New Delhi: The co-pilot of Air India Express Dubai-Kozhikode Vande Bharat flight had asked the pilot flying (PF) to go around and not land there on August 7, 2020. Despite this, PF — who had to operate another flight the next day due to AI Express’ captain shortage in Kozhikode — landed the aircraft with 189 passengers and six crew members. The Boeing 737 (VT-AXH) did not stop in time on the tabletop runway and fell to a depth of 110 feet. This crash-landing led to the death of 19 passengers and both the pilots.
“Faulty HR” policies of AI Express have been found to contribute to this accident as the captain who operated this flight was asked to do so at the last minute and was to operate another flight from Kozhikode the next day, putting “additional pressure on the PIC (pilot-in-command) to land back at Kozhikode in time on August 7 evening,” says the final investigation report into this accident made public by the Aircraft Accident Investigation Bureau (AAIB) on Saturday night.
The windshield wiper on the PIC side was not working properly. “The aircraft carried out a ‘missed approach’ while attempting to land (in first attempt) (due to) ‘weather, heavy rain’. However, landing with unserviceable wiper in rain (second ill-fated attempt) may also have been a contributory factor for not being able to sight the runway.” Both approaches and final landing at Kozhikode were made in active rain without a fully serviceable wiper on the PIC side.
“The probable cause of the accident was the non adherence to SOP by the pilot flying (PF), 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 a mandatory ‘Go Around’ and the failure of the PM to take over controls and execute a ‘go around’,” says the report says.
“The first officer had correctly identified that the approach for runway 10 was an ‘unstabilised approach’. After making two unassertive attempts to attract the PIC’s attention towards the unstabilised approach, using non-standard vocabulary, he asked the PIC to ‘go around’ just before touchdown. In spite of knowing full well that the approach was unstabilized and the PIC was not responding, the FO did not take over the controls as per the company SOP and initiate a ‘Go Around’,” it says.
Several other issues also led to the mishap which have been listed as “contributory factors.” The pilot-in-command of this flight was actually on standby duty to operate Kozhikode-Doha-Kozhikode flight on August 8, 2021, but was asked to operate the August 7 Kozhikode-Dubai-Kozhikode flight “due to non-availability of captains at Kozhikode.”
“This last minute assignment of August 8 morning flight to Doha put additional pressure on the PIC to land back at Kozhikode in time on August 7 evening,” it says.
“The actions and decisions of the PIC (pilot-in-command) were steered by a misplaced motivation to land back at Kozhikode to operate next day morning flight. The unavailability of sufficient number of captains at Kozhikode was the result of faulty Air India Express 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,” it says.
The report says had the aircraft diverted, “PIC would have exceeded his FDTL (flying duty limitations) and would not have been available for the following day morning flight. This would have resulted in shortage of PIC at Kozhikode for operating the three scheduled flights ex-Kozhikode the next day.”
“The PIC was taking multiple un-prescribed anti-diabetic drugs that could have probably caused subtle cognitive deficits due to mild hypoglycaemia which probably contributed to errors in complex decision making as well as susceptibility to perceptual errors,” it adds.
“Poor CRM (crew resource management) was a major contributory factor in this crash. As a consequence of 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 castigates AI Express (AIXL) safety culture. “AIXL policies of upper level management have led to a lack of supervision in training, operations and safety practices, resulting in deficiencies at various levels causing repeated human error accidents in AIXL.”
The Air-India Express B737-800 aircraft VT-AXH was operating a quick return flight on Kozhikode-Dubai-Kozhikode under Vande Bharat Mission on August 7, 2020, to repatriate passengers who were stranded there due to closure of airspace.
11/09/21 Saurabh Sinha/Times of India
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