The 349 bodies from the worst mid-air collision in aviation history had hardly been disposed of before the finger-pointing began. Early speculation centered on confused instructions between air traffic controllers (ATCs) at New Delhi's Indira Gandhi Airport and the pilot of an incoming Kazakhstan Airlines Ilyushin 76. India's civil aviation chief, H.S. Khola, insisted that "the ATC is not to blame." While the Saudia commander wanted to gain height to achieve cruising speed at the earliest, the Kazakh plane sought permission to descend. Just before two planes collided, ATC told the approaching Saudi jet to climb to 14,000 feet (4,308 meters) and instructed the Kazakh plane to descend to 15,000 feet (4,615 meters), leaving little margin for error. "At the time when they were given the instructions, it is crucial at what height they were flying," Bharadwaj said. According to Airports Authority of India sources, the recording of the conversation between the control tower and the commanders of flight SV-763 and KZA-1907 clearly indicate that they had been instructed to maintain their height at 14,000 feet and 15,000 feet respectively.

The charred debris smoldering

The two planes were at a distance of 13 miles at the time of the last communication with the ATC. Since the Kazakh commander had been apprised of the position of the Saudia Boeing 747, the reason for the collision remains unanswered. The ATC had informed the Kazakh operated IL-76 pilot that a Saudia airliner was flying at ``12 o'clock'' position at 14 miles latitudinal distance. The location of the debris led to speculation that the Saudi pilot might have misinterpreted the controller's instructions and climbed higher than the 14,000 he had been cleared for. One of the plane's engines was found on top of the Ilyushin's tail -- a possible indicator of the point of impact. The juxtaposition also suggested that the Boeing had been flying higher than the Kazakh plane at the time of collision. The cockpit instruments show that impact occurred at 14,800 feet, which means the Ilyushin was some 200 feet below its prescribed height and the Boeing 800 feet above it.

Indian authorities fingered the Kazakh pilots and their equipment. The aviators from the former Soviet republic, they said, did not understand English instructions clearly, flew badly maintained aircraft and had been involved in near collisions in the past. And "KazAir," they added, is the worst of the national airlines formed when the Central Asian republics gained independence. Kazakhstan authorities closed the airline down a few months ago because of safety considerations. It was restarted after a local bank took over its administration. But the vice-president of KazAir, Ildus Nazmutdinov, defended his airline. The plane involved in the accident was in good technical condition, he said. "Our pilot knew English. We're just starting the investigation and have very few details." The transcript of the controller's conversation suggested that the Kazakh pilot did, in fact, understand the instructions. Indian officials, however, believe he might have failed to recalculate the altitude into feet. But KazAir officials insist the aircraft had altimeters in feet as well as meters.

India's commercial pilots union accused the government had dragged its feet on flight safety improvements, even after three near in-flight collisions over a six-month period in 1994 and 1995. The Indian Commercial Pilots' Association released a letter dated May 1995, outlining the three incidents and citing outdated equipment at India's busiest airport as a primary culprit. The radar at Delhi was an older model that gives readings in only one dimension -- range. More modern systems indicate the height, speed and direction of aircraft, giving controllers a three-dimensional picture of the traffic. Although the controller involved had told the planes to fly at different heights, his equipment could not verify whether they were actually keeping to the prescribed limits. He could only watch as the two blips on his screen hurtled toward each other at a combined speed of 800 miles an hour, hoping they would pass each other safely.

The pilots' association had recommended installation of state-of-the-art radar systems, such as transponders, VHF communications equipment and CAT II equipment, to aid landings. A newer radar, purchased from the American Raytheon Corp. for $128 million, had been installed. But, say government sources, it was not working -- even though it should have been by October last year. New Delhi has ordered another investigation to find out why. The Air Traffic Controllers' Guild says that it urged authorities a month ago to upgrade the capital's systems. Some aviation experts have questioned the wisdom of allowing the aircraft to pass directly over and under each other within New Delhi's 40-km commercial air corridor. They advocate horizontal separation. Because of security considerations, the capital has only a single corridor for incoming and outgoing flights that is oriented east and west -- the general direction of Pakistan. Neither aircraft was fitted with automatic airborne advisory systems that would have warned pilots they were on a collision course. The Saudi Boeing was an older model which did not have the device, and the Russian-made Ilyushin was not equipped with them. And for the systems to work, the planes would have had to be fitted with compatible models. In the United States, all aircraft are required to be so outfitted, and the same rules will be in force in Europe by 2000. Some foreign pilots say they have had no problems flying in India. Others, however, refer to the airspace here as "the black hole" and bemoan the low quality of information they receive from controllers.

As faint past criticisms suddenly became a noisy chorus, government officials defended their guidance systems. At a hurriedly called press conference on Nov 12, the Civil Aviation Minister, Mr. C.M. Ibrahim, and Civil Aviation Secretary, Mr. Yogesh Chandra, gave a clean chit to the Air Traffic Controllers (ATC) in Delhi and said that they were constantly informing the two planes about their respective positions. "Whatever air traffic did was absolutely right," said Yogesh Chandra. He added that upgraded equipment is already being put in place. "It was not a head-on collision," Chandra said. "Probably, their wings brushed each other. The cockpit and fuselage of the Kazakh airliner was found intact." They denied suggestions made by sections of the foreign visual media that ATC could have been at fault in the incident. Mr. Chandra said the Guild's threat to go on strike for reinstatement of some of their colleagues suspended for Purulia arms dropping, had been ``sorted out'' the previous day. "Indian airports handle more than a thousand aircraft a day. I do not think our systems are at fault," said Ibrahim. The Director General of Civil Aviation, Mr. H.S. Khola said that the limited reconstruction of the train of events suggests that the wing of IL-76 collided with the wing and tail portion of the B747 aircraft between 1842 and 1843 hours. The impact of the collision detached the rear portion of the B747 cabin from the rest of the plane including the cockpit even as it hurtled down the skies towards the fields of Charkhi village in Dadri, Haryana.

Since the B747 had just taken off for a four-hour flight to Jeddah at 1833 hours, it was carrying nearly 40,000 to 45,000 kilolitres of fuel including a two-hour reserve. The presence of a large volume of fuel obviously burnt the plane completely, leaving behind charred aircraft parts and 312 mangled bodies inside the plane and all over the fields. A large portion of the cockpit windscreen and fuselage of the IL- 76 remained intact notwithstanding the mid-air collision which again substantiates the theory that a head-on collision did not take place. According to eye-witness reports and local police officials, the fuel tank of the Kazakh aircraft got detached and bounced off a few 100 metres away before the plane crashed into the earth. The large ball of fire was noticed falling away from therest of the burning plane by some local villagers, the policemen said. Besides, the bodies of the pilot and co-pilot of IL-76 was found inside the cockpit on their seats itself, consolidating the theory that only the wings brushed with one side of the plane.  

Prime Minister H.D. Deve Gowda ordered a Court of Inquiry into the accident. "We will not spare any culprit, if any individual was to blame," Gowda said. But Deve Gowda, who visited the macabre crash site, cautioned against jumping to conclusions. "Until the report is available, it cannot be said whether it was failure of pilots or the air traffic control," he told reporters. Preliminary indications showed the mishap was "probably due to the Kazakh pilot's error." The Delhi High Court judge, Mr. Justice R. C. Lahoti headed the Court of Inquiry into the accident. Mr. Lahoti was assisted in the inquiry by two assessors- Captain A. K. Verma, General Manager (Training) of Air India and Air Commodore (Retd.), Mr. T. Pannu of the Indian Air Force, Mr. V. K. Arora, Controller of Airworthiness in the Directorate General of Civil Aviation functioned as the Secretary to the Court. The Court was to complete its inquiry and submit its findings to the Central Government by February 15, 1997. The Court was to make a report to the Central Government stating its findings as to the cause of the accident and the circumstances thereof, adding any observations and recommendations which it thinks fit to make with a view to the preservation of life and avoidance of similar accidents in future, including a recommendation for the cancellation, suspension or endorsement of any licence or certificate issued under the rules. Teams from Saudi Arabia, Kazakhstan and the crew of the U.S. military transporter aircraft, which saw the mid-air collision were to appear before the Court of Inquiry.

Two years later in 1998, an Indian investigation under Justice R.C Lahoti blamed the Kazakh pilot, Commander Gennady Cherapanov and exonerated the Saudia crew of any fault. The Kazakh Airlines pilot's failure to understand instructions from air controllers was one of the main causes collision, the investigation had concluded. The report is very critical of air traffic control co-ordination in India in general but finds that correct instructions were given to both aircraft before they hit each other head-on. The hundred-page report said "the root and approximate cause of the collision was the unauthorised descending by the Kazakh aircraft to FL-140 and failure to maintain the assigned FL-150." The Kazakh Airlines aircraft was instructed by air traffic control to descend to FL-150 but was flying instead at FL-140, or 14,0000 ft (4,270 m), which was the altitude assigned to the departing Saudi Arabian flight. Vertical separation of 1,000 feet for the crossing of the two aircraft as assigned by the Delhi Air Traffic Control was adequate and met the International Civil Aviation Organisation standards of safety, the report points out. It also says that turbulence in a cloud layer encountered by both planes 30 seconds before the accident were not severe enough to cause the Kazakh plane to drop from FL-150 to FL-140, as had been argued by Kazakh Airlines shortly after the accident.

Among the factors contributing to the unauthorised descent of the Kazakh aircraft, the report cites the pilot's "inadequate knowledge of English language," which resulted in misinterpretation of air traffic controllers' instructions. The report also charges the Kazakh pilots with "poor airmanship," lack of proper crew resource management skills on the part of the pilot-in-command and the "casual attitude of the crew." The investigation's report noted that there was no secondary surveillance radar in New Delhi, and said that although the airport's single air corridor did not contribute to the accident, unilateral routes would enhance traffic handling capacity. It also noted that neither plane was equipped with airborne avoidance collision systems, not obligatory under Indian civil aviation law at that time. Though it did not play a role in the mid-air accident, the report also faulted India's air traffic control organisation for not having a system of licensing of air traffic controllers and for not maintaining the same standards throughout the country both for civil and military air traffic controllers.

The 1998 Investigation was accused of shortcommings. Preventing disasters depends partly on analyzing data from past disasters, which requires funding as well as training, both of which are in short supply in India. To find core problems, "you have got to examine all the possible factors over a period of 10 to 20 years and look out for patterns. Then you can successfully analyze, but that is not how it is done here," said Dinesh Mohan, a transport expert and professor at the Indian Institute of Technology. In India, investigation tends to focus on who was at fault. "The attempt is not to examine how the system is at fault, and then correct it, but only to fix individual blame," Mohan said. "In any crash, it is not a single cause but many factors which cumulatively lead to it. If you focus only on one factor, then you do not solve the problem."

In March 1999, the Air Traffic Controllers' Guild urged the Government to implement post-haste the air safety recommendations made in the November 1996 mid-air collision inquiry report. The guild, has in a communique to the Civil Aviation Minister, Mr. Ananth Kumar, drawn his attention to the procedural delay in probing the reasons behind any incident, and the subsequent time lag in implementing the lessons learnt from the episode. The guild has said that even after the worst air disaster in India which claimed over 350 lives, the safety recommendations of the inquiry report were yet to be implemented. The tragic incident took place on November 12, 1996. The inquiry report was submitted to the Government nine months later on July 15, 1997. While 14 months later in October 1998, the Government accepted the report, the implementation was still awaited. According to the guild, a similar fate met the reports of the Court of Inquiry into the accident of Indian Airlines B-737 at Ahmedabad in January 1989 and at Imphal on August 16, 1992. The guild has observed that clearly there was a need to look at the preparedness of the Indian safety umbrella, and act fast, more so after the recent incidents. Incidentally, the mid-air collision near Delhi had shifted the spotlight once again to the limitations of the air safety umbrella provided by AAI, and prompted them to speed up the modernisation of the air traffic systems in Delhi and Mumbai. While the Rs. 423-crore modernisation exercise is nearly complete, the ATCs have been alleging that some inadequacies still exist and need to be rectified immediately.

The Alliance Air Boeing 737 crash near Patna, eastern India on July 17, 2000, killing 57 people, again brought airline tragedy into living rooms across the country. There were renewed calls from ruling circles for the privatisation of the airline industry and airports, on the grounds that this is the only way to provide adequate funds to rectify the safety crisis. 

The Patna crash wreckage

However air transport in the wealthy countries, such as the United States, has become less and less safe as the industry has been deregulated. Moreover, dangerous cost-cutting and the lowering of safety standards are taking place around the world as airlines slash costs and demand lower taxes in order to undercut their rivals.