Air India Express flight crew's lapse probably led to runway incursion at Goa airport in April this year: AAIB

New Delhi: Air India Express flight crew's failure to adhere to air traffic controller's instructions and communication misinterpretation are the probable causes for the runway incursion of the plane when a Navy fighter jet was taking off at Goa's Dabolim airport in April this year, according to AAIB.

The incident happened in the morning of April 3 involving Air India Express' Boeing 737-8 aircraft which was to operate the flight AXB 1109 from Dabolim to Delhi, and Navy's single pilot fighter jet. There were 171 people onboard the flight and there were no injuries.

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At Dabolim airport, a civil enclave, air traffic services are provided by INS HANSA. Tower as well as approach controllers are from the Indian Navy.

The Surface Movement Control (SMC) controller at the airport is from the Airports Authority of India (AAI).

In its final report on the incident, probe agency AAIB has recommended that Dabolim airport's taxiway TWY N2 "may be considered as a HOTSPOT due to its proximity with Bay 1 & 2 of civil apron and increased probability of the risk of potential ground collisions and RWY (runway) incursions".

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"The flight crew did not fully adhere to the SMC Controller's taxi instructions to 'hold at holding point and to contact Navy- Approach on 119.7 MHz at the holding point.

"Had they stopped and established positive communication with the Navy- ATC before entering the active runway, the incident could have been avoided," the Aircraft Accident Investigation Bureau (AAIB) said.

According to the probe agency, another probably cause for the incident was that R/T call of 'Expect back track' by SMC controller was misinterpreted by the Pilot Flying as 'enter backtrack clearance'.

This resulted in the crew's cognitive focus to shift entirely toward executing the runway entry, without seeking an explicit clearance, AAIB said and added that failing to request clarification may have likely caused the Pilot In Command to believe erroneously that they have received an expected clearance to enter runway.

"If the SMC controller had insisted on a correct readback, read back error by the captain and hear-back error by the SMC with regard to a crucial R/T (Radiotelephony) call 'hold at holding point', could have prevented the serious incident," AAIB said and cited it as a contributory factor.

In the 35-page final report that includes annexures, AAIB cited another contributory factor that being a trainee, Pilot Monitoring (PM) of the flight was overly-reliant on the instructor and followed instructions without any hesitation.

"He got busy with heads down tasks after the taxi holding point trying to verify the values for RWY 08 take-off on the active runway due to which he was unable to monitor the R/T calls effectively; neither did the PM caution the PF from an unauthorised entry," it added.

Further, the AAIB has recommended that Air India Express should issue a circular to sensitise all the crew for the lapses encountered in the particular occurrence.

It has also suggested that the AXB 1109 crew should undergo counselling and that the Pilot In Command (PIC) should do training on the safety lapses that resulted in the runway incursion due to lack of operational clarity and communication miss outs.

Among other safety recommendations, AAIB has suggested that AAI issue a circular to sensitise Air Traffic Controllers (ATCOs) for emphasising the use of standard R/T phraseology and to review the use of phrases like 'expect backtrack' by ground controllers which can be easily misinterpreted as 'enter backtrack'.

"ATCOs/ SMC controllers must listen carefully to the read-back and correct any factual error or any apparent misunderstanding," the report said.

On priority basis, the probe agency has recommended establishing collaboration between DGCA/AAIB and Defence authorities.

Other safety recommendations are that INS HANSA consider establishing a standard frequency change over procedure for civil traffic transitioning from the ground frequency to the tower frequency,

This is to avoid "recurring confusion regarding the appropriate frequency to be used," the report said.

Following the occurrence, Naval and AAI authorities held a meeting and revised the handing over as well as taking over procedures.

"It was decided that the SMC controller will directly coordinate with the Navy ATC during watch taking over at the start of the day on the HOTLINE to particularly confirm critical elements pertaining to briefing like the Runway- in use, and change-over frequency," the report said.