Mumbai Airport Learjet Crash 2023: Time Pressure, Pilot’s Decision To Land In Bad Weather Cited As Key Factors

Mumbai: A cascade of human errors, procedural lapses and self-imposed pressure to beat an operational deadline during monsoon led to the crash of VSR Ventures’ private executive jet at Mumbai’s Chhatrapati Shivaji Maharaj International Airport (CSMIA) in September 2023. The final investigation report by the Aircraft Accident Investigation Bureau (AAIB) highlighted that the pilot’s decision to continue landing an unstabilised aircraft under inclement weather conditions was a probable cause of the accident.

Non-scheduled flight operator VSR Ventures’ Learjet 45XR, registered as VT-DBL, had crashed on CSMIA’s runway on September 14, 2023, during a low-visibility manual landing. The crash led to the aircraft being completely destroyed, with its fuselage breaking into two parts. All eight occupants on board, including six passengers, a cabin attendant and two pilots, survived the high-impact crash with serious injuries.

Notably, VSR Ventures is the same company whose another Learjet 45XR crashed in Baramati on January 28 earlier this year, resulting in the death of Maharashtra’s then Deputy Chief Minister Ajit Pawar and four others.

The AAIB published the final investigation report of the 2023 crash on Friday – after a long delay of three years.

Pressure to beat landing restrictions

According to the AAIB’s investigation, the cockpit crew was in a hurry to land to save itself from the two-hour landing prohibition for general aviation operations at CSMIA, which started at 5.30 pm. According to the cockpit voice recorder (CVR) transcripts, the flight crew discussed the restrictions throughout the flight and had even asked air traffic control (ATC) for direct routings to shorten their flight time.

"The undue commitment of the crew to land the aircraft before existing restrictions in Mumbai prompted them to continue an unstabilised approach contrary to the laid down SOPs," investigators noted, identifying this self-imposed pressure as a primary contributory factor.

Pilot loses visual contact with runway

The investigation revealed that the pilot-in-command, who disconnected the autopilot to land the aircraft manually, lost visual reference with the runway after dark cloud patches obscured the airfield. However, the pilot continued the landing in low visibility of 800 m instead of executing an immediate missed approach according to the SOPs.

The decision led to the aircraft shifting towards the left of the runway centreline before drifting sharply to the right, crossing the runway threshold at 137 feet above ground level – which is significantly higher than normal – with an unmodelled 8 to 10-knot tailwind pushing the aircraft.

The AAIB noted that cockpit decision-making eroded during this critical window, with the pilots failing to conduct the standard challenge-and-response landing checklist, failing to monitor airspeed and the pilot monitoring – the first officer in this situation – failing to call for a go-around during the initial destabilisation.

Failed go-around precedes crash

However, when the first officer shouted, “No No… Go Around, Go Around,” at 122 ft above ground level, the airspeed had decreased to 111 knots, with engine power near idle. While the captain tried to execute a go-around by advancing the thrust levers to full power, the spike in the aircraft's angle immediately triggered the ‘stall’ warnings at a height of merely 112 ft.

As the aircraft had entered an aerodynamic stall at a very low altitude, the captain “abruptly” decreased the engine power and banked the aircraft hard to the right. In post-accident statements, he stated that the deliberate act was intended to avoid crashing into densely populated residential areas beyond the airport perimeter. The act led to the jet rolling to an extreme right-wing-down bank, with its nose down, slamming into an unpaved grass area near the intersection of Taxiway W and Taxiway N at 96 knots.

AAIB recommends training and safety reforms

The AAIB has asked the Directorate General of Civil Aviation to amend flight crew skill test standards to mandate stall recovery training in the landing configuration during simulator checks, and conduct a comprehensive audit of all non-scheduled operators' training records. It has asked the operators to mandate strict compliance with stabilised approach criteria and ensure SOP compliance.

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The AAIB’s scrutiny of VSR Ventures’ logbooks revealed incomplete documentation, missing certifying staff stamps and unrecorded maintenance details. Moreover, there were discrepancies in training procedures.

Sequence of events

3.15 pm – Aircraft took off from Visakhapatnam

4.44 pm – Aircraft cleared for descent for approach

4.56.29 pm – Pilot confirms runway approach light in sight

4.56.41 pm – Captain asks First Officer to disconnect autopilot

4.56.46 pm – Visual contact with the runway lost. Captain asks, "Where is it...?"

4.57.03 pm – First Officer anxiously asks Captain to turn right after noticing leftward drift

4.57.14 pm – First Officer calls out: "No No...Go Around, Go Around, Go Around"

4.57.19 pm – Captain applies full power, but aircraft was close to losing lift

4.57.22 pm – Aircraft rolls and banks to extreme right

4.57.23 pm – Aircraft crash-lands on grass at a speed of 96 knots

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