On October 12, 2013, a little over two years ago, an Air India Boeing 787-8 Dreamliner registration VT-ANK performing flight AI803 from New Delhi to Bangalore with 147 passengers and seven crew, had its right hand side (RHS) heat exchanger access panel 196KR detach from the aircraft as it was landing at Kempegowda International Airport, Bengaluru around 09:40 (0410Z) 04:10 UTC.

An investigative report into the incident, by India’s aviation regulator the Directorate General of Civil Aviation states “the cause of the incident was due to human error and not adopting Standard Operating Procedures (SOP),”

The national carrier is also cited for operating the aircraft under MEL conditions (minimum equipment list) beyond the allowed 10 days without taking approval from the DGCA as required.

Dangerous gaps in communication

Without sounding alarmist, a close reading of the report exposes the shoddy functioning of Air India’s much vaunted engineering department, and how close to a potential tragedy this incident really was.

To briefly recap what happened. The aircraft was already operating under MEL (minimum equipment list) when it arrived from Frankfurt in to New Delhi on October 9. Due to additional sub-systems malfunction, the aircraft was declared AOG (aircraft on ground) and sent for repairs.

Accidents and incidents are always a result of cascading events. This incident was a case of communication lapses through the many layers of bureaucracy that plagues Air India which eventually resulted in only four of the 47 screws required secure the 196KR panel, being fitted, and even these four screws not tightened fully.

As per the report, the first shift engineering team removed all but four screws of the panel, but not the panel itself. The second shift engineers claim the first shift did not hand over the screws to them, nor did they make any notes in the records. The first shift denies this of-course. If the second shift engineers were unaware of developments in the first shift, they have obviously not done anything about the 196KR panel. The aircraft was released to service on October 10, 2013 with only four of the 47 screws fitted. On subsequent flights the panel fluttered in the high winds as the jet travelled at speed. Cracks developed near the screw holes in the panel, and finally, as the aircraft was landing at Bangalore, two days later, the panel detached from the aircraft.

Similar gaps in communication and improper hand-over between shifts have resulted in fatal crashes, like Continental Express Flight 2574 in 1991, and I shudder to think of the consequences has this panel detached mid-flight over the ocean.

Post the “repairs”, Air India operated VT-ANK on six flights with only the four of 47 screws fitted. Two of these flights included the longest non-stop Dreamliner flights Air India operates, New Delhi to Sydney and from Melbourne to New Delhi.

Quoting the report “The Panel 196KR was only on four screws instead of 47 screws thereby the entire load was being taken by these four screws. As these four screws were not fully tightened, the air load caused fluttering of the panel further leading to fatigue crack around the four screw holes. Finally at touchdown in Bangalore the panel liberated from the aircraft, with three screws remaining on the aircraft”

Three screws remaining fixed to the aircraft fuselage highlights the progression of the cracks in the panel around the screw holes, and how close to a potential inflight panel detachment the aircraft came.

You might ask, why did the pilot and engineers not notice the lack of screws of the 196KR panel during their inspection performed before each of the flights? The General Visual inspection (GVI) that is performed during the “walk around” looks for obvious damage, obstructions, missing parts etc. on the visible exterior areas of an airplane. The 196KR panel is on the underside of the mid belly. To inspect it one must bend down, and there was no obvious indication that anyone would feel the need to do that.

Conflicting claims. Manipulation of records?

In a classic case of ‘he said, not said,” the report is filled by claims and counter claims by the various Air India engineers involved. It is distressing to see that the investigation does precious little to resolve these claims and counter-claims. Industry insiders say this bureaucratic, “protect my turf” method of functioning has become a regular feature in the engineering department at the airline.

The DGCA report is riddled with conflicting claims of the various engineers. The report also seems to suggest manipulation of records. Each of the engineers are making claims to protect themselves. The key point is the handover between the shifts. Quoting from the report “Manager Service Engineer (3) was interrogated twice; initially he denied neither having received any screws physically nor any handover verbally from Manager Service Engineer (1) During second time he stands by his earlier statement and also stated that the ’note” entry in the work allocation sheet was not there when he took over,

As the veracity of Manager Service Engineer (1)’s statement and also whether the ‘note” entry was made on 09.10.2013 [October 09, 2013] or later cannot be established. It is unable to establish beyond reasonable doubt that Manager Service engineer (3) received the handover regarding the panel screws properly”

I am not sure about India, but in the United States and most of Western Europe, manipulation of aircraft maintenance logs and records are considered criminal acts and dealt with most severely. How is the DGCA remaining silent on this possible records manipulation is baffling? It may sound harsh, but if the DGCA cannot get the truth, should it not call in the Central Bureau of Investigations to conduct criminal and forensic investigations to determine the truth and fix the blame?

One of the goals of any air incident/accident investigation is to prevent recurrence in the future. The nine page report does not make any significant recommendations towards that ultimate goal, leaving any actions on the head-quarters. Will this result in “business as usual” (BAU) at the airline? What will it take for true change to be initiated at the airline?

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Full DGCA report

You can download the DGCA report in PDF format from here.