SMS Bulletin No.

004/2016

DATED: 5th September, 2016

Ref: SEAMS/SMS/SCP/005A/004/2016
TO: All SEAMS Department (All stations)
FROM: SMS Department

Dear All,

Accident: Air India Maintenance Technician Ingested by A319 Engine

The technician, Ravi Subramanian, died on the spot -- as he stood with his back towards the aircraft
without realizing that it had started to move. A major communication lapse resulted in the death of
an Air India (AI) technician, who was sucked inside the aircraft engine at the Mumbai airport on
December 16, 2015.

The final investigation report submitted to the aviation ministry and accessed by HT lists a series of
lapses, including a terrible rostering error, which led to the tragic accident.

Lapses before Accident

Before operating the Mumbai-Hyderabad flight, the same pilots had operated a Rajkot-Mumbai
flight. Flight to Hyderabad from Mumbai was scheduled for departure at 7.30 pm. The one from
Rajkot was scheduled for arrival at 8.10 pm -- which meant that pilots were already 40 minutes late
for their next flight. A further delay resulted in the Rajkot flight arriving at 8.35 pm.

The aircraft began taxiing with the pilots not realizing that four ground personnel were still around
the nose of the aircraft. While Mr. Subramanian, who had his back towards the plane and
headphone on his head, was sucked in, others managed to run away. The co-pilot told investigators
that the ground personnel had given clearance followed by thumbs up. "However, as per the
statement of chocks helper and tow truck driver, the deceased engineer had neither shown thumb
or pin to pilot, nor had any other person," the report said.

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The aircraft maintenance engineer was missing and "was not near the aircraft for pushback and
departure," the report said. "Non adherence to SOP (standard operating procedure) resulted in the
accident," according to the report.

SEAMS SMS Recommendations:

1- Lack of Communication being the vital factor resulted in loss of life. Therefore, we as
maintenance professionals shall ensure Clear, Complete, Concise & Concrete information is
exchanged; especially at High risk based operations on Ramp i.e Re fuelling, Push Back,
towing etc.

2- Situational Awareness is also an ability which we as maintenance personnel shall learn

and practice for own and team member’s safety.

3- Adherence to Procedures is a basic rule of thumb in aviation and Incidents/Accidents are

inevitable when Violations become Organizational Norms. (Violations like Not following
Procedures or in above case Aircraft Engineer supervision was seen nowhere around the
Aircraft)

4- All SEAMS Staff for enhancing Safety culture shall Report Hazards, Incident & Accident to
SEAMS SMS Department by submitting SMS FORM 001/002 OR via email
(Safety@seams.com.pk)

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