emergency checklist for the snag. They were not aware about immediate
actions, co-relating the visual indications and cautions of the emergency.
3.1.15 Fire was triggered either during impact with the trees or after the first
impact with the ground from the baggage compartment. There was no inflight
fire.
3.1.16 ECU data is consistent with a lowering of collective and rapid descent
during the last 14 seconds of the flight.
3.1.17 At 9:10:50 IST and at a distance of 64 nm the helicopter entered the
clouds and remained in IMC through out the flight although it was cleared
under visual flight rules.
3.1.18 Mixing-up of VFR & IFR is a dangerous situation where chances of
disorientation are very high.
3.1.19 Helicopter experienced turbulence and the Captain reduced the speed
below 40 knots resulting in tripping of auto pilot, which was re-engaged by
co-pilot.
3.1.20 The crew got so engrossed with the observed snag and neglected the
weather ahead and experienced severe down draught; sudden loss of
height and impacted the ground.
3.1.21 Inspite of repeated callouts from Co-pilot during the last 14 seconds to “Go
Around”, the Pilot-in-command could not act apparently due to incapacitation.
3.1.22 M/s APACL had decided to handover the O & M of Bell 430 helicopter to
M/s OSS and in view of this decision reduced the strength of personnel
maintaining the helicopter. However for the reasons best known continued
O & M themselves with inadequate manpower which also did not possess
requisite professionalism.
3.1.23 There is lack of procedure for flight in turbulent weather conditions.
3.1.24 RCC Chennai failed to perform its assigned functions as per the manual.
All the agencies involved in search and rescue operation, acted
independently of RCC Chennai and it was merely reduced to obtaining
information about the activities and passing on the information to different
agencies. No assessment of search and rescue operation was carried out
after its termination. There are no structured exercises conducted to
evaluate the effectiveness of the system. The relevant requirements
demands that search and rescue plan for a particular region should be
developed with all other agencies that would participate or lend support
during such exigencies. However no plan has been developed in
coordination with other agencies and no mutual coordination meetings are
held.
3.2 Probable cause:
Accident occurred due to loss of control resulting in uncontrolled
descent in the terrain at a very high rate of descent due to entry into
severe downdraught
Contributory Factors:
1) Crew noticed a snag and was engrossed for more than vital six
minutes before the impact in searching for relevant information in the
emergency checklist and the Flight Manual. This distracted their
attention from the prevailing weather conditions which led to loss of
situational awareness.
2) The Crew was flying in Instrument Meteorological Conditions (IMC)
whereas the flight plan was cleared for VFR flying.
3) They had no intention either to divert or return back to base.
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