Accident Board Findings

The Court of Inquiry issued 85 findings, all of which were commented upon by the Government of India.

The complete documentation of findings can be viewed at the following link:  (Findings)

The Court of Inquiry determined the probable cause to be: 

"Failure of the Pilots to realise the gravity of the situation and respond immediately towards proper action of moving the throttles, even after the Radio altitude call-outs of "Four Hundred," "Three Hundred" and "Two Hundred" feet, in spite of knowing that the plane was in idle/open descent mode.  However, identification of the cause for the engagement of idle/open descent mode on short final approach during the crucial period of the flight is not possible."

A complete copy of the accident report is available at the following link:  (Accident Report). (Note: The copy of the accident report used to construct this accident module had a few missing pages, and was additionally of poor copy quality. The report was transcribed verbatim in order to enhance the readability, however, certain pages were not available for transcription, and the report, in that sense, is not complete. Efforts to locate and include the missing pages were unsuccessful. Missing pages did not affect the accident board's findings or recommendations.

The accident report states that "The entire crash is the result of what the pilots did not do between 295 to 320 seconds – during 25 seconds (i.e. less than half a minute) and not what they did."

The Government of India approved Accident Report rephrased the probable cause as follows, including some pertinent additions:

"Failure of the pilots to monitor speed during final approach, probably because they diverted their attention to find out the reason for the aircraft going into idle/open descent mode rather than realising the gravity of the situation and responding immediately towards proper action. This crash would not have happened if the pilots had taken any one of the following action:

(a) if the vertical speed of 700 feet as asked for by Capt. Fernandez at about DFDR 294 seconds had been selected and aircraft had continued in speed/vertical speed mode;

(b) if both the flight directors had been switched off between DFDR seconds 312 to 317 seconds;

(c) by taking over manual control of thrust i.e. disconnecting auto thrust system and manually pushing the thrust levers to TOGA (take off - go around) position at or before DFDR 320 seconds (9 seconds to first impact on golf course).

(d) if the go around altitude of 6000 feet had been selected on the FCU in accordance with the standard procedure at the time it was asked for by Capt. Fernandez."

The accident report contained certain specific findings related to airspeed, autothrust, and use of the Flight Control Unit (FCU), and Flight Director during the accident sequence;

Airspeed Related Accident Findings

Finding # 15. At 13:02:42 ( 295 DFDR Time Frame - i.e., about 35 seconds before the time of first impact with the ground). the aircraft was at a height of 512 ft. AGL.  Since then it started coming down below the profile and aircraft speed was falling below the target approach speed.  There is no specific indication that the crew monitored the speed and height since then.

Gov’t Comment  -  Agreed.

Finding # 57. Speed drop from 132 kts to 106 kts has taken 26 seconds from DFDR times 297 and 323 seconds.

Gov’t Comment  -  Agreed.

Finding # 63. CVR has shown no sign of panic or anxiety about speed loss until the PF spoke - "Hey we are going down". There were no calls of speed deviation though speed was 106 kts at DFDR time 323 seconds.

Gov’t Comment  -  Agreed.

Finding # 64. Low speed display on PFD on A-320 is excellent and they are computer generated. If correct they cannot be mistaken and speed trend display is compelling. There is no digital read out of value of current speed. PFD Air Speed display data is not recorded on DFDR.

Gov’t Comment  -  Agreed.

Autothrust Related Findings

Finding  # 20. This crash would not have happened:
(c) by taking over manual control of thrust i.e., disconnecting auto thrust system and manually pushing the thrust levers to TOGA (take off - go around) position at or before DFDR 320 seconds (9 second~ to first impact on golf course).

Gov’t Comment  -  Agreed. This finding could be amplified further by adding that had the pilot set the go round altitude of 6000 feet on the FCU, it would have prevented the aircraft from going into idle open descent mode as it is not possible for the aircraft to go into idle open descent mode below FCU selected altitude.

Finding  # 35. Prior to 305 seconds, the aircraft went into idle open descent mode.  A conclusive finding as to what pilots did at this point of time is not possible.

Gov’t Comment  -  Agreed to the extent that "Prior to 305 seconds the aircraft went into idle open descent mode".   As regards the cause for engagement of Idle/Open descent mode, the Court itself' at page No. 310, para 14 has noted.  "It is also probable that he wanted to select go around altitude first and therefore selected the altitude knob, but while dialing it, the words just delivered to him by CM-l regarding vertical speed influenced his action and thus he selected the altitude of 700 feet without even realising that he has selected wrong altitude".  It was this action of the pilot (PNF) which most probably put the aircraft in idle open descent mode.

Finding  # 36. DFDR recording shows that auto thrust -speed select discrete changed status from '1' to '0' at 295 seconds.  There is no doubt that plane was in idle open descent mode by 305 seconds, by which time the plane was at an altitude lower than 400 feet Radio altitude.

Gov’t Comment  -  Agreed.

Finding  # 37. The aircraft could not sustain the height and speed in the approach profile because of fixed idle thrust in idle open descent mode.

Gov’t Comment  -  Agreed.

Finding  # 38. The aircraft never went to speed mode thereafter, though it was the most proper mode for landing.

Gov’t Comment  -  Agreed.

Finding  # 61. Idle/open descent mode of auto thrust system has engaged some time after DFDR time 295 seconds. The exact reason for this mode engagement cannot be explained or proved because of non-availability of FCU selected altitude data or FCU controls selection data on DFDR.

Gov’t Comment  -  Acceptable to the extent that FCU selected altitude or FCU control selection data are not recorded on DFDR. As regards engagement of idle open descent mode, the most probable cause has been explained in comments on finding No. 35.

Finding  # 65. Power awareness may be deficient in A-320 pilots when auto thrust is active, as even an Airbus Industrie test pilot was not aware of power required during final approach at 1000 FPM rate of descent.

Gov’t Comment  -  In regard to this finding, it must be pointed out that in aircraft of this class, auto thrust system is meant to reduce the workload of the pilot on the final approach by maintaining the required speed.  It is the speed which is of paramount importance and when flying with manual thrust on this aircraft, it is easy to maintain speed even without referring to engine power indications. This is because of the facility of the speed trend arrow.

Finding  # 66. There is no warning if auto thrust brings thrust to idle for whatever reasons during approach.
Gov’t Comment  -  Agreed.

Finding  # 67. Idle/open descent on short final though corresponding to an aircraft in dangerous configuration leading to limit flight condition, is indicated in 'GREEN' on PFD and not in 'RED'.

Gov’t Comment  -   The finding relates to design features of the aircraft and will be referred to Airbus Industrie.

Finding  # 69. Static thrust levers when auto thrust is active removed the feel of thrust lever movement and visual indication of position corresponding to actual thrust or thrust change trend.  Only way to know the thrust is to read the value on ECAM.

Gov’t Comment  -   The finding relates to design features of the aircraft and will be referred to Airbus Industrie.  An A-320 operators conference held in Cairo early this year to review the autothrust fixed throttle concept supported the concept of nonmoving throttles incorporated in A-320 aircraft.

Flight Control Unit (FCU) Related Findings

Finding # 20. This crash would not have happened: (a) if the vertical speed of 700 ft. as asked for by Capt. Fernandez at about DFDR 294 seconds had been selected and aircraft had continued in speed/vertical speed mode;

Gov't Comment - Agreed. This finding could be amplified further by adding that had the pilot set the go round altitude of 6000 feet on the FCU, it would have prevented the aircraft from going into idle open descent mode as it is not possible for the aircraft to go into idle open descent mode below FCU selected altitude.

Finding # 34. CVR-DFDR correlation reveals that at about 38 to 40 seconds prior to the first touch down the aircraft was in proper auto thrust speed mode and was descending in vertical speed mode. At DFDR seconds 292 altitude capture mode was activated indicating that a selection on the FCU panel close to MDA of 3300 ft. had been made at an earlier stage of the flight.

Gov't Comment - Agreed.

Finding # 35. Prior to 305 seconds, the aircraft went into idle open descent mode. A conclusive finding as to what pilots did at this point of time is not possible.

Gov't Comment - Agreed to the extent that "Prior to 305 seconds the aircraft went into idle open descent mode". As regards the cause for engagement of Idle/Open descent mode, the Court itself' at page No. 310, para 14 has noted. "It is also probable that he wanted to select go around altitude first and therefore selected the altitude knob, but while dialing it, the words just delivered to him by CM-l regarding vertical speed influenced his action and thus he selected the altitude of 700 feet without even realising that he has selected wrong altitude". It was this action of the pilot (CM~2) which most probably put the aircraft in idle open descent mode.

Finding # 61. Idle/open descent mode of auto thrust system has engaged some time after DFDR time 295 seconds. The exact reason for this mode engagement cannot be explained or proved because of non-availability of FCU selected altitude data or FCU controls selection data on DFDR.

Gov't Comment - Acceptable to the extent that FCU selected altitude or FCU control selection data are not recorded on DFDR. As regards engagement of idle open descent mode, the most probable cause has been explained in comments on finding No. 35.

Flight Director (FD) Related Findings

Finding # 20. This crash would not have happened: (b) if both the flight directors had been switched off between DFDR seconds 312 to 317 seconds; or

Gov't Comment - Agreed. This finding could be amplified further by adding that had the pilot set the go round altitude of 6000 feet on the FCU, it would have prevented the aircraft from going into idle open descent mode as it is not possible for the aircraft to go into idle open descent mode below FCU selected altitude.

Finding # 21. In all probability one of the pilots acted to put off FD.2 by about TF.313 seconds, but FD.2 failed to go off resulting in confusion in the mind of Capt. Gopujkar.

Gov't Comment - Agreed.

Finding # 60. The times of change of FMGC used FD mode and GFC 1 bus (18) discrete status do not correspond to the time of CVR conversation of FDs to be put off and putting them off.

Gov't Comment - The finding is not based on material evidence; hence not acceptable.

Finding # 70. Use of VOR/DME during visual approach is in conformity with Indian Airlines and Aeroformation procedures. Use of FD during visual approach is not prohibited by Airbus Industrie. The pilots in the instant case, followed a visual or a mixture of VOR/DME with visual procedure in all probability.

Gov't Comment - Agreed.

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