Abstract
The paper on the Mangalore air disaster is a really important paper for the government authorities of developing countries. It faces serious difficulties with reality, honesty and bravery. In Great Britain the Home Office developed a standard system for investigating air disasters in Britain, and overseas for British registered aircraft, and for those overseas airlines relying on British expertise. These included East African, Ethiopian and Nigerian airlines. I worked on ten major air disasters as a forensic dentist, and my response stems from this experience.
When an air disaster occurs it is always, without exception, a complete surprise. Otherwise the crew would never have initiated take off! However, aircraft do crash, usually through pilot error, pilot illness, engine or airframe failure, or criminal behaviour. Some terrorist groups revel in causing disaster, terrorists and their supporters carry unstable explosive devices around the world, and just occasionally false insurance claims are made by persuading a trusting acquaintance to carry a bomb aboard in their luggage.
We have to have all these possibilities in mind when we investigate an air disaster. Our very first need is solid evidence. Much evidence may be destroyed by impact and by fire. We must be able to examine each and every part of the remaining airframe, especially the engines, the cockpit controls, the cockpit voice recorder and the air control settings recorder.
Often, more importantly, we need to examine every body or body part available. Experienced forensic pathologists can retrieve a vast amount of evidence from badly charred bodies. For example, in the Stockport air disaster in 1967, 1 we were able to establish that the cockpit crew were severely disabled by carbon monoxide poisoning. We first had to identify them beyond doubt, incinerated as they were. That incident led to changes in cockpit heating design. Exhaust engine gases had entered the cockpit. It also led to improved passenger seat design. Many passengers got up and walked out. Others, whose ankles were broken by metal bars across the back of the seat in front of them, could not walk, and so died in the ensuing fire.
To be able to conduct such forensic examinations the evidence must be left intact. So the first duty of any local authority is to seal off the disaster site. Fire and ambulance personnel must have immediate and unimpeded access to preserve whatever life possible. Then the disaster site should be treated as a crime scene. It should be sealed off with inner and outer perimeters, and only authorised personnel allowed in or out. A register of these should be kept, including times of entry. If curious members of the public are insistent on entering the scene they must be forcibly removed.
A senior public officer must be in overall command. The police, coroner, and all investigators must be directly answerable to him. Ideally he should have some mass disaster training. He must have sufficient authority to order out inquisitive or vote-seeking politicians and news-seeking journalists. He must have authority to select and clear a suitable mortuary and post mortem site. Ideally this should be in or near a hospital with pathology and X-ray facilities. A tented site may be suitable, as it can be expanded as required. The scientists and mechanics working on the airframe and engine remains may work better without pathologists among them. On the other hand they may value close contact with the pathologists, to discuss possible mechanisms of aircrew incapacity.
In the Rhodes air disaster a BEA aircraft crashed into the Mediterranean Sea. 2 There was no fire, and most bodies were recovered and brought to Rhodes. By careful identification of each, and a knowledge of the seating plan, it was eventually possible for the air frame experts to link up with the pathological finding of tiny, high explosive residue burns in a particular Greek body with the position of the bomb that exploded unintentionally killing all aboard. No one investigator can build the whole picture, and teamwork is essential. But the evidence must be preserved intact.
A further essential is to gather DNA samples from every body at an early stage. This can then be used for accurate identification. Ideally two forms of identification should be used in each case, such as DNA and personal belongings or dental identification. No body should be released until the public officer in charge of the scene and the coroner are fully satisfied with the identification.
That is why we may consider this report of the Bangalore disaster so useful in showing what can go wrong. Take a few moments, if you can, to study the pictures of the disaster. 3 Looking at these we can see that the paper on this disaster is very honest and factually correct. All sorts of people were milling around the disaster site, and a full scientific examination was impossible. This was in India, a rapidly developing nation with an expanding forensic medical service. They are rightly proud of their progress. But it is only with the honesty and courage to publish the report in this issue of our journal that further progress will be stimulated.
It is interesting that the official report into this air accident 4 found that the captain landed the aircraft far down the runway and applied the wheel brakes, the air breaks and reverse thrust. Apparently realising that he was too near the end of the runway he then applied full forward thrust in an attempt to take off again. This failed.
The official enquiry concluded that the Serbian captain was asleep for more than half of the three-hour flight from Dubai and was “disorientated” when he attempted to land the plane. He could be heard snoring heavily on the cockpit voice recorder shortly before the incident. This is a good example of why careful positive identification of his body had to be made. In the event no alcohol or drugs were found.