New Delhi: Pilot’s “non-compliance” to standard operating procedure is the probable cause of Air India Express plane crash at Kozhikode airport last year, but the role of systemic failures as a contributing factor in the crash cannot be ignored. According to the investigation report of AAIB
In the final report released on Saturday, the Aircraft Accident Investigation Bureau (AAIB) made 43 safety recommendations, including the installation of an approach radar at the airport and a DGCA study that specifically looked at the use of non-prescribed drugs among aircrew. To establish the breadth of . Diabetes.
It also contains 57 findings about the accident.
From systemic failures to poor crew resource management on Air India Express, the potential for visual confusion due to low visibility and sub-optimal performance of the PIC (pilot-in-command) windshield wipers, the AAIB cited several other reasons. who have contributed to the accident.
21 people, including two pilots, were killed and several others were injured when a Boeing 737-800 plane crashed.
While trying to land at the airport amid rain, the plane overshot the runway and later broke into pieces.
When the accident happened on August 7, 2020, 190 people were on board the ship.
Deepak V Sathe and Akhilesh Kumar were the two pilots who died in the accident at the Kerala airport.
The report, which is over 250 pages long, said, “The probable cause of the accident was non-compliance of SOP (Standard Operating Procedure) by the PF (Pilot Flying)”.
The PF continued a shaky approach and landed ahead of the touchdown zone, “halfway down the runway, despite a ‘go around’ call by the PM, which called for a mandatory ‘go around’ and the failure of the PM to control and execute remained. a ‘go around'”, it noted.
According to the report, the investigation team is of the opinion that the role of systemic failures as a contributing factor in this accident cannot be ignored.
“The large number of similar accidents/incidents that continue to occur, particularly in AIXL, reinforce existing systemic failures within the aviation sector.”
“These are usually due to the prevailing security culture that lead to errors, mistakes and violations of routine tasks committed by the people working within the system. Therefore, the contributing factors below include immediate causes and deep or systematic Reasons include both,” it added.
Among other recommendations, the AAIB has suggested strengthening its capacity in terms of filling vacancies with full-time investigators, having a permanent aviation medical specialist and setting up a state-of-the-art laboratory for flight recorders.
The AAIB, headed by Aurobindo Handa, has accepted the investigation report.
Civil Aviation Minister Jyotiraditya Scindia said on Thursday that the report would be made public in the next few days.
“Whatever action is advocated on the basis of that report, those steps will be taken and they will have to be implemented.”
“Within the ministry, we will also put together a group of people who will be entrusted with the responsibility of ensuring that the steps recommended in the report are implemented at the airport,” the minister said.
Last month, Minister of State for Civil Aviation VK Singh told the Lok Sabha that final compensation has been offered to all the next of kin of the deceased passengers, but “no relative has sent their approval till date”.
“Final compensation has been offered to all the 165 injured passengers, out of which 73 passengers have accepted the offer and a total of Rs 60.35 crore has been paid as final settlement so far,” he said.
The AAIB has made 43 safety recommendations, including the installation of an approach radar at airports and a DGCA study to establish the prevalence of non-prescribed drug use among aircrew, particularly for diabetes.
The report released by the Aircraft Accident Investigation Bureau (AAIB) on Saturday drew 57 findings about the crash of the Boeing plane, in which 21 people, including two pilots, were killed and several others were injured.
The plane coming from Dubai had 190 people on board and crashed into pieces after hitting the runway amid light rain.
From systemic failures to poor crew resource management of Air India Express due to the possibility of visual confusion due to low visibility and sub-performance of PIC (Pilot in Command) windshield wipers, the AAIB has cited various possible causes.
The report has made comprehensive safety recommendations to Air India Express, Airports Authority of India (AAI), Directorate General of Civil Aviation (DGCA), AAIB and India Meteorological Department (IMD).
“The investigation team is of the opinion that the role of systemic failures as a contributing factor in this accident cannot be ignored,” the report said.
It was noted that the large number of similar accidents/incidents which continue to happen, especially in AIXL (Air India Express Limited), reinforce the existing systemic failures within the aviation sector.
The report states, “These are usually due to the prevailing security culture that gives rise to errors, inaccuracies and breaches in the routine tasks performed by the people working within the system. Therefore, the immediate cause and deeper into the contributing factors.” or systematic reasons include both.” .
Noting that “the actions and decisions of the PIC (Pilot in Command) were driven by a wrongful motivation” to operate the morning flight AXB 1373 the next day to land back at Kozhikode, the AAIB stated that the Kozhikode had sufficient This was the result of non-availability of captains in numbers. AXIL’s faulty HR policy which does not take into account the operational requirement while providing permanent base to its captains.
“There were only 01 captain against 26 first officers on the strength deployed at Kozhikode,” it reported.
Stating that the PIC had extensive experience of landing in Kozhikode in similar weather conditions, the AAIB said that the experience may have led to overconfidence leading to complacency and a state of less conscious attention that affected his actions, decisions and Picking up and severely impacting CRM. (crew resource management).
“PIC was taking a number of non-prescribed anti-diabetic drugs that may have caused subtle cognitive deficits due to mild hypoglycaemia, which may have contributed to the susceptibility to complex decision-making errors as well as perceptual errors.”
The AAIB cited poor CRM as a major contributing factor to the crash, adding that as a result of a lack of articulation and a rapid authorization shield in the cockpit, the first officer did not control despite being well aware. took. from a serious condition.
“AeXL’s lack of effective CRM training resulted in poor CRM and steep cockpit gradient”.
The AAIB has made various recommendations to the airline, citing “the failure of the AIXL pilot training program to provide the skills needed to enhance performance due to its lack of effectiveness”.
With regard to human resource management, the report states that AIXL should take into account the volume of flights coming from the respective bases and accordingly assign them as ‘home bases’ exclusively for captains.
It also noted that the airline does not have an independent medical department and recommended the appointment of aviation/aerospace medicine specialists.
Noting that the DFDR is the most effective tool for identifying data monitoring excesses and providing appropriate corrective training to prevent runway accidents such as the accident of AXB 1344, the AAIB stated that the action taken report submitted by AIXL on the above findings should be considered. Was accepted year after year by DGCA. without ascertaining its implementation or without giving due importance to its adverse effects.
DFDR stands for Digital Flight Data Recorder (DFDR).
Among the recommendations of the AAI, the report states that the initial training of ATCO and the annual refresher should emphasize the precautions to be taken while deciding to change the runway in adverse weather conditions.
“The ARFF crew in Kozhikode were not familiar with the type of aircraft, resulting in a poorly coordinated rescue operation and delay in evacuation of the pilots from the cockpit,” it said.
AAIB has recommended installation of an approach radar at Kozhikode airport as it has a hilly terrain and experience of adverse weather conditions as well as wide perimeter road leading to the airport to facilitate quick movement of emergency vehicles.
“In November 2019, the DGCA during its monitoring made certain observations regarding deficiencies in the conduct of mock drills. The observed deficiencies were still present till the date of the accident. In order to achieve the desired training results from the mock drills, this recommendation was made. It is stated that all the deficiencies noticed in the report should be followed up on time.
As per the report, the DGCA should issue instructions to all scheduled and non-scheduled operators to educate their aircrew about the aeromedical consequences of self-medication.
DGCA may conduct a study to establish the prevalence of use of non-prescribed drugs among aircrew especially for diabetes.
In addition, the AAIB noted that the DGCA may advise its officers to participate in discussions by the investigative team as and when required.
Among other things, the report states that the DGCA may study the feasibility and efficacy of a ‘child restraint system’ for the safety of infants and children on board an aircraft.
It is recommended that DGCA may ensure periodic monitoring of flights to critical and table top runways including “Red Eye” flights” and increased monitoring should be done during monsoons.
The report states that the availability of runway centerline illumination will certainly enhance the spatial orientation of the PIC.
Among other aspects, the AAIB noted that the Tower Weather Officer (TMO) was not available in the ATC tower at the time of the accident, adding that the airspace was subject to two concurrent weather warnings and that TMOs were required to be present to update . Notify you of rapidly changing weather changes to enhance air safety.
“Absence of detailed proactive policy and clear cut guidelines by the regulator on monitoring of long landings at the time of accident was another contributing factor in such runway overrun accidents.
As suggested to strengthen your capability in terms of filling up vacancies with full time investigators, having a permanent Aviation Medical Specialist and setting up a state-of-the-art laboratory for flight recorders.
These are part of the recommendations made by the AAIB in its final investigation report into the fatal crash of an Air India Express Boeing aircraft at the Kozhikode airport in August last year, in which 21 people were killed.
The report was made public on Saturday.
“It is recommended that the AAIB should establish a state-of-the-art flight recorder (DFDR and CVR) lab with the necessary hardware and software to perform the readout and analysis (including spectrum analysis). Mandatory to provide aircraft manufacturers with the necessary technical literature, hardware and software for all types of aircraft operating in India,” the report, which is over 250 pages long, said.
DFDR is Digital Flight Data Recorder and CVR is Cockpit Voice Recorder.
“It is recommended that the AAIB take necessary action to ensure that the existing positions of investigators are filled with permanent full-time investigators and that additional positions be created to meet the growth of aviation in India,” the report said. “
According to the report, it is recommended that the AAIB may have a permanent aerospace/aviation medicine specialist to assist the ‘go team’ as a human factors specialist, as well as participate in the investigation of the plane crash.
An official said the AAIB works with a small number of investigators and needs to be strengthened.