The plane crash at the Kozhikode airport in August last year, in which 21 people died, occurred due to pilot error but systemic error cannot be ruled out, stated the probe report released by the Aircraft Accident Investigation Bureau (AAIB) on Saturday.
Air India Express's B737-800 aircraft crashed at the Kozhikode (Calicut) International airport in Kerala on August 7, 2020. The plane coming from Dubai had overshot the runway at Kozhikode airport and later broke into pieces. There were 186 people onboard the ill-fated aircraft; 21 people, including pilot and co-pilot, were killed in the mishap. The remaining 165 people onboard the flight, including passengers and cabin crew, were rescued. Several had sustained injuries.
WHAT THE CRASH REPORT SAYS
- PILOT ERROR
The probable cause of the accident was non-adherence to the standard operating procedure by the pilot flying the aircraft, the 257-page report said.
“The probable cause of the accident was the non-adherence to SOP by PF (pilot flying), wherein, he continued an unstabilised approach and landed beyond the touchdown zone, half way down the runway, in spite of ‘Go Around' call by PM (pilot monitoring) which warranted ‘Go Around' and the failure of the PM to take over controls and execute a ‘Go Around',” the crash report stated.
- SYSTEMIC FAILURE
All aircraft systems operated normally. However, the investigative team is of the opinion that the role of systemic failures as a contributory factor cannot be overlooked in the accident.
- NO BRIEFING ON LANDING DISTANCE
Pilot in command (Captain DV Sathe) did not brief or discuss the LDA/ALD (landing distance available) and made the landing flaps and auto-brake selection setting without considering this important aspect in violation of the SOP.
Before the approach for runway 10 as well, the PIC did not carry out adequate briefing for landing with tailwinds, in rain and poor visibility. The mandatory calculation of landing distances was omitted.
- FAULTY WINDSHIELD WIPER
The windshield wiper on the PIC side stopped working during the first approach. The CVR recording revealed that the PIC carried out an unusually detailed briefing to an experienced FO (flight officer) regarding a routine action for selection of windshield wipers.
The CVR transcript points to an apprehension of the PIC regarding the reliability of the operation of the windshield wiper.
This undue concern and detailed briefing to FO indicates that the crew probably had prior knowledge of the unreliable windshield wiper.
- NO DIVERSIONS
Alternate airfields most suited for ‘diversions' in case of a second missed approach under the prevailing weather conditions and unserviceable windshield wiper were not covered during the briefing.
This was a violation of the SOP, and the error magnified on this approach as the landing was made in strong tail wind condition on a wet tabletop runway in active rain.
- APPROACH WITH FAULTY WIPER
During the approach on runway 28 into Kozhikode, the windshield wiper on the PIC side worked for 27 sec and then stopped.
Also, on the approach for runway 10, PIC wiper worked but probably at a slower speed than the selected speed.
Both approaches and final landing at Kozhikode were made in active rain without a fully serviceable wiper on the PIC side.
- ADVERSE WEATHER CONDITIONS
AXB 1344 carried out a ‘missed approach' at ILS minimums (DA) while attempting to land on runway 28. The reason for the missed approach transmitted to ATC by PM after consulting PF was “weather, heavy rain”.
However, landing with an unserviceable wiper in rain may also have been a contributory factor to not being able to see the runway.
The crew were experienced and had often operated in Indian monsoon conditions. They were aware of the adverse weather SOP of AIXL.
- NO RISK ASSESSMENT
The PIC took a decision not to divert after the ‘missed approach' on runway 28 even though there were alternate airfields available in close proximity and there was enough fuel on board.
Subsequently, without any risk assessment, the PIC continued for a second approach into Kozhikode.
The FO did not give any input regarding this gross SOP violation to the PIC, indicating a steep cockpit authority gradient resulting in poor CRM.
- SAFETY COMPROMISED
The Pilot Monitoring did not make the mandatory announcement for the cabin crew to be seated on the first approach for landing on runway 28 at Kozhikode. This is a very serious omission and compromises cabin crew safety.
