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Pilot error probable cause of Air India plane crash in Kozhikode but faulty CRM also to be blamed, says AAIB

Pilot error probable cause of Air India plane crash in Kozhikode but faulty CRM also to be blamed, says AAIB

New Delhi, Sep 11 (UNI) Pilot error was the main 'probable' cause of Air India Express plane crash in Kerala's Kozhikode in August 2020 but faulty crew resource management (CRM) of the airline, lapses on part of aviation regulator and adverse weather also contributed to the accident.
Aircraft Accident Investigation Bureau (AAIB) in its final investigation report said that the probable cause of the accident was the non-adherence to standard operating procedure (SOP) by pilot flying or PF.
The pilot flying 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), the AAIB report has said.
A Go Around refers to pilot deciding it to be safer to climb back up in the air rather than continuing the landing.
The investigation report noted that the role of systemic failures as a contributory factor cannot be overlooked in the plane accident.
"A large number of similar accidents/incidents that have continued to take place, more so in AIXL (Air India Express), 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," said the report.
The investigation was carried out by the members of the AAIB team even as Covid posed serious health risks to team members.
Discussing some of the key reasons behind the fateful accident involving Boeing 737-800 aircraft, one of the members of the AAIB investigation team told UNI that government should implement the recommendations given in the report to strengthen aviation safety.
"Poor CRM 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 lack of effective CRM training of AIXL resulted in poor CRM and steep cockpit gradient," the 283-page report said.
The report pointed out that Tower Met Officer (TMO) was not available in the ATC (Air Traffic Control) tower at the time of the accident.
"The airfield was under two concurrent weather warnings and it is mandatory for the TMO to be present to update and inform the fast changing weather variations to enhance air safety. During adverse weather conditions the presence of the TMO in the ATC tower was even more critical," said the AAIB report.
The report noted that Kozhikode airport is one amongst the 10 busiest airports in India, has hilly terrain and experiences extended adverse weather conditions. Therefore, it is recommended that for better guidance to the aircraft, Approach Radar be installed at Kozhikode airport, it said.
"The absence of a detailed proactive policy and clear cut guidelines by the Regulator on monitoring of Long Landings at the time of the accident was another contributory factor in such runway overrun accidents," said AAIB report.
Among recommendations to strengthen safety, the AAIB recommended Air India Express to review its PIC upgrade training procedure for handling of thrust levers by PIC Trainee Captain during the takeoff roll.
The Investigation Team observed that there were instances of verbal briefing for defect reporting in Air India Express.
"It is recommended that verbal briefing for any aircraft defect be strongly discouraged and correct procedures be followed as defined in relevant DGCA CAR (civil aviation rules)," the Board said.
Out of the total 190 on board the ill-fated flight, 19 passengers and two pilots died in the crash while 75 passengers and one cabin crew sustained serious injuries. As many as 33 passengers and one cabin crew had minor injuries while 57 passengers and two cabin crew did not sustain any injuries due to the crash.
UNI NK JW2313

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