Probe agency AAIB has recommended that the regulator DGCA may carry out a one-time check of all training records of fixed-wing pilots, especially for non-scheduled operators, to verify that all mandatory exercises are done during each simulator training session.
Also, the Aircraft Accident Investigation Bureau (AAIB) suggested issuing directions to non-scheduled and general aviation operators to develop specific methodologies to ensure pilots undergo all mandatory training, including critical emergencies, as per laid-down regulatory requirements.
The recommendations are part of the final report into the accident involving VSR Ventures' Learjet 45XR aircraft VT-DBL at Mumbai airport on September 14, 2023, that resulted in serious injuries to all eight people onboard -- six passengers and two crew members.
The aircraft, which was operating a non-scheduled flight from Visakhapatnam, was destroyed in the accident while landing at Mumbai airport. One of the taxiway lights was found broken due to the accident.
"The probable cause of the accident was the flight crew's decision to continue the unstabilised approach under marginal weather conditions and inappropriate handling of the aircraft which led to an aerodynamic stall at low altitude from which the aircraft did not recover," AAIB said in its final report.
According to the report, the flight crew's non-adherence to SOP (Standard Operating Procedure) for not monitoring the airspeed against a rising low speed cue and pilot monitoring's non-adherence to SOP for delay in calling out for go-around were among the contributory factors for the accident.
The agency also cited marginal weather conditions prevailing at that time, which impaired the flight crew's visual cues and a high tailwind component, as well as undue commitment to land the aircraft before the restricted time as per the existing restriction at Mumbai airport, as contributing factors.
Against the backdrop of these findings, AAIB has come out with a slew of safety recommendations, including that DGCA may consider adding stall recovery in landing configuration also during simulator training of pilots.
This means that pilots during each simulator training shall undergo a training exercise of 'recovery from a full stall, or after activation of the stall warning device in climb, cruise, approach and landing configurations'.
Another suggestion is that DGCA may carry out a one-time check of all training records of fixed-wing pilots, especially for non-scheduled and general aviation organisations, to verify whether all mandatory exercises are carried out during each simulator training.
"DGCA may issue specific directions as deemed fit to all non-scheduled/general aviation operators to develop specific methodologies to ensure that the pilots undergo all the mandatory training, including critical emergencies as per laid down regulatory requirements.
"Further, these methodologies should also include verification of the training records of the pilots from time to time to ensure there are no discrepancies in the training undergone by the pilots," the report said.
AAIB said VSR Ventures may sensitise their pilots to ensure cockpit crew carry out proper challenge-and-response checklists by verifying the settings and ensuring all systems are properly configured for safe operations as per the SOP.
"VSR Ventures may sensitise their maintenance/engineering personnel to maintain the aircraft documents such as technical log books, airframe log-books as per the laid down procedures in order to ensure that all entries are recorded without fail," the report said.
Also, AAIB recommended that DGCA may issue specific directions to all non-scheduled and general aviation operators to ensure internal audits are carried out in "true letter and spirit", and that effectiveness of internal audits may be checked during audits/surveillance of these organisations.
Among others, the probe agency has suggested that the regulator issue specific directions to all such operators to strictly adhere to the laid-down procedures wherein pilots are sensitised to carry out a go-around at any time of the approach if it is not stabilised.
Besides, AAI may sensitise their air traffic controllers to maintain the required separation between aircraft to mitigate wake turbulence as per the laid-down procedures.