Hot, High, and Harebrained: The crash of Indian Airlines flight 491

Admiral Cloudberg
25 min readJun 17, 2023
The wreckage of Indian Airlines flight 491 lies in a field three kilometers outside Aurangabad Airport. (AFP)

On the 26th of April 1993, a crowded Boeing 737 collided with a truck as it attempted to take off from Aurangabad, India, damaging its left engine and flight controls. The crippled plane flew another three kilometers, streaking low across the ground, before it struck power lines and crashed to earth, breaking apart amid billowing flames. As fire overtook the cabin, the passengers and crew attempted a panicked evacuation through the smoke-filled darkness, but many never had a chance — although 62 people escaped, 56 others perished in the crash and the inferno that followed. Among the lucky survivors were the two pilots, who soon became the focus of a judicial inquiry into the circumstances of the crash, as investigators zeroed in on the captain’s takeoff technique. Faced with conflicting testimony, faulty data, and unreliable documentation, finding answers was far from easy. But in the end, the conclusions reflected poorly on everyone involved, from the captain who never should have been in the left seat of a passenger plane, to the airline that desperately deflected responsibility, to the airport authority that knowingly neglected to regulate traffic on a nearby road. These findings were an indictment of aviation safety in India — but looking back now, they also provide some measure of comfort, revealing just how far India has come, even as work remains to be done.

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(Soham Sen)

Formed in 1953 by the nationalization and merger of eight regional carriers, the state-run Indian Airlines was founded as the domestic counterpart to the international-facing Air India. For some time it was actually the only domestic airline in India, and private competitors were not allowed to emerge until the early 1990s. Operating under dangerous conditions with poor infrastructure, old aircraft, and almost non-existent oversight, the airline developed a poor safety reputation, and for good reason — especially during the years leading up to market liberalization, Indian Airlines was having a fatal crash almost every year. In 1988, for instance, an Indian Airlines Boeing 737 flew into terrain on approach to Ahmedabad, killing 133; then in 1990, an Airbus A320 crashed on approach to Bangalore, killing 92; and in 1991, another 737 flew into terrain while landing in Imphal, killing all 69 people on board. The airline also suffered from lax security and political instability, ultimately experiencing 16 hijackings between 1971 and 1999.

VT-ECQ, the aircraft involved in the accident. (Werner Fischdick)

It was against this background that Indian Airlines flight 491 arrived in the central city of Aurangabad on the 26th of April, 1993. The 18-year-old first-generation Boeing 737–200 had been hopping across the western part of the country all morning, originating in Delhi before flying to Jaipur and Udaipur in Rajasthan, from which it then proceeded to Aurangabad, a city of about 1 million on the Deccan plateau in the western state of Maharashtra.

Ever since it departed Delhi, the flight had been operating with a crew of six, including four flight attendants and the two pilots, 38-year-old Captain S. N. Singh, and his 30-year-old First Officer Manisha Mohan. Neither was exceptionally experienced in their roles: Captain Singh had nearly 5,000 total hours, but he had only recently upgraded to captain on the 737, and he had just 140 hours in the role. First Officer Mohan was still relatively new to flying in general, with less than 1,200 hours total, mostly on the 737.

This crew pairing would not have been particularly noteworthy except for the fact that neither was an exceptional pilot. First Officer Mohan had struggled during her theoretical training, requiring retests on several items, and she failed the technical essay component of her license examination. Her actual flying skills were assessed as “standard,” but that grade was sufficiently marginal that India’s Directorate General of Civil Aviation (DGCA) required that she be subject to fortnightly route checks as a condition of its approval of her license.

Next to Captain Singh, however, Mohan might as well have been a stellar student. Singh’s documented troubles began in June 1989, when he attempted to upgrade to captain on the 737 but voluntarily withdrew after an instructor made several “adverse proficiency observations.” In 1991 he tried again, but his skills were judged to be so marginal that the airline had to put him through over 100 extra Line Oriented Flight Training (LOFT) sessions just to get him to a standard proficiency level, and even then, in October of that year he failed a routine Boeing 737 performance refresher test and was taken off the flight line. He returned for retraining in December, but during a check ride, the check airman assessed his performance as “below standard” due to poor knowledge of “[aircraft] performance, planning, [and] crew briefing.” Consequently, he was made to undergo additional route checks beyond the norm before being released for unsupervised duties as pilot in command. Perhaps unfortunately for everyone, he passed the checks and became a fully qualified Boeing 737 captain on October 9th, 1992. Why he had accumulated only 140 hours in the following 6 months — an abnormally low number — is not explained in available documents.

The route of the puddle-jumping flight 491. (Own work, map by Mapwire)

To make matters worse, the pilots were flying into and out of airports that lacked basic infrastructure, of which Aurangabad Airport was a prime example. Although the airport served a city which at that time had a population of 600,000, the terminal was tiny and poorly equipped, prompting comparisons with a “rural railway station,” and there was only enough room on the apron to park two planes at a time. Those planes also had to use a single 6,000-foot runway, considered relatively short, without the benefit of an instrument landing system, runway distance markers, or other forms of pilot assistance. Furthermore, the airport was located at 2,000 feet above sea level, and the temperature on April 26th, 1993 was over 39˚C (102˚F), both factors that decrease engine performance and further reduced the already restricted maximum takeoff weight of departing aircraft.

For these reasons, the pilots were probably displeased to hear that their next leg from Aurangabad to Mumbai, the capital and largest city in Maharashtra, was fully booked. Indian Airlines had a policy of selling 100 tickets on the 126-seat plane on flights out of Aurangabad, followed by a waiting list, of which some number of additional passengers could be boarded up until the plane reached the maximum allowable takeoff weight. Today, all 100 tickets were booked and the waiting list was long, with more passengers than could be accommodated. Among them was another Indian Airlines captain and his family, who had to ask Captain Singh for some of the extra seats because the company did not provide its employees with reserved seats on its aircraft. Captain Singh therefore allowed his colleague, his wife, and their two children on board, along with 8 other passengers, bringing the total number to 112, the most they could carry.

An Indian Airlines Boeing 737–200 prepares for boarding. (Eric Salard)

Singh and Mohan had already calculated that given the high temperature, altitude, short runway, and other factors, their maximum takeoff weight (MTOW) would be 42.6 metric tons. According to the load manifest, their actual weight was 42,546 kilograms, only 54 kilograms short of the maximum, but Captain Singh knew that this was likely an underestimate. It was apparently common practice at Indian Airlines for ground personnel to fudge the weight of the baggage in order to avoid having to disembark passengers, which was a common problem at Aurangabad, and in this case the baggage numbers clearly smelled funny.

Furthermore, Captain Singh was concerned not only about their MTOW, but their climb limit weight as well. The climb limit weight is the maximum weight at which the aircraft can achieve a required minimum climb gradient after takeoff, and even after wrangling the numbers a bit by inputting a slightly lower temperature, Captain Singh wasn’t sure whether the climb limit weight would be exceeded or not. The pilots discussed the matter for about two minutes prior to engine start, before apparently trying to laugh it off: “It doesn’t matter,” Captain Singh said with a chuckle.

“Everything is fine, only nothing should happen, that is all,” Mohan added. But she wasn’t laughing.

Despite his outward assurances, however, Singh was apparently worried enough about achieving the minimum climb gradient that he developed a dubious plan to ensure that he reached it, even if the plane was overweight. Going against proper procedures, he planned to wait for several seconds after the “rotate” call during takeoff, holding the plane on the ground instead of immediately pulling the nose up to lift off. This would allow the plane to build up more speed before starting to climb, making it easier to achieve the minimum climb gradient.

An instructional slide explaining the concept of minimum takeoff climb gradient. (Francine Richard)

Minutes later, flight 491 taxied out to the runway under the scorching heat, ready for takeoff. Although the air traffic controller suggested that they use runway 27, Captain Singh insisted on using runway 09, the same strip in the opposite direction. Why he made this decision is unclear, given that the wind was a direct crosswind out of the south regardless of which runway they used.

At 13:05 local time, flight 491 lined up at the head of runway 09, and the pilots advanced the thrust levers for takeoff. As the heavily laden plane accelerated, First Officer Mohan made the standard callouts: first, 80 knots; then V1, the highest speed at which the takeoff could be aborted; and finally, “rotate,” the command to pull the nose up for liftoff. By this point, the plane had been accelerating normally, and had used up 4,200 feet (1,280m) of the 6,000-foot (1,830m) runway. But instead of immediately responding to the rotate call, Captain Singh kept holding the nose down, and the plane continued to accelerate toward the rapidly approaching runway end. Three seconds passed, then four, five, six, seven…

Suddenly, the pilots spotted a serious complication: the path ahead of them was not clear! Some 340 feet (104m) beyond the runway end was the airport perimeter wall, which they would easily clear, but 70 feet (21m) beyond that was a highway known as the Beed Road, a thoroughfare connecting Aurangabad’s eastern suburbs with the town of Beed, some 100 kilometers to the south. And on the road, moving from south to north across their path, was a truck laden with 36 bales of pressed cotton. The truck was fitted with a wood-and-iron superstructure rising to a height of 11 feet (3.3m), and the cotton bales were stacked to the same height, presenting a substantial obstacle at a distance of only 410 feet (125m) from the end of the runway.

The accident report doesn’t say what kind of truck was involved in the accident, but it probably looked something like this. (Alamy)

Recognizing the danger, Captain Singh suddenly pulled back on his control column to climb, but he rotated too far, overshooting the optimal pitch angle. Perhaps counterintuitively, the best possible climb gradient is achieved not by pitching up as much as possible, but by limiting the pitch angle to about 15 degrees, because higher pitch angles present more of the fuselage and wing surfaces to the oncoming air, causing increased drag that adversely affects the climb rate. First Officer Mohan apparently recognized this and instinctively reached for the controls to help Singh achieve the proper pitch angle, but before she could make any inputs, Singh admonished her for her boldness: “Leave it, leave it!” he said.

At this point, flight 491 finally lifted off in the vicinity of the painted number “27,” only about 200 feet (60m) from the end of the runway. Streaking over the grass, its tail hanging precariously low, the 737 barely cleared the 1-meter-high airport perimeter wall before slamming headlong into the passing truck. The left engine clipped the truck’s iron superstructure, ripping off the left thrust reverser, while the left main landing gear plowed hard into the side panel and the cotton bales, overloading the strut and severing the bogie. Having been liberated from its home beneath the wing, the gear was then struck in midair by the plane’s own low-dragging tail, shearing off the outboard 98 inches (249 cm) of the left horizontal stabilizer and the outboard 115 inches (292 cm) of the left elevator, both critical control surfaces. The impact was felt strongly in the cockpit, where First Officer Mohan immediately shouted at her captain, “Shit, sir, what have you done!?”

Although the collision did not immediately send the plane crashing to the ground, it did inflict severe damage. In addition to the significant loss of pitch control caused by the damage to the horizontal stabilizer and elevator, the pilots also had to contend with a loss of thrust on the left engine, as the abrupt departure of the entire thrust reverser erroneously triggered a safety system intended to ensure that the reverser — used for braking on the ground — would not deploy in flight. As a result, the left engine rolled back to idle thrust and its thrust lever could not be moved. Taken together with the plane’s precarious attitude, with a high pitch angle and virtually no room to pitch down and gain speed, these failures meant that getting the plane safely back to the airport for an emergency landing would be difficult, if not impossible. This would have been true even if Captain Singh was up to the challenge, which he manifestly was not — and although First Officer Mohan attempted to assist him, Singh again shouted, “Leave it, leave it,” urging her not to touch the controls.

Flight 491’s overturned tail section. (Lokmat Times, blurring added)

Less than two minutes later, the brief but dramatic flight came to an abrupt end as the plane struck high-tension power lines at a height of 35 feet (11m), shearing the line in two and sending the 737 crashing to earth some three and a half kilometers past the end of the runway. Although the occupants were fortunate that the lines were undergoing maintenance and had not been powered, their luck did not last long, as the plane careened into several trees, sliding sideways across the ground, then struck a particularly large babul tree, which ripped the fuselage in two. The forward section, with the wings and cockpit attached, slid to a halt upright, but the tail section rolled onto its right side and came to rest nearly upside down, surrounded by flames fed from the plane’s riven fuel tanks.

As soon as the plane stopped, the survivors found themselves engaged in a mad rush to escape. Eleven passengers had been killed outright in the crash, including some whose seats were now entangled in the branches of the toppled babul tree, but the others now faced a desperate rush to get out before flames consumed the cabin. One of the flight attendants managed to open the left main entry door, and passengers queued behind it amid pitch black smoke, but the right main door was jammed, and no one managed to open the overwing exits — probably because those seated near them had not been briefed on their use. The single door proved enough to evacuate several dozen people, but it was only useful to those in the front half of the plane. The overturned tail section, by contrast, was an almost total loss. Amid the confusion and disorientation, only one passenger managed to open a door and crawl to safety — everyone else seated aft of the wings perished in the fire, including the two rear flight attendants, Vivek (who went by only one name) and Laxmi Raman Yadav. Yadav was later found still in her seat with the seat belt fastened, having been unable to reach the catch release while hanging upside down from the ceiling.

The only known photo of the wreckage taken before the fire was extinguished. (Rajendra Darda via Lokmat Times)

Although emergency services reached the scene within minutes, they arrived to find the evacuation already over, as survivors milled about beside the burning plane and onlookers rendered first aid. Of the 112 passengers, 59 had survived, along with the two forward flight attendants and both pilots, who made their exit via the captain’s side cockpit window. Captain Singh would later claim that he went back in the front door to help extract more passengers, but witnesses said he was actually standing nearby in stunned silence. Also among the survivors was the truck driver, who had to make an awkward call to the truck’s owner. The official accident report recorded their interaction for posterity: after learning that the truck had been struck by an airplane, the owner derisively replied, “Were you flying!?”

Meanwhile, by the time reporters and officials began to arrive at the crash site, most of the injured had been carted away, and the plane had mostly burned to the ground. First responders were beginning to pull charred bodies from the wreckage, accompanied by a crowd of an estimated 25,000 to 30,000 onlookers, drawn to the scene both by the column of smoke and by word of mouth. It would ultimately take more than a day to determine that 55 people — 53 passengers and two flight attendants — had died in the crash, while 63 others survived. One of the survivors would also die in hospital almost a month after the crash, bringing the unofficial death toll to 56.

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The 737’s cockpit was the only area spared from the flames. (AFP)

The occurrence of yet another deadly accident involving Indian Airlines infuriated Indian air travelers. Amid widespread complaints about the quality and safety of the state-run airline, the Ministry of Civil Aviation appointed the Honorable Justice V. A. Mohta of the High Court of Bombay to lead a court inquiry into the circumstances and causes of the disaster. With specialist air crash investigators leading the technical analysis, the plane’s cockpit voice recorder and flight data recorder were recovered, while Justice Mohta and his team gathered expert and eye witnesses, whose testimony at a series of hearings provided the basis for Mohta’s final report and its damning conclusions.

The proximate cause of the crash was, prima facie, the collision of the plane with a truck, which could only have occurred if the plane failed to gain sufficient altitude on takeoff. Examinations of the wreckage of the truck proved that the plane impacted the vehicle at a height of 7 feet (2.1m) above the roadway, which was itself 4.9 feet (1.5m) below the runway level, meaning that in the 410 feet between the runway end and the collision, the plane had only managed to climb 2.1 feet (0.6m). Furthermore, witness testimony agreed that the aircraft lifted off at a point 5,800 feet down the 6,000-foot runway, just moments before the end, and struck the truck not more than five seconds later.

The reason for this delayed liftoff became the central question faced by investigators. The flight data recorder proved to be of limited use in resolving it, because the primitive device, which recorded only four parameters onto a spool of foil, was found to be faulty — only heading and vertical acceleration were recorded, while a maintenance error had led to the failure of the airspeed and altitude traces. The vertical acceleration trace corroborated the assertion that the plane lifted off mere seconds before it crashed into the truck, but without the airspeed trace, it could not prove whether or not the plane accelerated normally. An examination of the engines showed that they were working normally until impact, nor did the pilots report any engine issues, so engine performance was ruled out. But could the plane have been so overloaded that it was unable to become airborne until 5,800 feet down the runway? This question would prove much more complex.

Officials examine the remains of flight 491’s forward fuselage. (CityKatta via Alamy)

It was obvious from the start that flight 491’s weight and balance manifest was not telling the whole truth about the weight of the airplane. For instance, of the 51 passengers who boarded in Aurangabad, only 7 were listed as having checked bags, which was dubiously low. Furthermore, if these passengers were flying without checked bags, one would expect their carry-on and hand baggage to be heavier, but using the numbers on the load sheet resulted in an average carry-on bag weight of 2.6 kg, as opposed to 10 kg for passengers who disembarked at Aurangabad. This was a clear sign that the numbers were manipulated. In order to learn more, Justice Mohta requested that Indian Airlines produce the original baggage weight card that was used to fill out the manifest, and an airline official promised to find it, only to come back empty-handed. He claimed that the card may have been destroyed a few days after the crash because it was deemed irrelevant — but it was obviously relevant, given that the plane crashed, and weight could have been a factor. Furthermore, the official was able to find the baggage weight cards for other flights that left Aurangabad that day, but not the accident flight. Justice Mohta thought this smelled of a cover-up, and he wrote in his report that the destruction of the card was “very unnatural.”

Without the original data, the only way to estimate how much the baggage really weighed was to recover as much of it as possible. Sifting through the charred wreckage, investigators found 83 checked bags more or less intact in the forward cargo hold, which collectively weighed about one metric ton. Given that there also would have been bags in the aft cargo hold that were too badly burned to recover, the real weight of the checked bags would have been significantly more than one ton, perhaps as much as two, which was substantially more than the manifest claimed. Justice Mohta estimated that the weight of the checked bags exceeded the manifest weight by 740 kilograms, plus some extra for the additional weight of the carry-on bags, resulting in a total somewhere north of one ton. Indian Airlines argued that this was a gross overestimation, claiming that the bags were wet from the firefighting operations, but Justice Mohta derisively pointed out that the bags were weighed a week after the accident after sitting out in the scorching Aurangabad heat and could not possibly have been wet.

Another view of the nose section. (Bureau of Aircraft Accidents Archives)

Next, Justice Mohta asked, if the plane was 1.5 tons over its maximum takeoff weight, would that have made any difference in its takeoff performance? A sophisticated test on Boeing’s 737–200 flight simulator showed that the answer was actually no. Even with a total weight 1.5 tons above the calculated MTOW, the plane should have accelerated normally with minimal effect on climb performance and takeoff distance. All else being equal, the plane should have lifted off at 4,900 feet and should have reached a height of at least 35 feet above the runway level by the time it crossed the road. An overload of at least 6.5 tons above the MTOW would have been required to replicate the observed takeoff performance, and there simply was no evidence that the plane was so grossly overweight.

First Officer Mohan’s lawyers tried to argue otherwise, noting that the day before the flight, Indian Airlines’ Aurangabad office had sent a telex to the company headquarters warning that too many people were booked on flight 491 and that the plane could only carry 80 passengers under the expected conditions. A request was put in for a version of the 737 with more powerful engines, but the better plane never materialized. The argument was made that the weight of 32 additional passengers beyond the 80 mentioned in the telex had not been included in the weight and balance calculations, but Justice Mohta rejected this, noting that the listed total passenger weight was clearly the result of multiplying the industry average weight by 112, not by 80.

Taken together, this evidence showed that the plane was overloaded, but that this did not cause the crash. On the other hand, in a more roundabout way, it seems that it did — not because of how it affected the performance of the airplane, but how it affected the crew. The conversations captured on the cockpit voice recorder showed that the pilots knew they were overweight, and were concerned about their ability to meet the minimum climb gradient after takeoff. Captain Singh ultimately declared that it would not be a problem, and First Officer Mohan appeared to agree, although she seemed nervous. At this point, experts proposed an unsettling theory: had Captain Singh deliberately delayed rotation for liftoff in order to build up more speed and achieve the required minimum climb gradient?

The effects of a slow or late takeoff rotation. This diagram is related to a different incident, but it illustrates the point nicely. Note that the result is the same regardless of whether the rotation is too slow or simply delayed. (AAIB India)

Both pilots acknowledged that this was a technique that would result in a better climb gradient during an overweight takeoff, and simulator exercises confirmed that delaying the takeoff by about 7 seconds would cause the plane to lift off at about 5,800 feet down the runway, as witnesses had observed. Both pilots denied that they had actually used this technique on the accident flight, but Justice Mohta identified considerable evidence to the contrary. First Officer Mohan’s “rotate” call occurred at the point at which the plane was expected to reach rotation speed, or VR, indicating normal acceleration up until that point. However, the vertical acceleration data indicated that the plane did not begin to rise until seven seconds after the “rotate” call, which was highly unusual — normally, the flying pilot rotates immediately after the callout. Justice Mohta believed that Captain Singh deliberately held the plane on the ground for these seven seconds, intending to use up the entire runway to gather speed before lifting off. Singh counter-argued that he did rotate in a timely manner, but that the nose would not come up, indicating some kind of wind shear or malfunction, and First Officer Mohan changed her testimony to back him up. However, there was no evidence that either of these factors was present, and Justice Mohta pointed out that Singh had given testimony three times before without mentioning any difficulty rotating, so he was probably just making excuses.

Furthermore, Justice Mohta argued, the fact that neither pilot made any expression of surprise, confusion, or alarm during those seven seconds indicated that the maneuver was likely planned. In his view, Singh only realized that there was an obstacle about four or five seconds before impact, when he abruptly raised the nose, but he over-rotated, spoiling their lift, and the plane was unable to clear the truck in time. Singh now argued that he had actually started to rotate earlier, but then saw the truck and became panicked and disoriented for several seconds before taking further action, but Justice Mohta ridiculed this notion as well. If he had already been starting to rotate normally when he saw the truck, all Singh had to do was avoid rotating further and the plane would have climbed enough to avoid it. Furthermore, both pilots claimed they saw the truck 4 to 5 seconds before impact, which would mean 6 to 7 seconds after the “rotate” call, exactly when Justice Mohta believed Singh actually initiated the rotation, and not earlier.

A local newspaper revisits the tragedy. (Lokmat Times)

In the end, Justice Mohta ruled that Captain S. N. Singh “consciously but recklessly” held the plane on the ground for an unreasonable length of time, then used an improper rotation technique, directly leading to the failure of the aircraft to clear the obstacle. He also pointed to Singh’s dismal training record, which showed that he had serious deficiencies in terms of knowledge and ability. These shortcomings were apparent in court, where Justice Mohta wrote that Singh was a “slow and unclear witness” who “took time even to answer simple questions,” and that his “ability to comprehend questions,” his ability to “formulate … answers,” and his “level of professional knowledge and confidence” were all very poor. Justice Mohta effectively concluded that Singh was not smart enough to be a captain on the Boeing 737 and that the airline should not have pushed him through upgrade training in light of his difficulties. Even though he was clearly not cut out to be pilot in command, Indian Airlines simply kept administering more LOFT sessions until he could pass a line check, without stopping to consider whether this was a goal worth achieving.

Justice Mohta was rather more sympathetic to the plight of First Officer Manisha Mohan. Although she frequently changed her testimony to back up whatever Captain Singh happened to be saying, Mohta attributed this to a simple unwillingness to testify against a colleague, writing that her loyalty was “worth appreciating” as a human quality but did not serve the public interest. “Public interest ought to have prevailed over other personal considerations. But ideal is not always practical in life,” he wrote.

In actuality, evidence indicates that Mohan was never okay with Singh’s plan, and she probably tried to intervene on multiple occasions, only to be rebuffed. The cockpit authority gradient was steep, not only because Mohan was inexperienced, but also because she was a woman at a time when the overwhelming majority of pilots in India were men. Confronting Captain Singh could have earned her a reputation for being “difficult,” something which is still a problem women in aviation face today, and after the crash, her unwillingness to testify against a captain whom she almost certainly knew was in the wrong highlighted her enduring dependence on the good will of the company hierarchy.

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The front cover of Justice Mohta’s final report. (DGCA India)

All of this having been said, one critical question remained: why was the truck allowed so close to the runway while a plane was taking off? That its presence violated obstacle clearance limits was unquestionable. Regulations around the world, including in India, required the removal or mitigation of any obstacles which protrude into the obstacle clearance plane, defined as a plane with an inclination of 2% starting from the clear way at the end of the runway. Because the road was only a couple dozen meters from the end of the clear way, the 11-foot-tall truck exceeded the height of the obstacle clearance plane by 7.1 feet, and should not have been allowed to pass in front of a departing airplane.

Investigators found that that between 1975 and 1985 the Beed Road was equipped with gates to block traffic during aircraft movements, but sometime around 1985 these were removed and were never replaced. Despite this, the obstacle charts for Aurangabad Airport still stated that traffic regulation was taking place, and no document available to flight crews indicated that there were any obstacles on runway 09. Justice Mohta noted that the removal of the traffic barriers happened at around the time responsibility for the airport was transferred from the DGCA to the newly created National Airports Authority (NAA), and he suggested that the need to regulate traffic on the Beed Road was somehow overlooked during the handover. Furthermore, the DGCA never updated the obstacle charts because the NAA never informed it that traffic regulation had stopped. However, testimony by NAA officials revealed that they actually were well aware that traffic on the road was violating the obstacle clearance limit for at least one year before the accident. In April 1992, an obstacle survey of Aurangabad Airport detected the issue, and the surveyors informed the NAA, which was legally responsible for removing or mitigating the obstacle. Either traffic regulation should have been resumed, or a Notice to Airmen (NOTAM) should have been issued to warn pilots of the danger, but the NAA did neither. Apparently, doing nothing was an internal “policy decision” by misinformed officials who thought that the obstruction was “marginal” and didn’t matter. Certainly the presence of a truck on the Beed Road during a normal takeoff would present no real danger, but conservative obstacle clearance limits are designed to account for abnormal takeoffs as well, and choosing to ignore them removed a critical layer of redundancy. This shortsightedness had deadly consequences. Had the NAA simply done its job and enforced the rules, flight 491 would not have crashed and 56 people would still be alive.

In an attempt to justify this obvious negligence, the Senior Aerodrome Officer for Aurangabad Airport testified that he was aware of the issue, and of his responsibility to inform pilots of any obstacle, but that his duties ended at the airport boundary and the Beed Road was therefore not his concern. This contradicted all legal precedent, as well as common sense, and was rejected by the court. Obstacles near a runway are obviously of concern regardless of whether they are inside or outside the airport boundary.

Justice Mohta also criticized an Indian Airlines pilots’ group for much the same reason, noting that numerous pilots were aware of the obstacle posed by traffic on the Beed Road, including Captain Singh, but no one at the company cared enough to escalate the issue. “The price of an indifferent and callous attitude can be heavy,” the justice wrote, taking aim at all those who stayed silent. Then, bringing his criticism even further, he accused almost every person and agency involved, from the NAA to Indian Airlines to Captain Singh, of engaging in “buck passing” and of lacking any work ethic or sense of duty. His disappointment and moral outrage were channeled into the opening line of his final report, where he simply wrote, “This accident was unbelievable.”

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Justice Mohta introduced his report with an amusing amount of literary flair. (DGCA India)

In the end, Justice Mohta identified numerous deficiencies throughout India’s aviation industry and issued 25 recommendations aimed at addressing them. He noted that Indian Airlines flight attendants were not trained with mock emergency evacuations, which he suggested should be rectified, and he speculated that the saris worn by female flight attendants could interfere with their duties in an emergency. He then called for better enforcement of maximum hand baggage sizes and weights; recommended that briefings of exit row passengers be “strictly enforced;” and proposed that Captain Singh be stripped of his rank and his license suspended for three years. He also recommended that better communication be established between the DGCA, NAA, and the airlines; that more care be taken in promoting pilots who struggle with command training; that the passenger facilities at Aurangabad Airport be updated; and that a better mechanism be developed for implementing previously adopted recommendations. And perhaps most importantly, he proposed that the runway at Aurangabad Airport be lengthened by 3,000 feet, that the Beed Road be moved, and that traffic regulation resume until such time as the works were completed.

Looking at Aurangabad Airport today, it’s apparent that all of these latter recommendations were indeed implemented. The runway at Aurangabad is now 9,000 feet long, and it has extensive clear ways at both ends, which appear to fully comply with international standards. The old Beed Road was shifted significantly and now lies 1,700 feet beyond the runway. It’s also no longer an important thoroughfare: Aurangabad and Beed are now connected by a modern expressway, and the former Beed Road is little more than a quiet farm lane. The airport also now features a modern terminal with two jet bridges and an expanded apron, with further expansions planned in the future to accommodate Aurangabad’s growing population and increasing tourism.

Aurangabad Airport as it appears today. (Bhimachi Punyai)

The development in Aurangabad exemplifies broader trends across India in the last three decades. Although India remains a poor country, so much has changed that the conditions of 1993 seem almost unrecognizable. As untold millions have risen out of extreme poverty, India’s aviation industry has risen with them: gone are the days when an ancient Boeing 737–200 could strike a truck rumbling past the end of the runway, as though no one thought to care about its presence. Those days belong to another era. And while aviation safety in India is imperfect, it’s a lot better than it used to be, with only two fatal accidents in the last 13 years. Those accidents were nearly identical, as I discussed in my article on the 2020 crash of Air India Express flight 1344, which highlights the lingering unresponsiveness of Indian aviation authorities. But the fact that there haven’t been more accidents clearly indicates that progress was made, even as work remains to be done in many areas. Perhaps it helps that Indian Airlines, whose behavior was so maligned in Justice Mohta’s report, was absorbed into Air India in 2007. Even so, the company’s once dismal safety record had by then already turned around, as flight 491 proved to be the airline’s last fatal accident. At long last, it seemed, the scale of the negligence could no longer be ignored.

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Admiral Cloudberg

Kyra Dempsey, analyzer of plane crashes. @Admiral_Cloudberg on Reddit, @KyraCloudy on Twitter and Bluesky. Email inquires -> kyracloudy97@gmail.com.