Low visibility and sub-optimal performance of windshield wiper in rain might have well triggered visual illusions for the pilot, resulting in erroneous distance and depth perception as the ill-fated Air India Express plane crashed at the Kozhikode airport last year.
Besides, steep authority gradient prevented the pilot monitoring to make assertive call outs and take actions as per the Standard Operating Procedure (SOP), becoming a major contributory factor for the accident.
These are among the findings of the Aircraft Accident Investigation Bureau (AAIB) report that delved into the accident on August 7 last year when the Boeing 737-800 aircraft overshot the table top runway and fell to a depth of about 110 feet below the runway elevation and broke into three pieces.
Two pilots and 19 passengers, including three infants, lost their lives as the plane coming from Dubai with a total of 190 people onboard crashed.
Non-adherence of the pilot to the SOP as well as systemic failures have been cited in the report as the probable causes for the crash at the Kozhikode airport in Kerala.
“Due to degraded visual cues of orientation caused by low visibility and sub-optimal performance of the PIC’s (Pilot In Command) windshield wiper in rain, the PIC probably experienced visual illusions causing errors in distance and depth perception,” the report, released on Saturday, said.
According to AAIB, the events of AXB 1344 crash replicated the Mangalore crash of 2010. “Ten years later, on 7 August, 2020, it was once again a similar tabletop aerodrome, the same airline, the same type of aircraft that landed off an ‘Un-stabilised Approach’ and touched down past half the runway and resulted in another major disaster”.
The report noted that in the Kozhikode accident, the windshield wiper on the captain’s side stopped working after operating for about 27 seconds during the first approach to land and in the second approach it worked, albeit at a speed lower than the one selected.
“The SOP clearly states that after a second missed approach due to weather, it is mandatory for the aircraft to divert to an alternate airfield. This factor was important, since this aircraft had already carried out one missed approach and considering the prevailing weather and visibility conditions, there was high likelihood of another missed approach.
“With an unserviceable wiper, even the choice for alternate airfields in case of a second missed approach, was restricted to only those airfields where it was not raining,” the report said.
Noting that in the last ten years, Air India Express Ltd (AIXL) had two major accidents and a number of non fatal accident/serious incidents, AAIB said most of them were a result of continuation of unstabilised approach and total disregard to the repeated calls from the First Officer to ‘Go Around’, both being serious breach of SOP.
“This resulted in long landings in which the aircraft was unable to stop on the runway and terminated in excursion. There was reluctance on the part of the First Officers to take over controls and execute a missed approach, which is the correct procedure, as given in the SOP and is expected to be done without any hesitancy.
“A steep authority gradient discouraged and prevented participation of the First Officers. Hence, they were extremely reluctant to exercise their duties and responsibilities in emergency/ critical situations,” it said.
Further, the report pointed out that it was evident that there is a serious safety concern of steep authority gradient in the company which prevented the PM (Pilot Monitoring) to make assertive call outs and take actions as stipulated in SOP and that it was again is one of the major contributory factors to the accident.
Among other aspects, the probe report has flagged that AIXL did not have provision for child/infant restraint system and they rely solely on lap-held infants without any supplemental restraint.
Out of the 10 infants on board the plane, three sustained fatal injuries, three had serious injuries and four escaped unhurt.
“The laboratory studies have confirmed that an adult may not be able to hold on to an infant on the lap in sudden decelerations, even when prepared. The infant may then be projected through the cabin and suffer serious injury as a result.
“Therefore, the studies have concluded that lap holding of infants without supplemental restraint is not deemed the safest method during air travel,” it added.