Ideas sometimes steal in
unbidden to an unwary mind….and if shared with others, the more outlandish ones
are at best often laughed off the table. I have long suffered from this
affliction.
In 2002, as a young officer onboard Viraat, I had
suggested that the next fighter aircraft (the MiG 29K was then being offered
along with Gorshkov) should be purchased in larger numbers (larger than the 23
Sea Harrier FRS Mk. 51s which we had obtained from UK) and a Naval Ground/
Flight Testing Unit should be set up in Bangalore (to take advantage of the
strong civil-military-industrial aviation presence) to continuously test two
“sample” aircraft allotted to it to their very limit in terms of operational
& maintenance cycles/ hours flown, etc. The idea being that such a unit
through its extensive cycles of operation would be able to forecast, suggest
and presumably initiate improvements and modifications to equipment, systems,
maintenance procedures, etc. (with active support from OEM/ indigenous
industry) before the frontline squadrons. Quite predictably, that piece of work
ended up in the waste basket….
This time, I would like to touch upon another subject
dear to me…the way we conduct aircraft accident and incident investigations.
Multiple tenures in fighter squadrons and a tenure each onboard Viraat and at
Headquarters Naval Aviation have driven home to me the necessity of conducting
a thorough “root cause” analysis and learning
well from each incident/ accident to save lives and aircraft/ equipment. In my
opinion, we have lost too many good men and aircraft in peacetime. What I would
like the powers that be to consider is no silver bullet, however I believe it
is time to move ahead with certain structural changes and thus build upon the
edifice laid by those who have gone before us.
Chapter 63 of INAP 2 deals with investigation of aircraft
accidents with articles 6308 and 6309 in particular (if my notes of years ago
on the subject are still valid) getting into the nuts and bolts of a Board of
Inquiry. A quick examination of article 6309 would indicate the degree of
flexibility and gathering of professionals it facilitates to ensure an
impartial/ unbiased inquiry into each accident. I would like to suggest here that
this system we have followed for so long needs to be restructured to meet the
challenges which would be posed by a numerically and technologically vastly
superior aviation force (a veritable mini air force, if you like) which Naval
Aviation is set to become over the next few years.
The existing orders for constitution of a Board of
Inquiry necessitates the nomination of the President as well as the members
from five different organisations and as far as possible not from the same
ship, air station or air squadron involved in the accident. And this process is
repeated for each and every BoI set up for accidents. The report of the BoI is
subsequently analysed in great detail by the Administrative Authority, HQNA,
AIRCATS, IHQMoD(Navy), etc. Remedial measures are instituted, action taken to
prevent recurrence and so on. So basically, literally the whole of Naval
Aviation jumps onto the bandwagon after an accident and oversight is provided
over the findings and recommendations of the BoI by anyone with the authority
to do so. In the present system, this oversight is very much a necessity due to
the inherent flaws built into the investigative process.
To begin with, the present system requires the President
and members to overnight transport themselves to a totally different frame of
reference from their respective existing primary responsibilities…that of an
inquiry into an accident. I will stick my neck out here & say that almost
always, none of them has any formal training in the art of accident investigation.
At times, with the inquiry period stretching from weeks to months (particularly
in cases where feedback from OEM or specialist laboratories like NAL are
awaited), the focus of the BoI team is inevitably interrupted with the team
being temporarily disbanded to attend to their primary duties at their
respective units. The team is also often caught between a rock and a hard place
while its individual members play the delicate balancing act between their
primary responsibility at respective parent units and the need to do justice to
the job at hand (shoddy investigations being quite understandably,
inexcusable).
Under the present system, aircraft incidents are
usually investigated at the level of the unit/ air station without a BoI being
ordered. Often, the local RAQAS or NAQAS is also tasked to associate. We have
to understand here that we have a fine QA organisation led by NAQAS and its
satellite RAQAS units. They have a definite role to play in ensuring adherence
to pre-determined standards of quality by all Naval aviation maintenance
organisations. So, while one particular incident on an aircraft type might
involve RAQAS assistance the others,
being
considered benign, might not. Therefore, even as everyone from the local unit
to HQNA pores over and analyses the individual incidents, the threading
together of all incidents on an aircraft type to create a mosaic to understand
and possibly prevent a future accident may well fall between the cracks (I
allude to the Swiss cheese model of the alignment of contributory factors
towards an accident).
It is estimated that as the sheer volume of number of
sorties/ hours flown increases due to increase in overall UE, the sum total of
incidents and accidents to be analysed by RAQAS/ NAQAS/ HQNA would also increase.
Is it therefore time to deal with the analysis of incidents and accidents in a
different way, quite apart from the primary roles and responsibilities of the
existing organisations? Would it be fair to the BoI team to expect it to
consider each accident involving an aircraft type in the past while analysing
the current one? Should not all incidents
of each aircraft type be continuously analysed by a dedicated team of personnel
whose primary duty it would be to prevent a consequent accident somewhere else?
Would such a team not be inherently more efficient at handling such a challenge
than expecting disparate organisations like NAQAS, AIRCATS, HQNA and CATO/ CAVO
at respective AAs to do the job in a Naval aviation environment with 400+
aircraft operating from a variety of different platforms?
Given the rapidly emerging complexities over the next 10+
years, I would like to propose the setting up of a Naval Aviation Safety Board
(NASB) as a commissioned
unit. The envisaged Unit would be staffed with personnel (aircrew as well as
technical) from each aircraft type forming different type-specific teams. All
personnel would have a minimum tenure of 3-5 years with key personnel in each
team trained in the art of accident investigation.
The NASB would be charged with the task of analysing each
incident and accident of all aircraft types as well as all ground support
equipment. It would operate under the functional control of HQNA with inputs
being provided by NAQAS/ RAQAS and AIRCATS as per requirement. NASB’s
involvement would be automatic immediately upon receipt of an incident/ accident signal. It would have the authority to access the site of
the incident/ accident, take custody of relevant documents, interview
witnesses, etc.
With a Unit like NASB in place, it is opined that the
interests of “root cause” analysis
would be better served. A BoI team working with an immediate deadline (notional
or otherwise) in place would inevitably be working under time constraints to
reach its conclusions which might be of the first order rather than delving
deeper. For example, it is of critical importance to ascertain why a person
committed a certain act or why did a Cat ‘A’ item fail within its first life
cycle leading to an incident/ accident instead of terminating the investigation
once the offending person/ item has been identified.
NASB would have the freedom to interact directly with
OEMs, other aviation units within the military/ paramilitary services,
specialist laboratories, etc. Indeed, over a period of time, it is envisaged
that the Unit would build up a working liaison with such organisations to
further its investigative and analytical capabilities. It would be empowered to
conduct safety audits of all Naval air stations/ squadrons with respect to
aircraft & equipment and the SoPs which govern their operation.
As I said before, the NASB might not be the silver bullet for enhancing our
investigative capabilities and improving aviation safety, but I would consider
it to be an operational imperative for the growth trajectory being followed by
Naval aviation.
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