Charter/Taxi (Non Scheduled Revenue Flight)

The following factors were identified:
- Attention – undetermined.
It was found the possibility that the PT-ONJ aircraft crew had their attention (focused vision) on the runway at the expense of maintaining proper separation with the terrain on a visual approach.
- Piloting judgment – a contributor.
Regarding the approach to landing profile, there was an inadequate assessment of the aircraft's operating parameters, since the downwind leg was elongated by a significantly greater distance than that expected for a "Category B" aircraft in landing procedures under VFR.
- Memory – undetermined.
It is likely that, based on the experience of ten years of operation in a company governed by the RBAC 121, the PIC procedural memory has influenced the decisions made concerning the conduct of the aircraft. The habit of performing long final approaches in another type of operation may have activated his procedural memory, involving cognitive activities and motor skills, making the actions automated in relation to the profile performed in the accident.
- Flight planning – undetermined.
A possible non-use of the available aeronautical charts (CAP 9453 and WAC 3189), which were intended to meet the needs of visual flight, may have contributed to low situational awareness about the characteristics of the relief around the SNCT Aerodrome and the presence of the power grid that interfered with the aircraft's landing approach.

The pilot-in-command’s (PIC) and second-in-command’s (SIC) failure during preflight inspection to ensure that the nose landing gear’s pip pin was properly installed, which resulted in separation of the pip pin during takeoff. Contributing to the accident was the ground crew supervisor’s failure to inform the PIC or SIC of the anomaly concerning the pip pin following a towing operation.

The pilot’s decision to continue visual flight rules (VFR) flight into instrument meteorological conditions (IMC), which resulted in controlled flight into terrain. Contributing to the accident was the FAA’s reliance on voluntary compliance with the Ketchikan Operator’s Letter of Agreement.

The probable cause of the accident was the non adherence to SOP by the PF, wherein, he continued an unstabilized 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’.

The following contributing factors were identitified:

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.

(i) The actions and decisions of the PIC were steered by a misplaced motivation to land back at Kozhikode to operate next day morning flight AXB 1373. The unavailability of sufficient number of Captains at Kozhikode was the result of faulty AIXL HR policy which does not take into account operational requirement while assigning permanent base to its Captains. There was only 01 Captain against 26 First Officers on the posted strength at Kozhikode.

(ii) The PIC had vast experience of landing at Kozhikode 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, decision making as well as CRM.

(iii) 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.

(iv) The possibility of visual illusions causing errors in distance and depth perception (like black hole approach and up-sloping runway) cannot be ruled out due to degraded visual cues of orientation due to low visibility and suboptimal performance of the PIC’s windshield wiper in rain.

(v) 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.

(vi) 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

(vii) The AIXL pilot training program 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. Frequently recurring major snags resulted in negative training. Further, pilots were often not checked for all the mandatory flying exercises during simulator check sessions by the Examiners.

(viii) The non availability of OPT made it very difficult for the pilots to quickly calculate accurate landing data in the adverse weather conditions. The quick and accurate calculations would have helped the pilots to foresee the extremely low margin for error, enabling them to opt for other safer alternative.

(ix) The scrutiny of Tech Logs and Maintenance Record showed evidence of nonstandard practice of reporting of certain snags through verbal briefing rather than in writing. There was no entry of windshield wiper snag in the Tech log of VT-AXH. Though it could not be verified, but a verbal briefing regarding this issue is highly probable.

(x) The DATCO changed the runway in use in a hurry to accommodate the departure of AIC 425 without understanding the repercussions on recovery of AXB 1344 in tail winds on a wet runway in rain. He did not caution AXB 1344 of prevailing strong tail winds and also did not convey the updated QNH settings.

(xi) Accuracy of reported surface winds for runway 10 was affected by installation of wind sensor in contravention to the laid down criteria in CAR. This was aggravated by frequent breakdown due to poor maintenance.

(xii) The Tower Met Officer (TMO) was not available in the ATC 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.

(xiii) The AAI has managed to fulfil ICAO and DGCA certification requirements at Kozhikode aerodrome for certain critical areas like RESA, runway lights and approach lights. Each of these, in isolation fulfils the safety criteria however, when considered in totality, this left the aircrew of AXB 1344 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 spatial orientation of the PIC.

(xiv) 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. Long Landing has been major factor in various accidents and incidents involving runway excursion since 2010 and has not been addressed in CAR Section 5, Series F, Part II.

(xv) DGCA did not comprehensively revise CAR Section 5, Series F, Part II Issue I, dated 30 Sep 99 (Rev. on 26 Jul 2017) on ‘Monitoring of DFDR/QAR/PMR Data for Accident/Incident Prevention’ to address the recommendations of the COI of 2010 AIXL Managlore Crash regarding the exceedance limits, resulting in the persisting ambiguities in this matter.

(xvi) DFDR data monitoring for prevention of accidents/incidents is done by AIXL. However 100% DFDR monitoring is not being done, in spite of the provisions laid down in the relevant CAR and repeated audit observations by DGCA. DFDR data monitoring is the most effective tool to identify exceedance and provide suitable corrective training in order to prevent runway accidents like the crash of AXB 1344. However, ATR submitted by AIXL on the said findings were accepted by DGCA year after year without ascertaining its implementation or giving due importance to its adverse implications.

The failure of both pilots to see and avoid the other airplane.
Contributing to the accident were:
1) the PA-12 pilot’s decision to fly with a known severe vision deficiency that had resulted in denial of his most recent application for medical certification and
2) the Federal Aviation Administration’s absence of a requirement for airborne traffic advisory systems with aural alerting among operators who carry passengers for hire.

The failure of the pilots of both airplanes to see and avoid the other airplane.