Issued: -- | To: Air India Express | 4.1.1 |
TRAINING
In view of the failure of the AIXL pilot training program to impart the requisite skills for performance enhancement due to lack of its effectiveness, it is recommended that:
(i) Simulator Training
(a) In order to impart training in realistic situations, flight simulators to be used extensively. Emphasis to be laid on the following scenarios during the flight simulator briefing/training:
(aa) To promote assertiveness of the First Officer to take-over control and initiate a go-around on an unstabilized approach when PIC fails to respond.
(ab) Tail wind landing on wet runway.
(ac) Landing on wet/contaminated runway (up to 3mm depth)
(ad) Extended Flare and Balked landing.
(b) Simulator Training Assessment: It is recommended that the Chief of Training to ensure that the assessment reports (CA 40/CA41) done by the DEs are complete in all aspects. All training forms to be scrutinized critically by the AIXL Training Department as well as by DGCA during their inspections.
(ii) CRM Training
Trainers of AIXL to 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.
(iii) PIC Upgrade Training on Aircraft
AIXL to review its PIC upgrade training procedure for handling of thrust levers by PIC Trainee Captain during the takeoff roll. |
Issued: -- | To: Air India Express | 4.1.10 |
INTERNATIONAL BEST PRACTICES REGARDING STABILIZED APPROACHES
It is recommended that AIXL should introduce following practices in its flight operations.
(i) 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.
(ii) The operator may like to introduce a standard call out at 1000 feet AGL during an instrument approach and 500 feet AGL for visual approach Stabilised/Unstable Go Around for better situational awareness of the pilot flying. |
Issued: -- | To: Air India Express | 4.1.2 |
ONBOARD PERFORMANCE TOOL (AIRCRAFT)
Majority of aircraft in AIXL are equipped with OEM fitted EFB, capable of Onboard Performance Calculation. It is recommended that Onboard Performance Tool be made mandatory part of the Electronic Flight Bag (EFB) and all pilots to be trained and checked for their proficiency in the use of OPT for accurate aircraft performance calculations.
It is recommended that AIXL may implement the B737 performance module in the EFB (OEM fitted or currently used iPad) to calculate Take-off, Cruise, Landing, Single-engine operations to enhance safety. |
Issued: -- | To: Air India Express | 4.1.3 |
SIMULATOR MAINTENANCE
In view of the fact that simulator continued to be used for training by AIXL in spite of maintenance issues and pending defects on the simulator which does not fall in the preview of MMI, it is recommended that the Head of Training of AIXL ensures that at the time of use, the simulator should meet all regulatory requirements.
It should be ascertained that the simulator meets all training objectives as prescribed in the training plan of the airline and no negative training is carried out. |
Issued: -- | To: Air India Express | 4.1.4 |
COCKPIT CREW SUPERVISION
In order to ensure compliance of SOPs and CRM principles, it is recommended that AIXL to enhance their observation flight by senior pilots, trainers and carry out additional observation flights during monsoon as recommended by DGCA.
Further all scheduled operators may implement a regular LOSA programme (Line Operation Safety Assessment) to observe system weaknesses. |
Issued: -- | To: Air India Express | 4.1.5 |
DFDR DATA MONITORING
DFDR monitoring is the most effective tool to identify exceedance and provide suitable corrective training in order to prevent aircraft accidents; it is recommended that AIXL must ensure that 100% DFDR data is downloaded as per CAR for FOQA monitoring and trend analysis is done so that timely follow up action is taken. |
Issued: -- | To: Air India Express | 4.1.6 |
INSPECTION OF FLIGHT RECORDER SYSTEM
In view of the fact that RH Brake pressure transducer unserviceability could not be identified during repeated checks and monitoring, it is recommended that, personnel involved in analysis of data from Flight Recorders as per CAR Section 2, Series I, Part V are provided Technical Training so as to ensure that proper analysis is carried out, discrepancies are identified and timely remedial measures are undertaken. |
Issued: -- | To: Air India Express | 4.1.7 |
CVR MONITORING
As a policy AIXL is monitoring CVR. It is recommended that AIXL uses CVR monitoring to effectively analyse and address the established weaknesses in non technical skills including Cockpit Gradient. |
Issued: -- | To: Air India Express | 4.1.8 |
AIXL HR MANAGEMENT
(i) To ensure better availability of Crew at all bases, it is recommended that AIXL HR to take into consideration the quantum of flights originating from respective bases and accordingly assign them as home base, especially for the Captains.
(ii) AIXL may ensure that all post holders and sub-post holders are available at their designated office to ensure proper supervision of their area of operations. The operator may define clear office days/hours for such post holders and sub post holders as a part of their company HR policy. Their office days must be considered as a part of duty as defined in DGCA CAR Section 8.
(iii) At present AIXL does not have an independent medical department. It is recommended that Aviation/Aerospace Medicine Specialists be employed in accordance with DGCA General Advisory Circular No. 01 of 2011 dated 17 December, 2011. Also, the Aerospace Medicine specialist to take classes during ground training for cockpit crew to indoctrinate aircrew in aeromedical issues. |
Issued: -- | To: Air India Express | 4.1.9 |
AIRCRAFT DEFECT REPORTING
The Investigation Team observed that there were instances of verbal briefing for defect reporting in AIXL. It is recommended that verbal briefing for any aircraft defect be strongly discouraged and correct procedures be followed as defined in relevant DGCA CAR. |
Issued: -- | To: Airports Authority Of India (AAI) | 4.2.1 |
AIR TRAFFIC CONTROL
It is recommended that AAI ensures that during the ab-initio training of ATCO and annual refresher the following aspects to be strongly emphasized: -
(i) The impact of tailwind conditions in adverse weather.
(ii) The impact of change of QNH.
(iii) Precautions required to be taken while deciding the change of runway in adverse weather. |
Issued: -- | To: Airports Authority Of India (AAI) | 4.2.2 |
TRAINING OF ARFF CREW
The ARFF crew at Kozhikode were not familiar with the type of aircraft, which resulted in poorly coordinated rescue operations and delayed evacuation of the pilots from the cockpit. Therefore, it is recommended that AAI must ensure that mandatory Aircraft Familiarization Training is provided to all ARFF crew at posted station within defined timeline in addition to recurrent training as per the existing requirements.
In order to achieve the same, APD at all airports should coordinate with airline operators for timely conduct of aircraft familiarization training for ARFF crew on all types of aircraft operating through that aerodrome as mentioned in ICAO Doc 9137-AN/898 Airport Services Manual, Part 1- Rescue and Fire Fighting. This should be monitored by DGCA through realistic surveillance inspections. |
Issued: -- | To: Airports Authority Of India (AAI) | 4.2.3 |
MAINTENANCE OF RESA
Proper maintenance of soft ground portion of RESA offers crucial defence in case of a runway excursion. It is recommended that upkeep and maintenance of RESA be ensured at all times as per the laid down specifications. |
Issued: -- | To: Airports Authority Of India (AAI) | 4.2.4 |
AIRPORT PERIMETER ROAD
The Kozhikode airport perimeter road which surrounds the airport should be capable of supporting heavy Fire Fighting vehicles in order to achieve the required response time with adequate safety. In Nov 2019, DGCA during their surveillance had made similar observations however, the observed deficiencies still existed as on the date of accident. It is recommended that the perimeter road should be wide enough to facilitate quick movement of emergency vehicles. |
Issued: -- | To: Airports Authority Of India (AAI) | 4.2.5 |
AIRPORT DOCTOR
The Airport Doctor has an important role in the Aerodrome Emergency Plan (AEP). It is recommended that all doctors detailed at the Airport Terminal Clinic must undergo formal and structured familiarisation training for their roles and responsibilities during an aircraft accident as per the published AEP.
The Airport Doctor must participate in the periodic refresher training and mock drills carried out at the airport for the ARFF crew. It is also recommended that the Airport Doctor should train the ARFF crew in respect of prioritization of mass casualties (triage) and casualty carriage procedures. |
Issued: -- | To: Airports Authority Of India (AAI) | 4.2.6 |
APPROACH RADAR
Kozhikode airport is one amongst the ten 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. |
Issued: -- | To: Airports Authority Of India (AAI) | 4.2.7 |
MOCK DRILL
In Nov 2019, DGCA during their surveillance had made certain observations regarding deficiencies in conduct of Mock Drills. The observed deficiencies still existed as on the date of accident. In order to achieve the desired training outcomes from the Mock Drills, it is recommended that there must be a timely follow up action on all deficiencies observed. |
Issued: -- | To: Airports Authority Of India (AAI) | 4.2.8 |
VIDEO RECORDING OF RESCUE OPERATIONS
The requirement for video recording of rescue operations is laid down in ASC 04 of 2013. It is recommended that, all CFTs and Command Post should be fitted with cameras for real time video recording of the entire rescue operation. Also, the requirement of video recording of rescue operation should be incorporated in the Aerodrome Emergency Plan of all Airports. |
Issued: -- | To: Airports Authority Of India (AAI) | 4.2.9 |
PRESERVATION OF CCTV FOOTAGE FOR ACCIDENT INVESTIGATION
CCTV footage can provide important leads into various aspects for the purpose of Accident Investigation. It is recommended that guidelines contained in the ASC 05 of 2014 should be promulgated as CAR for better compliance and same should be incorporated in the organisation manuals of aerodromes. |
Issued: -- | To: Indian Meteorological Department | 4.3.1 |
TOWER MET OFFICER
The role and responsibilities of TMO during adverse weather are clearly delineated in CAMD Aviation Circular dated 01 Nov 2018. It is recommended that the presence of TMO be ensured in the tower along with DATCO especially during dynamic weather situations. |
Issued: -- | To: Indian Meteorological Department | 4.3.2 |
SURFACE WIND OBSERVATION FOR RUNWAY 10
Since the accuracy of reported surface winds for runway 10 was affected by non standard installation and poor maintenance, it is recommended that the sensors for measuring surface winds for runway 10 to be installed as per the specifications mentioned in DGCA CAR and regular maintenance should be ensured. |
Issued: -- | To: Indian Meteorological Department | 4.3.3 |
VISIBILITY LANDMARK CHARTS
At Kozhikode airfield, most of the daytime/night time visibility markers as per the available Chart were not distinctly noticeable therefore, it is recommended that the chart be updated in accordance with the current existing landmarks. |
Issued: -- | To: Indian Meteorological Department | 4.3.4 |
RUNWAY VISUAL RANGE SYSTEM
Vide DGCA letter No. 20025/13/06 AL dated 08 August 2018, AAI was permitted to recommence wide body operations in Kozhikode post installation of transmissometer for RVR reporting. However, at the time of the accident RVR instrument had not been installed at Kozhikode. RVR can significantly enhance accuracy of visibility reporting leading to a better situational awareness of the pilots during low visibility. It is recommended that AWOS and RVR system be installed. |
Issued: -- | To: DGCA India | 4.4.1 |
REVISION OF CARs
The Investigation Team observed that the recommendations made in respect of FOQA anomalies (post AIXL 2010 Mangalore Accident), have not been addressed for the last 10 years. It is recommended that DGCA should revise CAR Section 5, Series F, Part II Issue I, dated 30 Sep 99, Rev 1 dated 26th 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 touchdown zone and to standardize the FOQA limits for all type of aircraft operating in India.
While draft CARs are placed in open domain and public comments are solicited, however, to ensure better inclusiveness it is recommended that Subject Matter Experts from the industry be also utilized while planning and formulating CARs. |
Issued: -- | To: DGCA India | 4.4.10 |
AIRPORT SAFETY RISK ASSESSMENT
DGCA may 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. |
Issued: -- | To: DGCA India | 4.4.11 |
SMS TRAINING DURATION
In order to ensure standardization in the duration of SMS training across all stakeholders, it is recommended that CAR Section 1 Series C Part-1 on Establishment of Safety Management System may be revised to include minimum duration of training especially for the SMS Managers/Nodal officers. |
Issued: -- | To: DGCA India | 4.4.12 |
INSTALLATION OF RUNWAY OVERRUN AWARENESS & ALERTING SYSTEM (ROAAS)
It is recommended that DGCA may consider installation of ROAAS for all scheduled operators especially those operating turbojet aircraft (reference EASA Ed Decision 2020/001/R). |
Issued: -- | To: DGCA India | 4.4.13 |
LOW VISIBILITY TAKE-OFF (LVTO) MINIMA
The Investigation Team reviewed the low visibility take-off minima of AIXL at Kozhikode (Calicut) and the LVTO minima was found to be 300 m. As per the DGCA CAR Section 8 Series C Part I, whenever RVR is not reported, the lowest visibility value is required to be 800 m.
It is recommended that DGCA may ensure that no operator files LVTO minima below 800 m visibility when RVR is not reported for the specific runway. |
Issued: -- | To: DGCA India | 4.4.14 |
COMPETENCY BASED TRAINING AND ASSESSMENT (CBTA)
DGCA may introduce Competency Based Training and Assessment as recommended by ICAO and ensure pilots are trained and assessed on the nine competencies listed below:
(i) Communication
(ii) Aircraft Flight Path Management Manual Control
(iii) Aircraft Flight Path Management Automation
(iv) Leadership and teamwork
(v) Problem Solving and Decision making
(vi) Application of procedures
(vii) Work load Management
(viii) Situational Awareness
(ix) Knowledge |
Issued: -- | To: DGCA India | 4.4.15 |
USE OF ONBOARD TECHNOLOGY FOR ASSESSMENT OF WIND
DGCA may advise all operators/flight crew to better utilize the onboard wind indication to enhance their situational awareness in order to execute a stabilized approach. |
Issued: -- | To: DGCA India | 4.4.16 |
CLUBBING OF CIRCULARS INTO CAR
The investigation team observed that there are far too many circulars and CARs on the same topic e.g. Monsoon Operations, Adverse Weather, Stabilized Approach etc.
DGCA may compile all information in a single document addressing a particular topic in form of a CAR, Circular etc for ease of reference to the user. |
Issued: -- | To: DGCA India | 4.4.17 |
SELF MEDICATION FOR DIABETES MELLITUS
DGCA should issue directions to all scheduled and non-scheduled operators to educate their aircrew regarding the aeromedical consequences of self medication. DGCA may undertake a study to establish prevalence of use of non-prescribed medications amongst aircrew especially for Diabetes. |
Issued: -- | To: DGCA India | 4.4.18 |
COOPERATION BY DGCA DURING INVESTIGATION
The information sharing mechanism between the Investigation Team and concerned DGCA officials during aircraft accident/serious incident investigation should be in accordance with the Aircraft (Investigation of Accidents and Incidents) Rules, 2017 Rule 10(1) (a) and (b). DGCA may advise its officials to participate in discussions whenever required by the Investigation Team |
Issued: -- | To: DGCA India | 4.4.2 |
FOQA MONITORING
It is recommended that DGCA should ensure that 100% DFDR monitoring as stipulated in CAR is carried out by all scheduled operators. In addition to the unstabilized approach, long landings should also be monitored. Reference DGCA CAR Section 8 All Weather Operations (Adverse Weather), DGCA may ensure compliance with the recommendations regarding use of Flaps, Thrust Reverser etc. and the same may be monitored during FOQA/SOP monitoring especially during monsoon and pre-monsoon. |
Issued: -- | To: DGCA India | 4.4.3 |
SOQA MONITORING
Similar to FOQA, DGCA may consider implementing Simulator Operations Quality Assurance (SOQA) when an operator chooses to bring in new FSTDs or may choose to upgrade their existing simulator for better monitoring of training/checks being performed in the FSTD. |
Issued: -- | To: DGCA India | 4.4.4 |
FLIGHT SURVEILLANCE
It is recommended that DGCA may ensure:
(i) Periodic surveillance of flights to critical and table top runways including red eye flights.
(ii) Increased surveillance should be carried out during monsoons (DGCA CAR Section 5 Series F Part I).
(iii) Further, the monsoon circular ASC 03 of 2017 and ASC 02 of 2019 should also be aligned with the requirement of this CAR and CAR section 8
All Weather Operations Adverse Weather/Monsoon Operations.
DGCA may ensure compliance of implementation of LOSA programme during their regular audits and surveillance. |
Issued: -- | To: DGCA India | 4.4.5 |
NATIONAL AVIATION SAFETY PROGRAMME
There is an urgent requirement to revise targets for Safety Performance Indicator for remaining period of NASP (2018-22). Therefore, it is recommended that the NASP may be reviewed and Safety Performance Indicator/Safety Action Plan be 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 its implementation and safety data should be published in a timely manner by DGCA. |
Issued: -- | To: DGCA India | 4.4.6 |
CHILD RESTRAINT SYSTEM
It is recommended that DGCA may study the feasibility and efficacy of Child Restraint System for safety of infants and children on board the aircraft. |
Issued: -- | To: DGCA India | 4.4.7 |
RUNWAY STRIP
It is recommended that the long pending permanent exemption for runway strip width for Kozhikode airfield as sought vide letter No. AAI/AL/30-23(Misc- SA)/2018/660 dated 28 Sep 2018 may be resolved by DGCA on priority. |
Issued: -- | To: DGCA India | 4.4.8 |
RUNWAY CENTRE LINE LIGHTS
The topography and weather phenomenon at Kozhikode and Mangalore put serious constraints on Flight operations at these airports. For maintaining directional control by the flight crew during adverse weather and to enhance situational awareness, centre line lightings may be made available on such runways. The need of installing centreline lights was highlighted in the recommendations involving incidents of AIXL aircraft in the year 2012 at Managlore and Etihad aircraft in the year 2019 at Kozhikode. Based on Airlines requests and on recommendations of investigation reports, AAI has agreed to install Runway Centre Line Lights at Kozhikode and Mangalore during next re-carpeting of runway which is due in 2022 and 2024 respectively. It is recommended that DGCA may ensure that Runway Centre Line Lights are installed at these airports within the said time frame or earlier. |
Issued: -- | To: DGCA India | 4.4.9 |
PROMULGATION OF SAFETY CIRCULARS
It is recommended that DGCA may ensure that guidelines contained in ASC 06 of 2010, ASC 04 of 2013 and ASC 05 of 2014 are promulgated through CARs for better compliance and same is incorporated in the organization manuals of Airlines and Aerodrome Operator. |