A Ministry of Civil Aviation-appointed probe panel has said the failure of the pilot in command to adhere to standard operating procedure and “systemic failure” were the probable reasons for the crash of the Air India Express B737-800 aircraft at Kozhikode on August 07, 2020.
A total of 21 people including the pilot and the co-pilot died in the crash. There were a total of 190 people aboard the aircraft including six crew members. The Kozhikode-bound flight from Dubai had been pressed into service to repatriate passengers who were stranded overseas due to the closure of airspace and flight operations owing to the Covid-19 pandemic.
The aircraft carried out a missed approach on the first attempt while coming into land on one of the runways. During the second approach, the aircraft overshot the tabletop runway, broke through a fence and plunged to a depth of approximately 110 ft. The aircraft was destroyed, and its fuselage broke into three sections. Both engines were completely separated from the wings.
“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, halfway 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’,” Aircraft Accident Investigation Bureau said in its report which this newspaper has seen. The six-member probe was led by Capt. Surender Singh Chahar.
‘Systemic failure’
The investigation team pointed out 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 gives rise to errors, mistakes and violation of routine tasks performed by people operating within the system.”
The probe panel also said that poor CRM (crew resource management) 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 report said. It also said the pilot training programme lacked effectiveness and did not impart the requisite skills for performance enhancement. One of the drawbacks of 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.
Experienced pilot
The probe report said the pilot in command had vast experience of landing at Kozhikode under similar weather conditions. “This experience might have led to overconfidence leading to complacency and a state of reduced conscious attention that would have seriously affected his actions, decision making as well as CRM. This indicates a complete loss of situational awareness of the PF.”
Narrating the sequence of events that could have played during the course of the touchdown, the probe report said the pilot continued with the landing while the PM (pilot monitoring) recognised the unstable approach and gave another distinct call of “Go around” at around 10ft RA (radio altitude), just before touchdown.
The company SOP also warranted a mandatory go-around. This call was also ignored by the pilot, and he continued with the landing, touching down immediately thereafter. The response of both the pilot and PM was not in accordance with the SOP, thereby indicating further loss of situational awareness. The accident could have been averted if there was good CRM or if any of the flight crew had reacted as per the SOP, or if the PF had initiated a mandatory ‘go around’ after PM’s call for the same or if the PM took over control and initiating a ‘go around’ himself (in the absence of any response from the pilot).
Possibly, the degraded ambient/peripheral vision (because of moderate rain and slow wiper operation) failed to provide the pilot with the required cues to know exactly where he had touched down. Even the ‘simple touchdown zone lights’ did not attract his attention on the late touchdown. During the landing roll, the pilot seems to have realised his judgement error and therefore made a fleeting decision to stow the TRs (thrust reverser) (possibly to go around) and then redeployed them quickly and applied full brakes again indicating loss of situational awareness. At no stage during the landing roll did the pilot contribute gainfully to control the situation. There was no communication between the flight crew after the touchdown reflecting poor CRM.
The report said the pilot was a highly experienced pilot who had nearly 11,000 hours of total flying experience and had operated 36 flights in and out of Kozhikode during the last year prior to the accident.
During the course of the investigation, the evidence provided by the Airport Authority of India concerned agencies in the form of statements or answers to the questions by the Investigation Team were contradictory to their own previous statements or other evidence collected by the team, the probe report said.