Vistara fuel incident, faults with regulators

Low fuel

The Vistara fuel emergency in 2019 has highlighted the poor safety culture prevailing in the aviation sector. The investigation report has pointed out serious deficiencies with the DGCA flight standards directorate & the operator for a change. The same has been enumerated in the safety culture survey 2019 carried out by Safety Matters. Airlines continue to compromise safety at the expense of a little more money-saving. In an earlier blog on fuel policy, it was highlighted how airlines are uplifting less than the mandated fuel for a diversion from destination to alternate. Historically, no action has been taken on the operator for endangering public safety but the easy target, the flight crew is suspended at the drop of a hat. My petition and the RTI still remain unanswered by the top policymakers as to why just culture is not being implemented in Indian aviation and the crew being targetted without determining the root causes.

Read the full investigation report here…

The Ghatkopar crash report similarly pointed out a number of deficiencies in the regulatory approval process wherein the flight standards directorate had recommended the grant of the operating permit without the mandatory key post holder. The operator was shielded by the investigation report. The Katra helicopter crash and the Mumbai Aarey helicopter crash follow similar lines of selective protectionism. RTI reply has revealed that there is no policy for acting on the recommendations of the investigation report and they are simply forwarded to the concerned authorities.

Flight from Mumbai to Delhi diverted to Lucknow after having attempted landing at Delhi. The 1st alternate which was planned was Lucknow and so was it the company preferred alternate. Little did the crew predict that after diverting to Lucknow, the weather there would deteriorate rapidly and the closer alternate Jaipur which was not recommended by the airline remain clear.

Flight path with Jaipur as alternate

Airlines are uplifting less than regulation fuel: Read the blog below.

Read the blog

The serious incident report reveals the airline policy of uplifting a standard 100kgs for a missed approach procedure which is supposed to be followed if a landing is not possible at an airport. The procedure then takes the aircraft away from the flow of incoming traffic and also helps in entering a holding pattern or attempt another approach. Options are plenty.

Vistara Fuel Policy

The catch here is that at certain busy airports for example Delhi and Bengaluru, the procedure could be as long as 30-40 nautical miles (55-75 km). A standard 100kgs fuel for an aircraft like an A320/B737 would be grossly inadequate. The airlines are therefore uplifting 200-300kgs less fuel for every flight to such an airport with a long missed approach procedure. The regulations are very clear and there is no ambiguity. It is also upon the regulatory oversight of safety that this should have been checked while approving the airline fuel policy.

A small yet significant fuel quantity that is overlooked by the airline will help save the day when a Vistara like situation arises.

Choice of alternates

The airline policy and the framing of policies have been a matter of discussion on the blog before. There is a positive and negative connotation to each policy. Whereas the airline will not explicitly state its intentions but there are subtexts and implied meaning of the policies. This policy of the airline regarding the choice of alternate is very obvious. The airline recommends that the flight crew divert to Lucknow if Delhi weather was poor and does not recommend Jaipur as an alternate. Even though it is a recommendation and the company implies that it does not mandate and the PIC is finally responsible, the fact that the PIC is questioned on the decision or expected to justify a decision when diverted to an acceptable alternate will always paly in the subconscious. Please refer to the table below.

Airline decision making matrix
Extract of the worded airline policy

For the psychology of framing policies, read the blog below.

Prevailing enroute weather
Extract of investigation report
ATC tape read out

mindFly analysis

The flight crew complied with the airline’s policies and did not use their discretion, critical thinking, or authority till it was a do or die situation. They were rewarded for it. For a change, the regulator pardoned them and did not suspend them. Something to thank the regulator for applying the tenets of just culture.

However, looking at the company policies, it is the policy that may have led the crew to persist with Lucknow as the alternate whereas Jaipur was closer, clear of weather, and suggested by the ATC. The worded policy of the airline as given in the investigation report allows the crew to change the alternate from suitable to acceptable in the event of unacceptable delays, however, it was not the case.

The investigation reports highlights Unsafe Supervision

•Ambiguous instructions issued to the flight crew on fuel uplift and aerodrome alternates were not captured by the DGCA (FSD office)during audits/ oversight.

•Inadequate Flight Following by IOCCof the operator.

The investigation report does state that human factors were considered in the preparation of the report but the probable cause fails to reveal the real causes. The fuel uplift for a missed approach is less than the regulation fuel uplift especially for long procedures like Bengaluru and Delhi. There is a need to look at these aspects and develop policies mindfully with the policy maker choosing a risk-based solution as recommended by ICAO.

About Capt. Amit Singh

I think therefore I am Airlines Operations and Safety balance expert. A former head of operations/training and safety of successful LCC's in India. An experienced member of the startup teams of these airlines has hands-on experience in establishing airlines systems and processes.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.