Who failed in Crash of Flight IX-812? Part 3

Glaring Organisational Failure

For the purpose of brevity, the organisational failures are only listed here.

  • Fatigue Risk Management System.  Air India Express does not have a fatigue risk management system (FRMS) [5] in place, hence the crew are neither aware of fatigue limits nor its countermeasures.
  • Poor Training with overburdened resources.  Training of crew emerged as a significantly weak area in the accident report [1]. It was found to be disjointed and inadequate as was evident from performance of both crew – ignoring the SOP of stabilised approach and poor planning of descent profile. Moreover, there are compromised methods of continuing training with passengers on board and recording observation flights as hours gained towards reckoned experience.
  • CRM Training.  Considering that the supervisors are deputed from Air India and hiring of foreign pilots as PIC on contract, while majority of first officers are company employees from India, CRM training has not modified to streamline cultural and company practices.
  • Controlled Rest in Seat.  There is a lack of policy on ‘Controlled Rest in Seat’ for the aircrew operating multiple short hop or Quick Turn Around flights at night.
  • Crew Scheduling.  Crew scheduling is ad hoc, using primitive paper and pencil rather than a computerised schedule. Thus frequent scheduling changes in absence of transparency denies pilots advance information about their flight schedule. This in turn compromises their personal activities including period for adequate rest.
  • Unresponsive Management.  Fractious Management and Crew relationships due to lack of cohesion and poor coordination.

Most of the above enumerated factors, including role of the Regulator, have been attempted to be addressed in the recommendations of the report [1].

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1. Report on Accident to Air India Express Boeing 737-800 Aircraft VT-AXV on 22nd May 2010 at Mangalore. DGCA, New Delhi. 2010

2. Prince C, Salas E. Training and research for team work in military. In : Weiner EL, Kanki BG, Helmreich RL, editors. Cockpit Resource Management, San Diego: Academic Press, 1993: 337-66.

3.Kanki BG, Palmer MT. Communication and crew resource management. In: Weiner EL, Kanki BG, Helmreich RL, editors. Cockpit Resource Management. San Diego: Academic Press, 1993: 99-136.

4. Farmer EW, McIntyre HM: Crew Resource Management.In ErnstingJE,King PF, editors.Aviation Medicine, 3rd ed. London: Butterworths; 2000: 608-19.

5. Fatigue Risk Management System