Abdulla Puttur Ismail, 36, was in a window seat directly above the left wing of the Boeing jet when the plane landed with a violent shudder, followed by a “big sound", tilted towards its right and shot forward. Ismail recalls seeing the right wing catch fire, smoke billowing, and passengers crying and screaming in terror.

Then the fuselage broke next to his seat, 19A, and Ismail jumped 10ft through the hole, his fall cushioned by the vegetation below, picked himself up and started running. The Boeing 737-800 careened down the hillside and exploded into flames.

What went wrong? A file photo of the mangled remains of Air India Express flight IX-812 that killed 158 passengers and crew in India’s worst aviation disaster in a decade. Prasad Gori / Hindustan Times

“Too many people died, God has saved me," says Ismail, one of the eight survivors of the 22 May crash of Air India Express flight IX-812 in Mangalore. All 19 children on board the flight were among the 158 passengers and crew killed in India’s worst aviation disaster in a decade.

It was fortuitous that Ismail, a Dubai store manager who was travelling alone back home to Kerala, had a window seat so he could jump off the aircraft in time and cheat death.

It was also fortuitous that there had been no major accident involving a commercial airliner in India since the 17 July 2000 crash of an Alliance Air jet that killed 58 people in Patna.

But there had been numerous near misses, or close shaves, that preceded the disaster in an aviation market that doubled from 22.30 million passengers in 2005 to 44 million in 2009 and from 160 to 400 aircraft. Aviation safety infrastructure has failed to match the pace of market growth.

The aviation regulator has ascribed some of the escapes to sheer good fortune. The run of good luck snapped with the Mangalore accident, which exposed fault lines ranging from operational deficiencies in airlines to lack of airport licensing, from flier fatigue to the absence of proper background checks on expat pilots.

A court of inquiry, set up on 3 June to investigate the crash, is supposed to submit its report by 31 August.

“What this crash shows is the (low) level of professionalism that exists in various parties involved in aviation and makes evident the lack of safety oversight by both the airline and regulator responsible for safety of aircraft operation," says Shakti Lumba, who retired recently as vice-president (flight operations) at IndiGo, the low-fare carrier run by InterGlobe Aviation Pvt. Ltd.

Lumba has 40 years of aviation experience in management of flight operations with 15,000 hours of flying.

Flight chronicle

Until it landed, there had been no suspicion that anything could go wrong with flight IX-812, which was being flown by Serbian-born pilot Zlatko Glusica, 55, and first officer H.S. Ahluwalia, 41, from Dubai to Mangalore after a transit check conducted by Oman Air.

Air India says the two were well rested before taking charge of the three-and-a-half-hour flight. The commander had returned from leave and travelled on the Frankfurt-Mumbai Air India flight on 18 May and the next day to Mangalore after which he operated flight IX-811 to Dubai from Mangalore on 21 May, together with Ahluwalia.

In line with procedure, the passengers—many loaded with extra baggage because of the gifts they were carrying from Dubai for friends and family—were asked to fasten seat belts as they approached the Mangalore airport at about 6am.

The weather was clear as the aircraft descended towards the tabletop runway—one that is located on a hill top, with either end stopping abruptly and dropping into deep gorges. Such a runway tends to create an optical illusion and requires a precise landing approach by the pilot.

Preliminary findings of the crash investigation suggest the pilot landed far beyond the touchdown point.

According to an Airports Authority of India (AAI) official who didn’t want to be named, the pilot landed some 2,000-3,000ft beyond the point where the plane was supposed to touch down, reducing the area available to bring the aircraft to a halt.

Realizing he had touched down way too far, he tried to take off again, but failed, and the aircraft plunged down the hillside in a flaming wreck.

The 8,000ft of available runway in Mangalore is safe enough for Boeing 737 or Airbus A320 aircraft, but leaves little room for error. These aircraft require not more than 2,600ft of runway, to which a 60% safety margin is added, taking the required distance to 4,100ft. That leaves an extra 3,300ft of leeway for the pilot.

The end of each runway has what is called the safety area into which an aircraft can sink its wheels if it overshoots the concrete runway.

“There were deep tyre marks in the runway safety area, which is basically the sandy part towards the end of the runway. The three tyre marks (of the aircraft) run continuously in that sandy area and then at two places the nose wheel marks disappear for small patches, which suggests the front wheel or the nose wheel was in the air for a few seconds," said the AAI official quoted above. “It appears he tried to take off twice, but the engines did not spool (power) enough. The question is: did the brakes fail? Why did he not get the required power?"

Runway marks also indicate that there was no tyre burst as some survivors had thought.

Touch and go

Considering the speed of a Boeing 737, Glusica and Ahluwalia may have had as little as 12 seconds to decide whether to apply the brakes or try to take off again after touchdown.

“Assuming for the moment the aircraft did touch down beyond 3,000ft then it would take 12-16 seconds for the aircraft to run out of runway," says Lumba. “He could still stop, but if he elected to try a takeoff, a crash would be the only outcome since now there would not be enough runway. The important aspect is the 12-second time frame with a decision to be made...whether to stop or go. If the decision is right, well done. If wrong, a lot of people will die."

According to aviation experts, Glusica may have chosen to take off to avoid a hard landing, in which an aircraft impacts the ground with greater speed and force than in a normal landing and entails risks ranging from passenger discomfort to plane damage and even loss of life.

A hard landing is acceptable in the interest of safety and sometimes passenger comfort needs to be sacrified for safety, says Mohan Ranganathan, a Chennai-based air safety expert who is also a member of the Civil Aviation Safety Advisory Council set up by the government to review aviation policies in the aftermath of the crash of IX-812.

Gluscia had some 10,000 hours of flying experience. But he may have wanted to avoid a hard landing because he had been reprimanded at least once this year for such a landing, which needs to be reported as an aviation “incident" to the airline management, according to an official at the Directorate General of Civil Aviation (DGCA).

Airlines should allow hard landings in the interest of safety, Ranganathan says.

“Every safety-conscious system encourages that," he says. “Pilots are human and this kind of landing, when within the manufacturer’s limit, does not require management intervention. Only a myopic policy will consider this a punishable offence."

Air India declined to comment on the issue. DGCA has identified a review of the policy as a key measure it needs to focus on, according to a presentation it made to a government committee, which was reviewed by Mint.

Pilot workload

The aircraft was flying at 37,000ft and was 70-80 nautical miles—against the typical 140 nautical miles—away from its destination when air traffic control told Mangalore airport and the pilot to prepare for descent, the DGCA official said. That doubled the pilot’s workload. “He was (flying) high, he was fast and tired as it was an early morning flight when the body needs the most sleep and the emergency response works at 50% the normal efficiency. The reflexes become poor," the official said.

So, was the crash avoidable?

“This was definitely an avoidable accident. The crucial question that needs answering is what made the pilot lose control. A pilot can lose control because of various reasons—catastrophic failure, an act of god, terrorism, mechanical failure, human failure (pilot error)," says Lumba. “The cause of this accident is a no-brainer and can be established just by analysis of the cockpit voice and flight data recorders.

“If the pilot made an error, which is likely, it must be established: was it a judgement error or negligence. All the factors that contributed to the error need to be identified since they are the risk factors that need to be mitigated to avoid a recurrence," he says.

An inspection of Air India Express—the low-cost international carrier of Air India—that is nearly complete has identified some deficiencies, said a second DGCA official, who too sought anonymity.

Air India Express flight timings are such that most arrive in India in the mornings when the “body is very tired". Pilots on some sectors require more time to rest because they do four-five landings, he says.

“Even monitoring of flying hours are made by pencil; it’s not computerized. What is the authenticity that FDTL (flight duty time limitation) norms are being followed—you can rub it off when you want. You are not running a taxi service, are you?"

At Mangalore, the airline also did not have doctors to conduct pre-medical flight checks on crew before 24 May. “We were facing lot of problems in identifying qualified doctors willing to carry out (medical checks)," Air India said in an email reply to questions from Mint. “However, we now have two doctors working at Mangalore since 24th May, 2010."

The DGCA inspection found that senior officials from Air India doubled up for duties, including in training and flight operations, at Air India Express—something DGCA is averse to as the low-fare unit operates as a separate entity with a separate licence.

Air India has V. Kulkarni overseeing training at both Air India and Air India Express although the two carriers have different kinds of aircraft. Air India Express’ chief of operations, Rajendra Bajpai, is on deputation from Air India, for which he flies long-range Boeing 777 aircraft.

Air India Express, with 956 employees as of March 2009 according to the latest available data, had a chief operating officer (COO) P.P. Singh, a pilot, who retired last year after which another Air India official, Andy D’Souza from the finance team, was made the COO. Air India as a group has more than 33,000 employees.

“Basically they don’t have their own set-up," says the second DGCA official.

It was only recently that the airline sought applications from candidates for COO who would be “responsible for the safe and reliable operation of the airline" with “flight experience on the Boeing 737", “ensure the airline has the correct operational controls, administrative and reporting procedures", and “ensure compliance of safety regulations as specified by domestic and international regulatory agencies".

Air India, which said it conforms with all DGCA rules, has also offered jobs to survivors of the air crash. Ismail, who still can’t believe he is alive, says he will take another flight only if the job materializes. “There is no other way I should fly again."

This is the first of a three-part series on aviation safety.

Next: Of understaffed regulator and unlicensed airports.