MUSCAT: The probable cause of the Air India plane crash at Kozhikode airport on August 7, 2020, which killed 21 people including both the pilots, was non-adherence to the standard operating procedure by the pilot flying the aircraft, according to the Aircraft Accident Investigation Bureau (AAIB). The final probe report released the other day also stated that the role of systemic failures as a contributory factor cannot be overlooked in this mishap.
“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, half way 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’,” said the report.
The report also said a large number of similar accidents that have continued to take place, more so in AIXL, reinforce existing systemic failures within the aviation sector. “These usually occur due to prevailing safety culture that give rise to errors, mistakes and violation of routine tasks performed by people operating within the system,” it added.
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The first approach carried out into Kozhikode was on runway 28. It was flown with autopilot and auto throttle engaged and met the stabilized ILS approach criteria till the prescribed Decision Altitude (DA). The cockpit conversation recorded on CVR regarding windshield wiper, immediately after establishing on ILS localiser, indicates that the PF was uncertain of its serviceability. However, the first approach failed.
The report pointed out that lack of planning for second approach following the failure in the first approach also could be one reason for the mishap, and listed some critical factors that were not considered or briefed by the cockpit crew for a change in runway. “There was a change of runway in use from runway 28 to runway 10 to accommodate the departure of another aircraft namely AIC 425, that was departing at the time. AXB 1344 that had carried out a missed approach on runway 28 was then asked by ATC to confirm if runway 10 was acceptable for landing, PF agreed to the change after repeated enquires regarding the latest weather conditions for runway 10.
While, runway 10 was a convenient option for the ATC (as another departing aircraft was using it), the change in runway for AXB 1344 should have been thoughtfully considered by PF, in compliance with the SOP before agreeing for the same,” it pointed out.
There are many contributory factors that caused the mishap, according to the AAIB, which also blamed the HR practice of the Air India listed a few safety recommendations.
The actions and decisions of the pilot in command (PIC) were steered by a misplaced motivation to land back at Kozhikode to operate next day morning flight AXB 1373, it said pointing out the flaws on the part of the authorities. The unavailability of sufficient number of Captains at Kozhikode was the result of faulty AIXL HR policy which does not take into account operational requirement while assigning permanent base to its Captains. There was only one captain against 26 First Officers on the posted strength at Kozhikode.
The PIC had vast experience of landing at Kozhikode under similar weather conditions. This experience might have led to over confidence leading to complacency and a state of reduced conscious attention that would have seriously affected his actions, decision making as well as CRM (Crew Resource Management), it observed, adding that the CRM training of AIXL is weak.
Owing to this, “the senior captains of the company do not encourage a working climate in the cockpit where a junior pilot is confident enough to raise concerns, question decisions and also offer solutions. Also, the junior pilots do not possess assertiveness techniques to provide them the confidence to question authority of the PIC and play a full part in the team task,” it added.
Moreover, the PIC was a case of diabetes and was prescribed a single anti-diabetic drug but was medically fit to undertake the flight as PIC. However, the PIC was taking a combination of unprescribed drugs for his diabetes.
There were a total of 190people, comprising 184 passengers and six crew members, on board Flight 1344, the Air India Express 737-800 aircraft, that took off from Dubai and crashed upon landing in Kozhikode around 7.41 pm on August 7, 2020. Among those killed were 19 passengers and the two pilots. Many people suffered serious injuries and there was allegation right from the beginning that the pilot’s mistake caused the mishap