• Tail rotor overused beyond limit, tracking absent 
• Flight Safety Manual unapproved since 2011 
• Audit system exposed as procedural formality

 

 

June 16 NEARLY six months have passed since the Aircraft Accident Investigation Bureau (AAIB) submitted its final report, somewhere between late 2024 and early 2025, on the Agusta A109E helicopter crash at Swami Vivekananda Airport (SVA) in Raipur. Yet, the Government of Chhattisgarh has taken no visible action – neither have any responsibilities been fixed, nor has any departmental or legal accountability been initiated. As the report gathers dust in bureaucratic shelves, its findings – grave and urgent – stand in stark contrast to the inaction that has followed. In the wake of India’s deadliest aviation week, which claimed 286 lives across two crashes, the 2022 Agusta A109E helicopter tragedy at Raipur Airport resurfaces not as a forgotten accident –but as an emblem of systemic failure. Two senior pilots –Captain Gopal Krishna Panda and Directorate General of Civil Aviation (DGCA) Examiner Captain A P Srivastava – died on May 12, 2022 when the Government-operated chopper spiralled out of control during a night proficiency sortie and crashed violently off taxiway Alpha. ‘The Hitavada’ has obtained the 120-page final investigation report released by the Aircraft Accident Investigation Bureau (AAIB), through the Bureau’s official public portal.

 

The report, consistent with International Civil Aviation Organisation (ICAO)’s noblame mandate, refrains from assigning criminal liability –but presents an extensive account of factual lapses, oversight failures, and noncompliance within the operator’s domain. According to the AAIB, the Agusta A109E lost yaw control due to tail rotor pitch linkage failure stemming from worn-out components and incorrect torque values. The tail rotor hub assembly, as detailed in the Bureau’s findings, had exceeded its retirement life by 89.5 flying hours. This, the report explains, could occur only in the absence of a proper component tracking mechanism. Crucially, investigators found that the tail rotor assembly had suffered severe mechanical disintegration mid-air, with parts including the pitch link and slider system separating violently. The tail rotor was recovered at a distance of over 26 metres from the fuselage, and the AAIB highlighted this as evidence of in-flight control loss prior to impact. The Civil Aviation Department (CAD), Government of Chhattisgarh – operator of the aircraft under DGCA State Government Operating Permit No. 08/2012 – had no active system in place to monitor or flag expired critical parts, as per the AAIB. Maintenance logs examined during the probe revealed missing part numbers, vague entries such as “NEW” without supporting documentation, and blank fields where usage hours should have been recorded. Also central to the failure sequence was the half-scissor assembly, which connects the tail rotor pitch link to the control system. The AAIB determined that the torque values applied to these bolts were “significantly below specification,” making the assembly vulnerable to mechanical play and failure.

 

Leonardo Helicopters, which conducted metallurgical analysis, corroborated that improperly sized washers and visibly worn components had violated safety protocols prescribed in the manufacturer’s manuals. Photographic and structural analysis in the AAIB report further documented that the Main Gear Box (MGB) was found separated from the airframe, lying well behind the wreckage – an unusual post-impact configuration that indicated compromised transmission support during descent. This mechanical condition, the Bureau noted, added to the helicopter’s uncontrollable spin. The report also noted that the operator’s Flight Safety Manual (FSM) had not received DGCA approval since 2011, despite several correspondences. In the AAIB’s words, the absence of an approved safety framework for over a decade exposed both crew and VIP passengers to elevated risk. Additionally, the Bureau highlighted that no safety programmes or internal training activities had been conducted for at least a year prior to the accident, contravening Civil Aviation Requirements (CAR) provisions. Internal safety audits, though formally conducted, returned zero findings over five consecutive years – a pattern the AAIB found “statistically implausible,” especially given the irregularities found during physical inspections.

 

A particularly troubling discovery, detailed in Section 2.6 of the report, relates to an earlier incident involving a King Air B200 aircraft operated by the same Directorate. According to the AAIB, the crew and maintenance staff concealed the true nature of a wing dent from December 2021 and instead attributed it to a bird strike, even though subsequent inspections found no physical evidence to support that claim. On the operational front, the Bureau observed that Raipur Airport lacked basic emergency preparedness on the day of the crash. There was no available towing arm or emergency ground handling system. The post of Chief of Flight Safety (CFS) was also vacant at the time, a point AAIB notes as critically impairing oversight. AAIB’s Cockpit Voice Recorder (CVR) and Flight Data Recorder (FDR) analysis confirmed that the pilots had executed multiple missed approaches before their final attempt. The helicopter made a brief touchdown and then lifted uncontrollably, as a sudden increase in collective pitch was recorded. This rise in collective input during rollout was later linked to loss of control and subsequent crash. The report concluded that critical Crew Resource Management (CRM) procedures were either absent or not followed.

 

Throughout the report, the Bureau stresses that repeated concealment of prior incidents, operation of expired parts, ineffective audits, and the absence of leadership in flight safety cumulatively allowed a breakdown in the state’s aviation oversight framework. The report stops short of naming individual officials, but terms the culture as one of habitual non-conformity. The AAIB also flags the lack of DGCA audits for this operator prior to the crash, despite its responsibility for Very Important Person (VIP) flights. In its recommendations, the Bureau urges that CAR Section 5, Series F, Part 1 be expanded to cover all government-operated fleets –ensuring they fall under routine national surveillance. The Hitavada made multiple attempts to contact Civil Aviation Secretary Rahul Bhagat by sending him detailed queries seeking his version on the action taken report, but he repeatedly remained unavailable, citing his occupancy in back-to-back meetings.