Probe report on Kozhikode air crash lists non-adherence to SOP by pilot as probable cause
Nineteen passengers were fatally injured and seventy five passengers suffered serious injuries in the accident while ninety passengers suffered minor or no injuries. Both pilots suffered fatal injuries while one cabin crew was seriously injured and three cabin crew received minor injuries.
The final probe report on the Air India Express Kozhikode air crash that took place on August 7, 2020 released by the Aircraft Accident Investigation Bureau (AAIB) states the probable cause of the accident was non-adherence to the standard operating procedure by the pilot flying the aircraft. It also noted that the role of systemic failures as a contributory factor cannot be overlooked in this accident.
“The probable cause of the accident was the non-adherence to SOP by the PF (Pilot Flying), wherein, he continued an unstabilized approach and landed beyond the touchdown zone, half way down the runway, in spite of ‘Go Around’ call by PM (Pilot Monitoring) which warranted a mandatory ‘Go Around’ and the failure of the PM to take over controls and execute a ‘Go Around’,” the report noted.
On August 7, 2020 the Air India Express Boeing-737 plane repatriating Indians stranded in Dubai due to the pandemic overshot the runway in heavy rain, skidded off the table-top runway and broke into two parts after crashing nose-first into the ground. The flight was carrying 190 passengers and crew. It was the deadliest commercial aviation disaster in the country in 10 years and claimed 20 lives. Another Air India Express flight from Dubai overshot Mangalore’s table-top runway in 2010. It slid down a hill and left 158 people dead.
On Thursday, Union civil aviation minister Jyotiraditya Scindia said the final probe report on the Air India Express Kozhikode air crash that took place on August 7, 2020 that has been delayed for over eight months will be made public in a few days.
HT On January 21 reported that the final probe report due for submission in January 2021 will be delayed by two months. A civil aviation ministry order, reviewed by HT, had granted a two-month extension to the Aircraft Accident Investigation Bureau (AAIB), the regulatory body in charge of the investigation, to submit the report. Following an extension till March the final probe report was finally released on September 11.
The report noted that the investigation team is of the opinion that the role of systemic failures as a contributory factor cannot be overlooked in this accident.
“A large number of similar accidents/incidents that have continued to take place, more so in AIXL (Air India Express Ltd), reinforce existing systemic failures within the aviation sector. These usually occur due to prevailing safety culture that give rise to errors, mistakes and violation of routine tasks performed by people operating within the system,” it said.
The report noted the actions and decisions of the PIC (Pilot in Command) were steered by a “misplaced motivation to land back at Kozhikode to operate next day morning flight AXB 1373.”
It also said the unavailability of sufficient number of Captains at Kozhikode was the result of faulty AIXL HR policy which does not take into account operational requirement while assigning permanent base to its Captains. There was only 01 Captain against 26 First Officers on the posted strength at Kozhikode.
“The PIC had vast experience of landing at Kozhikode under similar weather conditions. This experience might have led to over confidence leading to complacency and a state of reduced conscious attention that would have seriously affected his actions, decision making as well as CRM (CREW RESOURCE MANAGEMENT),” it noted.
The report also noted the possibility of visual illusions causing errors in distance and depth perception (like black hole approach and up-sloping runway) cannot be ruled out due to degraded visual cues of orientation due to low visibility and sub- optimal performance of the PIC’s windshield wiper in rain.
“The AIXL pilot training program lacked effectiveness and did not impart the requisite skills for performance enhancement. One of the drawbacks in training was inadequate maintenance and lack of periodic system upgrades of the simulator. Frequently recurring major snags resulted in negative training. Further, pilots were often not checked for all the mandatory flying exercises during simulator check sessions by the Examiners,” it said.
Nineteen passengers were fatally injured and seventy five passengers suffered serious injuries in the accident while ninety passengers suffered minor or no injuries. Both pilots suffered fatal injuries while one cabin crew was seriously injured and three cabin crew received minor injuries.
The draft report was shared with the Accredited Representative appointed by the National Transport Safety Board of the United States of America. Relevant comments from them have been incorporated in the report, it noted.
There was fuel leak from both the wing tanks; however, there was no post-crash fire. The aircraft was destroyed and its fuselage broke into three sections. Both engines were completely separated from the wings.
The AAIB in August last year appointed a team of five investigators to lead the probe and submit a report within five months.
AAIB director-general Aurobindo Handa appointed Captain SS Chahar, a former Directorate General of Civil Aviation (DGCA)-designated examiner for pilots of B737NG aircraft, as the investigator-in-charge tasked with completing its inquiry and submitting the report.
He was assisted by Operations Expert Ved Prakash, Senior Aircraft Maintenance Engineer-B737 Mukul Bhardwaj, Group Captain Y S Dahiya, Aviation Medicine Expert, and Jasbir Singh Larhga, Deputy Director AAIB.
The bureau’s role is to conduct an independent aircraft accident investigation, obtain a preliminary report to assist in setting up a committee of inquiry in accordance with International Civil Aviation Organisation rules.