On 7 August 2020, a Boeing 737-800 (VT-AXH) being operated by Air India Express on an ad hoc repatriation flight from Dubai to Calicut as AXH1344 touched down half way along the ‘table top’ runway at destination after an ILS approach in night VMC, The aircraft overran the end of the wet runway before subsequently dropping over 100 feet down a hill, which resulted in the fuselage breaking into three pieces with 21 occupant fatalities including both pilots and 76 others with serious injuries and 34 with minor injuries.
An Investigation was carried out by the Indian Aircraft Accident Investigation Bureau (AAIB) The DFDR and two-hour CVR were recovered from the wreckage and all the data from both was successfully downloaded. Recorded ATC data and airport CCTV footage was also available.
The Flight Crew
The 59 year-old Captain, who was acting as PF for the flight, had a total of 10,848 flying hours of which 4,612 hours had been on type most of it in command. He was an ex military pilot who had joined Air India as an Airbus A310 Co-Pilot in 1994. Between 2010 and 2012, still with Air India, he was type rated as a Co-Pilot (P2) on the Boeing 737-800 and the Boeing 777-200 and 300 but in 2013, he failed an attempted upgrade to a Boeing 777 command (P1) rating “despite undergoing corrective training” and as a result requested and was granted a transfer to the operator’s wholly-owned subsidiary Air India Express. In 2014, this new employer then, after conducting an “extended refresher course” sought and obtained a “revival” of the Captain’s lapsed 737-800 P2 type rating and he commenced command training on the type. Although his progress was initially “unsatisfactory”, he eventually completed all the required training to the required standard and was granted a command (P1) type rating in January 2015. With effect from November 2017, he was promoted to Line Training Captain. Since then, although based in Mumbai, he had been regularly operating from Calicut and in the 12 months prior to the accident he had operated 36 flights from and back to it.
It was noted that in 2016, he had been declared temporarily unfit to fly for three months because of Diabetes Mellitus after which he was declared fit for flying in command with any “Qualified Experienced Pilot” and advised to take a monthly blood sugar test and a three monthly HbA1C test before being declared fit to fly in command without any limitations on 10 January, 2017 subject to a recommendation that all future medical renewals should take place at a specific principal examination facility and include an opinion from an endocrinologist. This recommendation continued until the accident except for his most recent medical renewal for which exemptions from these requirements were granted by the DGCA due to the prevailing COVID-19 pandemic. He had been advised on 1 August of his rostering for the Calicut-Dubai-Calicut trip which ended in the accident and had been positioned to hotel accommodation in Calicut the previous day.
The 32 year-old First Officer had a total of 1,989 flying hours of which all but 266 hours were on type. He held a CPL and had joined Air India Express on 1 December 2017, shortly after obtaining his Instrument Rating and a P2 type rating on the Boeing 737-800. He was based at Calicut and prior to the accident duty had last operated six days earlier.
Departure from Dubai was delayed by half an hour, which was apparently a matter of concern to the Captain as he wanted to achieve the scheduled arrival time at Calicut. As it was the monsoon season, additional fuel had been uplifted to ensure a wide choice of alternates should the destination prove unusable because of adverse weather there around the time of arrival after a flight expected to take about 3½ hours.
Whist still working Chennai ACC, the Calicut weather was obtained and runway 28 was advised as the runway in use. At that time, the surface wind velocity was given as 270°/14 knots and the visibility as 1500 metres rain with a “moderate thunderstorm”. The minimum visibility minima for a Cat 1 ILS approach to either end of the single “table top” runway was 1300 metres. Accordingly, the approach briefing given prior to the top of descent was for the runway 28 ILS with no reference to use of the 10 ILS approach. CVR data showed that the flap and autobrake settings were “decided by the crew” without any reference to a landing performance calculation.
When descending through FL 170 and cleared to FL120 and 52 nm from Calicut (aerodrome elevation 343 feet), the flight was transferred to Calicut APP. An updated weather report subsequently gave the visibility as 1500 metres “in feeble rain and thunderstorm”. In accordance with local procedures, the presence of a thunderstorm and a wind speed exceeding 17 knots, a local “Weather Standby” was in force which meant that rescue and fire fighting services (RFFS) tenders were in position at pre-determined positions along the runway.
With the visibility improved to 2000 metres in light rain and no mention of a thunderstorm, the flight was cleared for a procedural ILS approach to runway 28 from the CLC VOR located on the airport (there is no radar at Calicut). The approach proceeded uneventfully and the landing clearance was accompanied by a wind check of 280°/05 knots with the runway surface wet in light rain. A short reminder on how the First Officer should select the left windshield wiper, which was known to be malfunctioning, on when asked to do so was then given and this selection was then made passing 2,250 feet with the approach lighting confirmed in sight by both pilots soon afterwards. However, about half a minute after being switched on, the Captain’s windshield wiper then stopped working with the CVR recording the Captain saying “wiper is gone...what a day for the wiper to go”. When unable to see the runway at DA, a missed approach was commenced as per the prior instruction to fly a non standard missed approach due to the presence of CBs and continued to climb as cleared on an approximate runway heading.
The First Officer completed the ‘After Takeoff’ Checklist and asked the Captain if he should again set up the FMC for the ILS approach to runway 28, which was agreed “after slight hesitation”. At about the same time, an Air India flight about to depart was heard requesting runway 10 and in response, ATC immediately changed the runway in use from 28 to 10 despite the fact that the prevailing wind continued to favour runway 28. The controller then asked if the inbound flight would also “like to use runway 10 for arrival” whilst adding that the current surface wind was 270°/08 knots.
Despite the problem created by his unserviceable wiper, there was no recorded evidence that the Captain had considered diverting to an alternate and after further exchanges in respect of the visibility and wind velocity (which were essentially unchanged as was the fact that there were CBs all around the airport location at 2,500 feet) runway 10 was accepted for the second approach.
The flight was then cleared to descend to 3,600 feet and carry out the ILS approach to runway 10. Again, there was no evidence that a landing performance calculation had been made in association with the approach briefing for runway 10 and in the meantime, the departing aircraft had been given a spot wind of 270°/10 knots with its takeoff clearance. After establishing on the ILS LOC, the Captain was recorded again advising the First Officer how to switch on the unreliable windshield wiper adding “I hope it works”. Shortly afterwards, the problematic wiper was switched but appeared to operate only at a slow speed. Landing clearance was then given with the visibility still 2000 metres in light rain, the runway surface wet and the wind 250°/08 knots and after discussion, it was decided to use Flap 30 rather than the initially discussed Flap 40 because of possible turbulence. The Landing Checklist was completed in good time and during an initially stable approach, the AP was disconnected at 500 feet agl.
Thereafter, the pitch attitude was reduced and the descent rate began to increase, briefly reaching 1500 fpm which elicited PM cautions for a high rate of descent twice acknowledged by the Captain with “correction”. The rate of descent and deviation below the ILS GS increased beyond the stabilised approach criteria and two EGPWS Mode 5 ‘Glideslope’ annunciations followed. The Captain responded by increasing the pitch attitude which temporarily reduced the rate of descent to a recorded 300 fpm before it increased again to 1000 fpm. The runway threshold was crossed at 92 feet agl with the aircraft deviating to the left of the centre line and subject to a tail wind component slightly in excess of 14 Knots.
At this point speed began to gradually increase and the rate of descent began to reduce after thrust was manually added contrary to the still-engaged A/T which was attempting to reduce it. Thrust reached 83% N1 with the aircraft still 20 feet above the runway and already over 400 metres beyond the runway threshold. With the aircraft approximately 760 metres beyond the runway threshold, the First Officer, clearly concerned, made a non standard call “just check it”, but although the runway centreline was regained, the high thrust was not immediately reduced and it was not until over 900 metres beyond the runway threshold that the airspeed began to reduce, reaching the applicable approach speed approximately still airborne 15 feet above the runway with just 150 metres to go before reaching the end of the TDZ which was indicated by lights on either side of the runway centre line. As this point was passed, the First Officer made what the Official Report described as “a feeble, uncomfortable call of ‘...Captain’” and at about the same time, idle thrust was finally reached. He immediately followed this with a “Go Around” call but there was no response from the Captain and touchdown on the wet runway followed soon afterwards some 1,350 metres beyond the runway threshold. At touchdown, the airspeed was recorded as 150 KCAS and the tailwind component was 15 knots.
The Captain immediately reverted to maximum manual braking and the spoilers immediately automatically deployed with standard response calls made by the First Officer. An also immediate thrust reverser selection was made but after only a couple of seconds deployed, they were re-stowed as the applied brake pressure was momentarily reduced and the rate of deceleration immediately lessened. After a further ten seconds, the thrust reversers were again deployed to maximum with the aircraft now 2,500 metres beyond the threshold with only 200 metres of runway left. The aircraft passed the designated end of the runway 10 with a ground speed of 84.5 knots and continued across the 160 metre starter strip of runway 28 before passing onto the 60 metres Runway Strip and finally onto 90 metres of soft ground. During this time, it collided with the ILS antennae and a fence and then, at the end of the RESA travelled down an approximately 30° slope until a sudden change to level ground some 110 feet below. This change of direction led to an impact which caused the aircraft to come to an abrupt stop which resulted in the fuselage breaking into three pieces. Both pilots were amongst the fatalities. The accident site the following morning is shown below.
The accident site the following day with the aircraft in three pieces astride the perimeter road. [Reproduced from the Official Report]
Why it Happened
The Investigation did not find any evidence that any lack of airworthiness except the malfunctioning left side windshield wipers had played any direct part in accident causation. Rather, it was found to have been the result of the collective actions of the flight crew up to the point where the abrupt end to the RESA resulted in an extreme outcome which, at many if not most other airports, would have probably been avoided.
However, the very comprehensive nature of the Investigation sought to not only examine possible reasons for the poor performance of the flight crew and particularly the PF Captain but to put this into its wider context, particularly but not only its systemic context including the inherent risk to overruns created by “table top” runways with reference to the implementation or otherwise of some of the Safety Recommendations made after the Air India Express fatal overrun accident when landing on Mangalore’s table top runway in 2010.
In respect of the considerable number of individually abnormal actions or omissions identified in the prelude to the accident, the Investigation looked at a number of potential behavioural influences:
- The potential consequences of the Captain’s Type 2 Diabetes Mellitus, for which the prescribed regular treatment - sustained release formulation of Metformin - had enabled him to regain an unrestricted Class 1 medical, were reviewed. It was known from the available scientific literature and ICAO Doc 8984 that Metaformin could expose those taking it to the risk of mild hypoglycaemia but without any detriment to their performance. However, the Investigation came to the conclusion that whilst the Captain was (presumably) taking the prescribed Metformin, he had also been self-medicating with “multiple un-prescribed anti-diabetic drugs including ayurvedic medication” which would have increased the risk of performance consequences from hypoglycaemia. In particular, it was suspected that the Captain was regularly taking ‘Glimepride’ tablets which alone were known to have “a very high potential to cause hypoglycaemia when consumed along with other anti-diabetic drugs”.
- A number of specific lapses in the normal situational awareness of the Captain during the attempt to reach Calicut were noted. Although at first these were not cumulative, their consequences eventually culminated in the unplanned decision to fly the second approach with a significant tailwind component to land on a wet runway with impeded forward visibility due to the malfunctioning windshield wiper. Any Captain, especially a Training Captain, could reasonably have been expected to be able to objectively recognise that any approach to the airport involved in adverse weather conditions had enough unavoidable potential challenges to make an optional tailwind worth avoiding. In addition, the lack of any rational explanation for the Captain’s mismanagement of the thrust towards the end of the approach and when subsequently floating over almost half the runway length was considered indicative of a degree of cognitive impairment. It was considered that a similar conclusion could be drawn from the very brief initial deployment of the thrust reverses which were perhaps then immediately re-stowed with a view to commencing a go around before abandoning that idea and returning to the by then impossible full stop objective.
- From the CVR evidence whilst the working relationship between the two pilots was good, the authority gradient between them perceived by the First Officer was steep enough to deter positive and timely intervention before the accident outcome became inevitable.
- The fact that Calicut Airport has very little in the way of cultural lighting was considered to characterise night approaches there as ‘Black Hole’ approaches with consequences for manual visual flying of the final stage of the approach and in this respect, it was considered that although the runway was a familiar one for both pilots, other issues may have resulted in both the absence of a lit runway centreline and the mid-runway summit longitudinal profile of the runway acquiring more significance.
- The fact that, despite the first go around occurring because the Captain could not see the runway at DA because it was raining and his windshield wiper was inoperative, the option of diversion to an alternate with better weather was not discussed at any time was considered very unusual. Whilst the reason could not be known, there was circumstantial evidence that the Captain may have been unduly focused on being able to night-stop in Calicut as intended because he was rostered for a morning flying duty from there the next day which any diversion would have precluded.
- In personality terms, the Captain was seen as having been vulnerable to degraded performance in the form of “cognitive bias” by being subject to incrementally increasing stress derived from his known tendency to be “goal orientated”, have “cognitive rigidity” and a “tendency towards perfectionism”, which together would have been likely to adversely affect the quality of flight deck crew resource management (CRM).
The Probable Cause of the Accident was formally recorded as “the non adherence to SOPs by the Captain wherein he continued an unstabilised approach and landed beyond the touchdown zone, half way down the runway, in spite of a ‘Go Around’ call by the First Officer after which a mandatory Go Around was warranted followed by the failure of the First Officer to take over the controls and execute a Go Around himself".
A total of 16 Contributory Factors in respect of both the immediate and systemic causes of the accident were also identified as follows:
- The actions and decisions of the Captain were steered by a misplaced motivation to land back at Calicut to be able to operate the following day’s morning flight from Calicut. The unavailability of a sufficient number of Captains at Calicut was the result of a faulty Air India Human Resources policy which did not take into account operational requirements when assigning a permanent base to its Captains. Only one Captain and 26 First Officers made up the posted strength at Calicut at the time of the accident.
- The Captain had vast experience of landing at Calicut 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 and decision making as well as CRM.
- The Captain was taking multiple un-prescribed anti-diabetic drugs that may have caused subtle cognitive deficits due to mild hypoglycaemia which probably contributed to errors in complex decision making as well as susceptibility to perceptual errors.
- The possibility of visual illusions causing errors in distance and depth perception (like the black hole approach and up-sloping runway effects) cannot be ruled out due to degraded visual cues of orientation in relatively low visibility and the suboptimal performance of the Captain’s windshield wiper in rain.
- Poor CRM was a major contributory factor in this crash. As a consequence of a lack of assertiveness and the steep authority gradient on the flight deck, 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 at Air India Express resulted in poor CRM and a steep flight deck authority gradient.
- Air India Express senior management policies have led to a lack of supervision in training, operations and safety practices, resulting in deficiencies at various levels and causing repeated human error accidents at the operator.
- The Air India Express pilot training programme lacked effectiveness and did not impart the requisite skills for performance enhancement. One of the drawbacks in training was inadequate maintenance and lack of periodic system upgrades of the simulator used resulting in frequent recurrence of major snags which resulted in negative training. Also, pilots were often not checked in all the mandatory flying exercises during simulator check sessions by Examiners.
- The non availability of an OPT made it very difficult for the pilots to quickly calculate accurate landing data in adverse weather conditions. Quick and accurate calculations would have helped the pilots to foresee the extremely low margin for error, enabling them to opt for a safer alternative.
- The scrutiny of aircraft Technical Logs and Maintenance Records showed evidence of nonstandard practice in reporting of certain snags verbally rather than in writing. There was no defect entry for the pre-existing faulty left side windshield wiper in the aircraft Technical Log. Although it could not be verified, verbal communication regarding this issue is highly probable.
- The Duty ATCO changed the runway in use in a hurry to accommodate the departure of another aircraft without understanding the repercussions for the arrival of the accident aircraft on a wet runway in rain in the presence of a tailwind component nor did he caution the flight in respect of the prevailing strong tail winds or pass an updated QNH setting.
- The accuracy of the reported surface winds for runway 10 was affected by installation of the relevant wind sensor contrary to the laid-down regulatory criteria as aggravated by its frequent breakdown due to poor maintenance.
- The Tower Meteorological Officer (TMO) was not available in the ATC tower at the time of the accident despite the fact that two concurrent weather warnings were active for the airport and it was mandatory for them 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.
- Although the Airports Authority of India (AAI) has managed to fulfil ICAO and DGCA certification requirements at Calicut, for certain critical areas like the RESA and runway and approach lighting, each of these taken in isolation fulfils the specified safety criteria, but when considered in totality, the accident aircraft flight crew were left with little or no margin for error. Although not directly contributory to the accident causation, availability of runway centreline lights would have certainly enhanced the Captain’s spatial orientation.
- The absence of a detailed proactive policy and clear cut guidelines on the monitoring of Long Landings at the time of the accident on the part of the DGCA as Safety Regulator contributed to this and other runway overrun accidents. Long Landing has been a major factor in various accidents and incidents involving runway excursion since 2010 and is still not addressed in the Civil Aviation Requirements (CAR) Section 5, Series F, Part II.
- The DGCA has not comprehensively revised the CAR Section 5, Series F, Part II Issue I dated 30 September 1999 (as revised on 26 July 2017) on ‘Monitoring of DFDR/QAR/PMR Data for Accident/Incident Prevention’ to address the recommendations of the Court of Inquiry into the 2010 Air India Express crash at Mangalore in respect of the exceedance limits which has resulted in persisting ambiguities in this matter.
- Although Air India Express carries out OFDM for accident/incident prevention purposes, this does not cover 100% of its flights in spite of the provisions laid down in the relevant CAR and reiterated as observations during DGCA inspections. OFDM is the most effective way to identify exceedances and inform the need for corrective training in order to prevent runway accidents like the one investigated here. However, the Action Taken Reports on this matter submitted by the operator in response to findings were accepted by DGCA year after year without ascertaining their implementation or giving due importance to its adverse implications.
A total of 43 Safety Recommendations were issued at the conclusion of the Investigation based on its Findings as follows:
- that Air India Express should:
- In respect of Simulator Training:
- Make extensive use of flight simulators in order to impart training in realistic situations, with emphasis to be laid on the following scenarios during the flight simulator briefing/training:
- To promote assertiveness of the First Officer to take-over control and initiate a go-around on an unstabilised approach when a Captain fails to respond.
- Tail wind landing on wet runway.
- Landing on wet/contaminated runway (up to 3mm depth)
- Extended Flare and Balked Landing.
- In respect of Simulator Training Assessment, the Chief of Training must ensure that the assessment reports (CA 40/CA41) completed by the Delegated Examiners are complete in all aspects. All ‘training forms’ must be scrutinised critically by the Company Training Department as well as by the DGCA during their inspections.
- In respect of CRM Training: trainers should undertake random observation flights to assess the critical facets of CRM including the trans-cockpit authority gradient and assess the responses of Captain and the First Officer as a team.
- In respect of Aircraft Types Command Upgrade Training: the training procedure for handling of the thrust levers by the trainee Captain during the takeoff roll should be reviewed.
- that Air India Express should, since the majority of its aircraft are equipped with an OEM-installed EFB capable of Onboard Performance Calculation, make this Onboard Performance Tool (OPT) a mandatory part of the EFB and ensure all pilots are trained and checked for their proficiency in the use of this OPT for accurate aircraft performance calculations. The Boeing 737 performance module in the EFB (as OEM-installed in the aircraft or on currently used iPads) should be used to calculate Takeoff, Cruise, Landing and Single-engine performance to enhance safety.
- that Air India Express should, in view of the fact that simulators continue to be used for training in spite of maintenance issues and pending defects affecting them which do not fall within missing, malfunctioning or inoperative component reporting, require that its Head of Training ensures that at the time of use, the simulator meets all regulatory requirements, and in particular, it should be ascertained that the simulator meets all training objectives as prescribed in the training plan of the airline and also that no negative training is carried out.
- that Air India Express should, in order to ensure compliance with SOPs and the principles of CRM enhance the number of observation flights by made by senior training pilots and carry out additional observation flights during the monsoon season as recommended by the DGCA. A LOSA programme should be used to identify systemic weaknesses.
- that Air India Express should, since DFDR monitoring is the most effective tool to identify exceedance and provide suitable corrective training in order to prevent aircraft accidents, ensure that 100% DFDR data is downloaded as per the applicable regulatory requirements for OFDM and that trend analysis is done so that timely follow up action can be taken if required.
- that Air India Express should, in view of the fact that a right hand brake pressure transducer unserviceability had not been identified during repeated checks and monitoring, ensure that personnel involved in analysis of data from Flight Recorders as per the applicable regulatory requirements (CAR Section 2, Series I, Part V) are provided with technical training so as to ensure that proper analysis is carried out, discrepancies are identified and timely remedial measures are undertaken.
- that Air India Express should, since routine CVR monitoring is already a company policy, use it to effectively analyse and address established weaknesses in pilot non technical skills including the management of the prevailing flight deck authority gradient.
- that Air India Express should, in respect of Human Resources Management:
- take into consideration the quantum of flights originating from respective bases and accordingly assign them as ‘home base’, especially for the Captains, in order to ensure better availability of Crew at all bases.
- ensure that all post holders and sub-post holders are available at their designated office to ensure proper supervision of their area of operations by designating clear office days/hours for such post holders and sub post holders as a part of their company HR policy. Such office days must be considered as a part of a duty as defined in the applicable Civil Aviation Requirement (CAR Section 8).
- In the absence of an independent medical department, Aviation/Aerospace Medicine Specialists should be employed in accordance with DGCA General Advisory Circular 2011/01 dated 17 December 2011 and such specialists should take classes during flight crew ground training to educate them on aeromedical issues.
- that Air India Express should, given the finding that instances of verbal briefing as a means of defect reporting have occurred, ensure that verbal briefing for any aircraft defect is strongly discouraged and that relevant procedures correspond to the applicable DGCA regulatory requirements.
- that Air India Express should, in respect of international best practices regarding stabilised approaches, introduce the following into its flight operations:
- Final landing configuration should be selected by 1500 feet AGL for an instrument approach and 1000 feet for a visual approach to be stable by 1000 feet for instrument approach and 500 feet for visual approach.
- A standard call out at 1000 feet agl during an instrument approach and 500 feet agl for a visual approach of “Stabilised/Unstable - Go Around” should be introduced to improve the situational awareness of the PF.
- that the Airports Authority of India (AAI) should, in respect of Air Traffic Control, ensure that during both the ab-initio and annual refresher training of controllers, the following aspects are strongly emphasised:
- The impact of tailwind conditions in adverse weather.
- The impact of change of QNH.
- Precautions required to be taken when deciding the change of runway in adverse weather.
- that the Airports Authority of India (AAI) must, in the light of the finding that the ARFF crew at Calicut were not familiar with the Boeing 737-800 aircraft which resulted in poorly coordinated rescue operations and the delayed evacuation of the pilots from the flight deck, ensure that mandatory Aircraft Familiarisation Training is provided to all ARFF crew there within a defined timeline in addition to recurrent training as per the existing requirements. In order to achieve this, the Airport Directors at all airports should coordinate with their airline operators to achieve the timely delivery of aircraft familiarisation training for their ARFF crew on all types of aircraft operating through that aerodrome as referred to in ICAO Doc 9137-AN/898 ‘Airport Services Manual, Part 1- Rescue and Fire Fighting’ with this delivery to be monitored by the DGCA through realistic surveillance inspections.
- that the Airports Authority of India (AAI) should, in respect of the proper maintenance of the soft ground portion of RESAs which offer a crucial defence in case of a runway excursion, ensure that at all times RESA upkeep and maintenance occurs as per the applicable specifications.
- that the Airports Authority of India (AAI) should, given that the Calicut airport perimeter road which surrounds the airport must be capable of supporting heavy Fire Fighting vehicles in order to achieve the required response time with adequate safety as observed during a November 2019 DGCA inspection, but that the observed deficiencies still existed on the day of the accident, make the perimeter road wide enough to facilitate this required rapid movement of emergency vehicles.
- that the Airports Authority of India (AAI) must, since an Airport Doctor has an important role in any Aerodrome Emergency Plan (AEP), ensure that all doctors working at Airport Terminal Clinics must undergo formal and structured familiarisation training for their roles and responsibilities during an aircraft accident as per the published AEP. Such doctors must also participate in periodic refresher training and take part in practice emergency response drills carried out at airports for ARFF personnel training purposes as well as training them in respect of the prioritisation of mass casualty triage and casualty movement procedures.
- that the Airports Authority of India (AAI) should, since Calicut is one of the ten busiest airports in India, has hilly terrain and experiences extended adverse weather conditions, install Approach Radar there for better guidance to aircraft.
- that the Airports Authority of India (AAI) should, given that in November 2019, a DGCA inspection made a number of observations regarding deficiencies in conduct of Practice Emergency Exercises and that these deficiencies still existed on the day of accident, ensure that timely follow up action on all these deficiencies now occurs in order to achieve the desired training outcomes from such Exercises.
- that the Airports Authority of India (AAI) should, given that the requirement for video recording of rescue operations is laid down in Air Safety Circular 2013/04, ensure that all Crash Fire Tenders and Command Posts are fitted with cameras for real time video recording of an entire rescue operation and the requirement for video recording of rescue operations should be incorporated in all Aerodrome Emergency Plans.
- that the Airports Authority of India (AAI) should, given that CCTV footage can provide important leads into various aspects of an Accident Investigation, ensure that guidelines contained in Air Safety Circular 2014/05 are promulgated as a Civil Aviation Requirement (CAR) to achieve better compliance and the same should also be incorporated in the organisation manuals of aerodromes.
- that the Indian Meteorological Department should, given that the role and responsibilities of Tower Meteorological Officer (TMO) during adverse weather are clearly defined in the Civil Aviation Meteorological Circular dated 01 November 2018, ensure that they and the Duty Air Traffic Control Officer are present in the Tower during dynamic weather situations.
- that the Indian Meteorological Department should, since the accuracy of reported surface winds for runway 10 was affected by both non-standard installation and poor maintenance, ensure that the sensors for measuring runway 10 surface winds are installed as per the applicable regulatory specifications and that regular maintenance is undertaken.
- that the Indian Meteorological Department should, since most of the day and night visibility markers included on the Calicut airport chart were not distinctly noticeable, ensure that this chart is updated in accordance with currently existing landmarks.
- that the Indian Meteorological Department should, since under the terms of DGCA letter No. 20025/13/06 AL dated 08 August 2018, the AAI was permitted to recommence wide body operations at Calicut following the installation of transmissometers for RVR reporting but that at the time of the accident such instrumentation had not been installed but can significantly enhance the accuracy of visibility reporting leading to a better situational awareness of the pilots during low visibility, ensure that the said All Weather Operating RVR system is installed.
- that the Directorate General of Civil Aviation (DGCA) should, given the finding that recommendations made in respect OFDM anomalies following the 2010 Air India Express Mangalore Accident have not been addressed for the last 10 years, revise Section 5 of the Civil Aviation Requirements (CARs), Series F, Part II Issue I, dated 30 September 1999 at Revision 1 dated 26 July 2017 on ‘Monitoring of DFDR/QAR/PMR Data for Accident/Incident Prevention’ in order to remove ambiguities in exceedance parameters, introduce monitoring of landing beyond the touchdown zone and standardise the OFDM limits for all types of aircraft operating in India. Although draft CARs are placed on open access and public comments are solicited, it is additionally recommended that to ensure better inclusiveness, Subject Matter Experts from the industry are also utilised whilst these changes are being formulated.
- that the Directorate General of Civil Aviation (DGCA) should, in respect of OFDM, ensure that 100% DFDR monitoring as stipulated in the applicable regulatory requirements is carried out by all scheduled service operators. In addition to unstabilised approaches, long landings should also be monitored and with respect to the Civil Aviation Requirements Section 8 ‘All Weather Operations (Adverse Weather)’, compliance with the recommendations regarding use of Flaps, Thrust Reverser etc. and similar should be monitored by OFDM especially during the monsoon and pre-monsoon seasons.
- that the Directorate General of Civil Aviation (DGCA) should, consider requiring the implementation of Simulator Operations Quality Assurance (SOQA) in a similar manner to FOQA/OFDM when an operator chooses to bring in new FSTDs or decides to upgrade their existing simulator(s) to achieve better monitoring of training/checks being performed in them.
- that the Directorate General of Civil Aviation (DGCA) should, in respect of flight surveillance, ensure:
- Periodic surveillance of flights to critical and table top runways including ‘red eye’ flights.
- Increased surveillance should be carried out during monsoons (see DGCA CAR Section 5 Series F Part I).
- Air Safety Circulars 2017/03 and 2019/02 which deal with operations during the monsoon season should be aligned with the requirement of the aforementioned CAR Section 5 Series F Part I and with CAR section 8 “Adverse Weather/Monsoon Operations” which deals with All Weather Operations. Implementation of a LOSA programme may also be required during routine audits and surveillance of operators.
- that the Directorate General of Civil Aviation (DGCA) should, since there is an urgent requirement to revise targets for Safety Performance Indicators for the remaining period of the current (2018-2022) National Aviation Safety Programme (NASP) it should be reviewed and its Safety Performance Indicator / Safety Action Plan revised in line with international best practices to achieve the objective of reducing the number of Runway Excursions and Overruns. Clear directions/guidelines should be issued by DGCA for any such revision and related safety data should be published in a timely manner.
- that the Directorate General of Civil Aviation (DGCA) should study the feasibility and efficacy of ‘Child Restraint System’ for the safety of infants and children on board aircraft.
- that the Directorate General of Civil Aviation (DGCA) should, in respect of the Runway Strip ensure that the long pending permanent exemption for the width of the runway strip at Calicut as sought in letter No. AAI/AL/30-23(MiscSA)/2018/660 dated 28 September 2018 is resolved as a priority.
- that the Directorate General of Civil Aviation (DGCA) should, given that the topography and weather phenomena at both Calicut and Mangalore, impose serious constraints on flight operations and ensure that the already-agreed installation of centreline lighting on the runways at both these airports in 2022 and 2024 respectively during planned resurfacing (which should assist the maintenance of directional control on these runways during landings in adverse weather conditions and enhance overall situational awareness), is carried out as currently planned or earlier.
- that the Directorate General of Civil Aviation (DGCA) should ensure that the guidelines contained in Air Safety Circulars 2010/06, 2013/04 and 2014/05 are promulgated through the Civil Aviation Requirements (CARs) to achieve better compliance and their content is also incorporated in the organisation manuals of Airlines and Aerodrome Operators.
- that the Directorate General of Civil Aviation (DGCA) should, mandate all operators to carry out safety risk assessment for their type of aircraft so as to define the operational limits including tailwind while landing at critical runways, table top runways and runways when the braking action is reported as good, good to medium, medium, medium to poor and poor.
- that the Directorate General of Civil Aviation (DGCA) should, in order to ensure standardisation in the duration of SMS training across all stakeholders, revise Section 1 Series C Part-1 of the Civil Aviation Requirements (CARs) which covers the ‘Establishment of Safety Management Systems’ to include the minimum duration of training especially for SMS Managers/Nodal officers.
- that the Directorate General of Civil Aviation (DGCA) should consider requiring the installation of ROAAS on all aircraft used by scheduled service operators especially those operating jet aircraft (note the amendment to CS-25 for new aircraft type certifications - see EASA ED 2020/001/R).
- that the Directorate General of Civil Aviation (DGCA) should ensure that Air India Express amend its Low Visibility Takeoff (LVTO) minimum at Calicut currently applicable whenever RVR is not reported from the current 300 metres to the 800 metres required by the DGCA CARs Section 8 Series C Part I and additionally ensure that no other operator files LVTO minima below 800 metres applicable when RVR is not reported for a specific runway.
- that the Directorate General of Civil Aviation (DGCA) should introduce Competency Based Training and Assessment (CBTA) as recommended by ICAO and ensure that pilots are trained and assessed on the nine competencies listed below:
- Aircraft Flight Path Management - Manual Control
- Aircraft Flight Path Management - Automation
- Leadership and teamwork
- Problem Solving and Decision making
- Application of procedures
- Work load Management
- Situational Awareness
- that the Directorate General of Civil Aviation (DGCA) should advise all operators/flight crew to make better use of onboard wind velocity indications to enhance their situational awareness and assist in making a stabilised approach.
- that the Directorate General of Civil Aviation (DGCA) should, given the fact that there are far too many Circulars and Civil Aviation Requirements (CARs) on the same topic e.g. Monsoon Operations, Adverse Weather, Stabilised Approach, consolidate all information on a particular subject in a single CAR or Circular for ease of user reference.
- that the Directorate General of Civil Aviation (DGCA) should issue directions to all scheduled and non-scheduled operators requiring them to educate their aircrew on the aeromedical consequences of self medication and should also undertake a study to establish prevalence of use of non-prescribed medications amongst aircrew especially for diabetes.
- that the Directorate General of Civil Aviation (DGCA) should ensure that the information sharing mechanism between an AAIB Investigation Team and relevant DGCA officials during aircraft accident/serious incident investigation is in accordance with the Aircraft (Investigation of Accidents and Incidents) Rules, 2017 Rule 10(1) (a) and (b) and should advise its officials that they must participate in discussions whenever required to do so by an Investigation Team.
- that the Air Accident Investigation Bureau (AAIB) takes the necessary action to ensure that existing Investigator posts are filled with permanent full time Investigators, that additional posts are created to cater for the growth of aviation in India and that a permanent aerospace/aviation medicine specialist is recruited as an Investigator able to both participate in aircraft accident investigations and assist the “go team” as a Human Factors expert.
- that the Air Accident Investigation Bureau (AAIB) should set up a state-of-the-art Flight Recorder (DFDR & CVR) Laboratory with the necessary hardware and software to perform readout and analysis (including spectrum analysis) and that they should mandate aircraft manufacturers to provide the necessary Technical Literature, Hardware and Software for all aircraft types that operate in India.
The 281 page Final Report was completed on 17 August 2021 and published the following month.