Three years after turbulence during a SpiceJet flight resulted in the death of a passenger and left around 20 others injured, the Aircraft Accident Investigation Bureau (AAIB) has put the onus on ‘poor crew resource management and decision-making’ along with passengers not fastening seat belts as among the probable causes for the mishap.
Following its probe, AAIB concluded the accident was caused by poor Crew Resource Management (CRM) and decision making on part of the cabin crew. The AAIB said the primary goal of CRM is to have an enhanced situational awareness, decision-making, adaptability and communication. The Bureau also found out that the cabin crew had not been briefed about bad weather during the pre-departure briefing.
“The accident was caused by poor CRM (crew resource management) and decision making on part of the crew to penetrate bad weather, and not maintaining specified separation from turbulence prone weather,” the AAIB report released on May 5 said.
The final report into the accident also recommended that aviation regulator Directorate General of Civil Aviation (DGCA) should ensure that its officials follow the procedure laid out in the Airworthiness Procedures Manual (APM) for obtaining clearance from AAIB during the de-registration of an aircraft.
The recommendation has been made since the DGCA de-registered the Boeing 737-800 aircraft involved in the accident and returned to the lessor without AAIB approval. As per norms, DGCA is required to check for clearance or closing report from AAIB, if the aircraft has met with an accident before it is de-registered.
The AAIB also concluded that the announcement from the flight deck was made for all crew and passengers to be seated, but the cabin crew did not get sufficient time to ascertain if passengers beyond eight rows had their seat belts fastened.
It recommended that DGCA should ensure that the procedure for recurring defect monitoring and control is followed by the airline in letter and spirit.
"As it was the month of Ramadan, many fasting passengers were on board. They had not eaten their meals and were waiting for sunset time to start eating, hence the tray tables were not closed. Cabin crew would have required sufficient time to secure the cabin and ensure that all passengers have their seat belts fastened and tray tables are closed," AAIB said. The fateful incident resulted in the death of Akbar Ansari, one of the passengers on the flight.
On May 1, 2022 a Boeing 737-800 aircraft of low-cost private carrier SpiceJet, on a scheduled flight (SG-945) operating from Mumbai to Durgapur, with 195 passengers on board (189 passengers and six crew), experienced severe turbulence at around 16,000 feet while approaching the destination airport.
Due to severe turbulence, nearly 17 passengers suffered head, shoulder, spinal, forehead and facial injuries that were serious enough to warrant hospitalisation. The aircraft too experienced damage in the cabin. Around 14 passengers and three cabin crew members were injured during the flight due to severe turbulence, DGCA officials had informed.
Visuals showed oxygen mask compartments open, sections of the cabin ceiling having come apart exposing ducts, damage to some seat armrests and the cabin being in a state of disarray, with items from the galley as well as passenger belongings strewn around.
The flight deck took manual control of the aircraft from autopilot mode and the aircraft made a safe landing about 20 minutes later.
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