A probe report by the Aircraft Accident Investigation Bureau (AAIB) has said that the Air India Express pilot's "non-adherence" to the standard operating procedure is the probable cause of the plane crash at the Kozhikode airport last year.
The report also said the role of the systemic failures as a contributory factor cannot be overlooked in the accident.
The AAIB released its final probe report on Saturday. It has made 43 safety recommendations, including installation of an approach radar at the aerodrome and a DGCA study to establish prevalence of use of non-prescribed medications amongst aircrew, especially for diabetes. It also has 57 findings about the crash.
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From systemic failures to Air India Express's poor crew resource management to possibility of visual illusions due to low visibility and sub-optimal performance of the PIC's (Pilot-In-Command) windshield wiper, AAIB has mentioned about various other causes that have contributed to the crash.
The crash, involving a Boeing 737-800 aircraft, killed 21 people, including the two pilots, and injured several others. While trying to land at the airport amid rain, the aircraft overshot the runway and later broke into pieces. There were 190 people onboard when the crash happened on August 7, 2020. The two pilots who died in the accident that happened at the airport in Kerala were Deepak V Sathe and Akhilesh Kumar.
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The report, which is more than 250 pages long, said the "probable cause of the accident was the non adherence to SOP (Standard Operating Procedure) by the PF (Pilot Flying)".
The PF continued an unstabilised approach and landed beyond the touchdown zone, "half way down the runway, in spite of 'Go Around' call by PM which warranted a mandatory 'Go Around' and the failure of the PM to take over controls and execute a 'Go Around'", it noted.
According to the report, the investigation team is of the opinion that the role of systemic failures as a contributory factor cannot be overlooked in this accident.
"A large number of similar accidents/ incidents 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. Hence, the contributory factors enumerated below include both the immediate causes and the deeper or systemic causes," it added.
Among other recommendations, AAIB has suggested strengthening its own capacity in terms of filling up vacancies with full-time investigators, having a permanent aviation medicine specialist and establishing a state-of-the-art lab for flight recorders.
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AAIB, headed by Aurobindo Handa, has accepted the probe report.
On Thursday, Civil Aviation Minister Jyotiraditya Scinida said the report would be made public in the next couple of days.
"Whatever steps that have been advocated on the basis of that report, those steps will be and has to be executed.
"... within the ministry, we will be also putting together a group of people that will be tasked with the responsibility of ensuring that the steps that have been recommended in the report are put in place at the airport," the minister had said.
Last month, Minister of State for Civil Aviation V K Singh told the Lok Sabha that final compensation offers have been made to all the next of kin of the deceased passengers, but none of the "next of kin has sent their acceptance as of date".
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"Final compensation offers have been made to all the 165 injured passengers, out of which 73 passengers accepted the offer and have been paid a total amount of Rs 60.35 crore as the final settlement as of date," he had said.
(PTI inputs)
