Non-adherence to the standard operating procedure by the pilot-in-command and “systemic failures” probably led to the crash of the Air India Express’s aircraft at Kozhikode on August 7, 2020, that left 21 people, including two pilots, dead, the Aircraft Accident Investigation Bureau has said in a report.
The Boeing 737-800 aircraft that flew from Dubai with 190 people, including six crew, onboard, overshot the table-top runway at Kozhikode and broke into pieces as it hit the perimeter wall in the pouring rain.
Not just the pilot, the report that was released on September 11 pointed to failures at several levels, calling for better training and practices at Air India Express, the Airports Authority of India and the Directorate General of Civil Aviation among others.
“The investigation team is of the opinion that the role of systemic failures as a contributory factor cannot be overlooked in this accident,” said the report that was submitted after a year-long investigation.
“A large number of similar accidents/incidents that have continued to take place, more so in Air India Express, reinforce existing systemic failures within the aviation sector. These usually occur due to prevailing safety culture that give(s) rise to errors, mistakes and violation of routine tasks performed by people operating within the system,” it added.
The Aircraft Accident Investigation Bureau is a division of the civil aviation ministry.
Air India Express was operating a quick return flight on the Kozhikode-Dubai-Kozhikode sector under the “Vande Bharat Mission” to repatriate passengers stranded due to the closure of the airspace and flight operations because of the coronavirus outbreak.
Pilot error
The pilot-in-command (PIC) continued an unstable approach and landed beyond the touchdown zone despite a “go around” call by pilot monitoring (PM). The "go around" was a mandatory call and the pilot should have turned around and not gone ahead with the landing, the report said.
A “go around” is when pilots decide to abort a landing before or after touching down if they are noy sure of a safe landing. Stabilised approach is one of the many criteria used to make a “go around” decision. The air traffic control is informed about the decision to abort landing before making another attempt.
The pilot had vast experience of landing at Kozhikode under similar weather conditions and the experience might have led to overconfidence, the report said.
The crew often operated in monsoon conditions and was aware of the adverse weather standard operating procedure (SOP). The pilot decided not to divert after the “missed approach” on runway 28 even though there were alternate airfields available and enough fuel. Subsequently, without any risk assessment, the pilot tried landing on runway 10.
“During the approach briefing before the top of descent into Kozhikode for runway 28, the PIC did not brief or discuss the Landing Distance Available/ Actual Landing Distance (LDA/ALD) and made the Landing Flaps and Auto-brake selection setting without considering this important aspect which was in violation of the SOPs,” the report said.
Even while approaching runway 10, the pilot did not carry out adequate briefing for landing with tailwinds in the rain and poor visibility. The mandatory calculation of landing distances was omitted in violation of SOP, the report said.
The landing was made when there were strong tailwinds on a wet tabletop runway in rain.
Mismanagement by Air India Express
Blaming the Air India Express Limited’s (AIXL) HR policy, the report said the pilot was in a hurry to return to Kozhikode as he had to operate a flight to Doha the next morning. The pilot’s actions and decisions were “steered by a misplaced motivation” to land back in Kozhikode to operate a flight to Doha the next morning.
“The unavailability of a sufficient number of captains at Kozhikode was the result of faulty AIXL HR policy which does not take into account operational requirements while assigning a permanent base to its captains. There was only one captain against 26 first officers on the posted strength at Kozhikode,” the report said.
The pilot was on standby duty the next day but due to the non-availability of captains at Kozhikode, he was assigned the Doha flight for August 8, the AAIB report said.
“This last-minute assignment of 8th morning flight to Doha put additional pressure on the PIC to land back at Kozhikode in time on 7th evening,” the report added.
Had the flight been diverted, the pilot would have exceeded his Flight Duty Time Limitation and would not have been available for the morning flight.
The report also called out the airline’s crew resource management (CRM) policies. The flight officer (FO) had correctly identified that the approach for runway 10 was an “unstabilized approach”. After making two attempts to attract the pilot’s attention using non-standard vocabulary, the FO asked the PIC to “go around” just before the touchdown. “In spite of knowing full well that the approach was unstabilised and the PIC was not responding, the FO did not take over the controls as per the company SOP and initiate a ‘go around’, ” the report added.
Due to low visibility and “suboptimal performance” of windshield wiper in the rain, the pilot probably experienced visual illusions causing errors in distance and depth perception.
The Air India Express pilot training programme 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,” the report said.
The Cockpit Voice Recorder (CVR) recording revealed that the pilot carried out an unusually detailed briefing of an experienced flight officer regarding windshield wipers. The transcript points out that the pilot was perhaps apprehensive about the reliability of the windshield wiper, the report said.
During the approach to runway 28, the windshield wiper on the pilot’s side worked for 27 seconds and then stopped. Further, on the approach to runway 10, the wiper worked but probably at slower than the selected speed.
“Both approaches and final landing at Kozhikode were made in active rain without a fully serviceable wiper on the PIC’s side,” the report said.
“Poor CRM was a major contributory factor in this crash. As a consequence of the lack of assertiveness and the steep authority gradient in the cockpit, the First Officer did not take over the controls in spite of being well aware of the grave situation. The lack of effective CRM training by AIXL resulted in poor CRM and steep cockpit gradient.”
Though poor crew resource management was a major contributor to another serious accident, poor training was a factor in this crash as well.
Faulty equipment at the airport
Blaming the airport, the report said that the accuracy of surface winds for runway 10 was affected by the installation of a wind sensor in contravention of the Civil Aviation Requirements. The wind speed and visibility were misread.
“This was aggravated by frequent breakdowns due to poor maintenance. The air traffic controller (ATC) reported visibility of 2000 m in light rain and winds of 250/08 Knotts, while transmitting landing clearance for the Air India Express flight. Prevailing surface winds were much stronger than the winds reported by the ATC,” the report said.
The Tower Met Officer (TMO) was not available in the ATC tower at the time of the accident even though there were two concurrent weather warnings. The TMO must be present to update and inform about the fast-changing weather variations to enhance air safety, the report said.
No one in control
The post-crash rescue efforts lacked effective command and control. “There was no ‘command post’ established at the crash site. This was also an observation during the previous ‘Mock Drill’ held in November 2019,”
The Airport Rescue and Fire Fighting Services (ARFF) crew at Kozhikode were not familiar with the aircraft, which resulted in a delay in evacuating the pilots.
Despite the DGCA audit’s observation of 2018 and frequent emails throughout 2019 by the head of airport fire services requesting training on actual aircraft, no action was taken by any concerned agency in this regard, the report said.
The DGCA Safety Audit Report of April 2019 assessing Aircraft Familiarization of ARFF crew at Kozhikode as “satisfactory is factually incorrect and misleading”, the report said.
“Photography and Video recording of rescue operations was not carried out. Responsibilities of the Safety Investigation Coordinator are not included in the Airport Emergency Plan (AEP) or any other policy document of AAI,” the report said.
The runway end safety area was not maintained properly. “Vegetation growth was observed in the soft ground area and it was not being ploughed regularly. Also, the concrete base of the frangible equipment installed in the soft ground area was not found buried under the soft ground, but instead jutted out of the surrounding area,” the report said.
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