FINAL INVESTIGATION REPORT

ON ACCIDENT TO
M/s INDIRA GANDHI RASHTRIYA URAN
ACADEMY
TB20 AIRCRAFT VT-IGE
AT AZAMGARH, U.P ON 21st SEPTEMBER 2020.

AIRCRAFT ACCIDENT INVESTIGATION BUREAU, INDIA

K. Ramachandran Amit Kumar

Investigator -In- charge Investigator

1
 FOREWORD
In accordance with Annex 13 to the Convention on International Civil
Aviation Organization (ICAO) and Rule 3 of Aircraft (Investigation of Accidents
and Incidents), Rules 2017, the sole objective of the investigation of an
accident/serious incident shall be the prevention of accidents and incidents and
not to apportion blame or liability. The investigation conducted in accordance
with the provisions of the above said rules shall be separate from any judicial or
administrative proceedings to apportion blame or liability.

This document has been prepared based upon the evidences collected
during the investigation, opinion obtained from the experts and laboratory
examination of various components. Consequently, the use of this report for any
purpose other than for the prevention of future accidents or incidents could lead
to erroneous interpretations.

2
 INDEX

Para Content Page No.

SYNOPSIS 6
1 FACTUAL INFORMATION 7
1.1 HISTORY OF THE FLIGHT 7
1.2 INJURIES TO PERSONS 9
1.3 DAMAGE TO AIRCRAFT 9
1.4 OTHER DAMAGE 9
1.5 PERSONNEL INFORMATION 9
1.6 AIRCRAFT INFORMATION 10
1.7 METEOROLOGICAL INFORMATION 12
1.8 AIDS TO NAVIGATION 13
1.9 COMMUNICATIONS 13
1.10 AERODROME INFORMATION 13
1.11 FLIGHT RECORDERS 14
1.12 WRECKAGE AND IMPACT INFORMATION 14
1.13 MEDICAL AND PATHOLOGICAL INFORMATION 15
1.14 FIRE 15
1.15 SURVIVAL ASPECTS 15
1.16 TESTS AND RESEARCH 15
1.17 ORGANISATIONAL AND MANAGEMENT 15
INFORMATION
1.18 ADDITIONAL INFORMATION 18
1.19 USEFUL OR EFFECTIVE INVESTIGATION TECHNIQUES 21
2 ANALYSIS 22
2.1 SERVICEABILITY OF AIRCRAFT 22
2.2 WEATHER 22
2.3 ORGANIZATIONAL ASPECT 23
2.4 CIRCUMSTANCES LEADING TO THE ACCIDENT 24
3 CONCLUSIONS 25
3.1 FINDINGS 25
3.2 PROBABLE CAUSE OF THE ACCIDENT 28
4 SAFETY RECOMMENDATIONS 28

3
 GLOSSARY
AAIB Aircraft Accident Investigation Bureau, India
AMSL Above Mean Sea Level
ARC Airworthiness Review Certificate
ASR Airport Surveillance Radar
ATC Air Traffic Control
AUW All Up Weight
C of A Certificate of Airworthiness
C of R Certificate of Registration
CAR Civil Aviation Requirements
SPL Student Pilot License
CVR Cockpit Voice Recorder
DFDR Digital Flight data Recorder
DGCA Directorate General of Civil Aviation
FTO Flight Training Organisation
hrs Hours
IATA International Air Transport Association
ICAO International Civil Aviation Organization
ILS Instrument Landing System
LLZ Localizer
MEL Minimum Equipment List
MLG Main Landing Gear
NDB Non-Directional Beacon
NLG Nose Landing Gear
NM Nautical Miles
PA Passenger Address
PIC Pilot in Command
QRH Quick Reference Handbook
RA Radio Altitude
RESA Runway End Safety Area
SB Service Bulletin
VFR Visual Flight Rules
VMC Visual Meteorological Conditions
VOR VHF Omnidirectional Range
UTC Coordinated Universal Time

4
 FINAL INVESTIGATION REPORT ON ACCIDENT TO
M/s INDIRA GANDHI RASHTRIYA URAN ACADEMY, TRINIDAD TB20 AIRCRAFT,
VT-IGE IN AZAMGARH DISTRICT, U.P ON 21ST SEPTEMBER 2020

1. Type TRINIDAD TB20

Aircraft Nationality Indian

Registration VT-IGE

2. Owner and Operator Indira Gandhi Rashtriya Uran Academy

3. Pilot – in –Command Trainee Pilot

4. Extent of injuries Fatal

5. Date & Time of Accident 21.09.2020; 0540 UTC.

6. Place of Accident Azamgarh, U.P.

7. Last point of Departure Fursatganj Airport

8. Intended landing place Fursatganj Airport

9. No. of persons on board 01 (Trainee Pilot)

10. Type of Operation Training flight (Solo cross country)

11. Phase of Operation En-route

12. Type of Accident Uncontrolled flight into terrain

(Aircraft encountered bad weather)

13. Damage to the Aircraft Destroyed

(All the timings in the report are in UTC unless otherwise specified)

5
SYNOPSIS
On 21st September 2020, TB20 aircraft VT-IGE belonging to M/s Indira Gandhi
Rashtriya Uran Academy (IGRUA) was involved in a fatal accident at Azamgarh
district, U.P while operating a training flight. The aircraft was under the
command of a student pilot holding a valid student pilot license. The trainee
pilot was detailed for “solo cross country” flying from Fursatganj to Fursatganj
overflying Mau.
The Trainee Pilot took–off for a solo cross-country exercise from runway 09 of
Fursatganj airport after obtaining take-off clearance from Fursatganj ATC. The
weather at Fursatganj at the time of take-off was fine. The aircraft after take-off
was changed over and came in contact with ATC Lucknow. Initially, the aircraft
was cleared to and maintained 3500 ft. Thereafter, the trainee pilot requested
for climb to 5500 ft to ATC, Lucknow. The trainee pilot then informed ATC,
Lucknow the estimate of MAU as 05:31 UTC and Furstaganj as 06:31 UTC.
ATC Lucknow then instructed the aircraft to further climb in co-ordination with
Fursatganj & Varanasi ATC. The aircraft came in contact with ATC Varanasi
and in co-ordination with Furstaganj ATC was cleared for climb to 5500 feet.

It was observed on RADAR display that the aircraft had climbed to 6000 ft and
then descended to 5200 ft. The weather at that time became very bad. After
some time when the aircraft was around 36 NM North of BBN (Varanasi), the
Radar and VHF contact were lost and a synthetic radar position symbol
appeared. The controller gave many calls to the aircraft including calls on
emergency frequency, through other IGRUA aircraft and airlines aircraft
operating under the jurisdiction of ATC Varanasi, however, there was no
response. Later it was found that, the aircraft had crashed in an agricultural field
in Nizamabad village in Azamgarh district. The aircraft was destroyed during
the accident and the wreckage was scattered. The trainee pilot received fatal
injury.

Sh. K Ramachandran, Assistant Director, AAIB was appointed as Investigator

– In – Charge & Sh. Amit Kumar, Safety Investigation Officer as Investigator to
investigate into the probable cause(s) of the accident, vide Order No.
INV.11011/7/2020-AAIB dated 25th September 2020 under Rule 11 (1) of
Aircraft (Investigation of Accidents and Incidents), Rules 2017.
6
1. FACTUAL INFORMATION
1.1 History of Flight
For the purposes of imparting training in the organization, flying schedule is
prepared in the evening for the next day and accordingly flight plans are filed.
The Dy.CFI/ CFI of the organization use to inform trainee pilots about the flying
schedule for the next day. Accordingly, the trainee pilots reported in the morning
on 21.09.2020 for their respective flying training exercise.

On the day of accident, the CFI was on leave and all flying training operations
were authorized by Dy.CFI. At around 0145 UTC, the Dy.CFI conducted
morning briefing to the trainee pilots and after ensuring that the weather is fit
(for local as well as enroute for cross country) started flying training operations
as per the scheduled programme for the day.

The trainee pilot reported for flying training exercise in the morning as per the
programme. Trainee pilot was authorized for “solo cross country” long
navigational exercise from Fursatganj to Fursatganj over flying Mau by the
Dy.CFI. The trainee pilot then reported to one of the AFI at around 0300 UTC.
The AFI after ascertaining the local and enroute weather conditions detailed the
trainee pilot for solo cross country navigational exercise on VT-IGE from
Fursatganj to Fursatganj over flying Mau.

The aircraft was released for training flight after the AME qualified on type
carried out the first pre-flight inspection of the day and issued CRS for the
aircraft. There was no abnormality observed on the aircraft. The AFI accepted
the aircraft and carried out pre-flight inspection himself. He also did not observe
any abnormality in the aircraft.

The aircraft was then handed over to the trainee pilot. The trainee pilot after
obtaining the necessary clearances from the ATC, Fursatganj took off from
runway 09 at around 0450 UTC. The weather at the time of take-off at
Fursatganj was visibility 5000 meters with winds VRB/02 Kts (variable direction
with speed 2 knots). The aircraft was then changed over to ATC, Lucknow. The
aircraft came in contact with ATC, Lucknow at 0457 UTC and requested for
climb to FL55 and squawk. The trainee pilot then informed ATC, Lucknow the
estimate of MAU as 0531 UTC and Furstaganj as 0631 UTC.
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The ATC, Lucknow instructed the trainee pilot to climb in co-ordination with
Varanasi & Fursatganj and obtain departure squawk with Varanasi. The trainee
pilot then came in contact with ATC, Varanasi at around 0507 UTC and
informed that the aircraft is maintaining altitude 3500 feet and requested for
climb to 5500 feet. The ATC, Varanasi informed the radar squawk and
instructed to climb in co-ordination with Fursatganj and to report when released
by them. At 0510 UTC the trainee pilot again came in contact with ATC,
Varanasi and informed that ATC, Fursatganj has cleared for FL55. The ATC,
Varanasi also cleared the aircraft to climb to FL55 for which the trainee pilot
replied “Sir leaving 3500 for flight level 55” this was the last transmission made
by the trainee pilot. The aircraft then climbed to and was maintaining designated
altitude of 5500 feet.

It was observed on RADAR display that the aircraft had climbed to altitude of
6000 ft and then descended to 5200 ft. The weather at that time became very
bad. After some time when the aircraft was around 36 NM North of BBN
(Varanasi) at a radial of 30o, the Radar and VHF contact were lost and a
synthetic radar position symbol appeared. The controller gave many calls to the
aircraft including calls on emergency frequency, through other IGRUA aircraft
and airlines aircraft operating under the jurisdiction of ATC Varanasi, however,
there was no response. Another trainee pilot of the organisation was also
detailed for cross country long navigational flight on the same route (Furstaganj
– Mau- Fursatganj) on aircraft VT-FGF who was behind the deceased trainee
pilot. As per the statement of another trainee pilot, the ATC, Varanasi asked
him to contact VT-IGE and check its position. He tried calling VT-IGE two to
three times on Varanasi frequency but there was no response. He also tried
contacting VT-IGE on Gorakhpur frequency but there was no response. He
accordingly informed ATC, Varanasi about the same. He further stated that at
around 55 NM outbound from Fursatganj, he observed weather (vertically
developed clouds) in front and decided to set course back. After taking
necessary clearances from ATC, Varanasi and subsequent ATCs landed back
safely at Fursatganj. Another trainee pilot was also authorized for solo cross
country flight on aircraft VT-FGK for route Fursatganj – Ghazipur-Fursatganj
which departed before VT-IGE. The trainee pilot also stated he too observed

8
 developing weather near Varanasi and set course back to Fursatganj after
taking necessary clearances from ATCs.

Based on the last observed position of the aircraft the WSO, Varanasi called
District Magistrate (DM), Azamgarh. Later DM, Azamgarh confirmed the finding
of aircraft wreckage in a village called Seruddin Pur Usaha in Azamgarh district.

As per the eye witnesses, they heard a loud bang sound soon after a
thunderstorm and came out of their house. They observed that the aircraft was
losing height and then crashed in an agricultural field. Soon after the accident
it started raining in that area. The aircraft was destroyed during the accident
and the wreckage was found scattered. There was no fire.

1.2 Injuries to Persons

The trainee pilot who was the only occupant on board the aircraft received fatal
injury.
1.3 Damage to Aircraft
The aircraft was destroyed during the accident.

1.4 Other Damages

Nil
1.5 Personnel Information
1.5.1 Trainee Pilot
Nationality Indian
Age 25 years
Date of Joining Organization 26.09.2017
License Student Pilot License (SPL)
Date of Issue 14.08.2018
Valid up to 13.08.2023
Category Aeroplane
Date of Class I Med. Exam. 13.11.2019
Class I Medical Valid up to 12.11.2020
Date of issue FRTOL License 20.10.2018
FRTO License valid up to 19.10.2028
Endorsements as PIC (on SPL) TRINIDAD TB-20
Total flying experience 125:00 Hrs

9
 Total flying experience on type 125:00 Hrs
Last Flown on type 15.09.2020, TRINIDAD TB-20
Total flying experience during last 1 80:10 Hrs
year
Total flying experience during last 6 53:40 Hrs
Months
Total flying experience during last 10:05 Hrs
30 days
Total flying experience during last 02:35 Hrs
07 Days
Total flying experience during last Nil
24 Hours
Rest period before flight 12 hrs before the flight
Whether involved in No
Accident/Incident earlier
Date of latest Flight Checks and - 18.06.2020 Navigation Check
Ground Classes with CFI.
- 10.06.2018 Completion of ground
classes.

The student pilot started flying training in February 2019. He was released for
first solo flying on 6th June 2019 after obtaining flying experience of about 22:10
hours. The trainee pilot was released for first solo cross country long
navigational flight (Fursatganj – Rewa - Fursatganj) on 14th July 2021 after
almost 100 hours of flying training experience. The trainee pilot had carried out
09 solo cross country long navigational flight before the accidental flight
including 02 flights on the same route (Fursatganj – Mau - Fursatganj). All his
flying training had been carried out on TB20 aircraft.

1.6 Aircraft Information

Aircraft Model TRINIDAD TB-20
Aircraft S. No. 1883
Year of Manufacturer 1999
Name of Owner Indira Gandhi Uran Akademi (IGRUA)
C of R Valid
C of A Valid
Category Normal

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 A R C issued on 17.08.2020
ARC valid up to 02.07.2021
Aircraft Empty Weight 897.50 Kgs
Maximum Take-off weight 1400 Kgs
Date of aircraft weighment 14.02.2019
Max Usable Fuel 236.35 Kgs
Max Payload with full fuel 181.15 Kgs
Empty Weight C.G 1.001 m aft of Datum
Next Weighing due 14.02.2024
Total Aircraft Hours 8968:07 hrs
Last major inspection 100 Hrs/ 06 months app Inspection
List of Repairs carried out after NIL
last major inspection till date of
accident
Engine Type LYC.IO540C4D5D
Date of Manufacture 03.12.1992
Engine Sl. No. L-24159-48A
Last major inspection 100 Hrs/ 06 months app Inspection
schedule
List of Repairs carried out after NIL
last major inspection till date of
accident
Total Engine Hours/Cycles TSN-10305:20 Hrs-802:53 Hrs
Aero mobile License Valid upto 31.12.2021
AD, SB, Modification complied As applicable. AD, SB modification are
complied with
The aircraft was used for flying training purposes under Flying Training
Organisation approval No. 01/1999 which was last issued on 18th March 2020
and valid upto 26th March 2022. The accidented flight was the first flight of the
day on the aircraft.

All concerned Airworthiness Directives, mandatory Service Bulletins, DGCA

Mandatory Modifications on this aircraft and its engine had been complied with
as on date of accident.

11
 Scrutiny of the Pilot Defect Register (PDR) revealed that, there was no snag
pending on the aircraft prior to the accidented flight.

“Load and Trim” sheet of accidented flight was prepared and center of gravity
was found within limit.

1.7 Meteorological Information

The local weather for flying is taken from MET office situated at Fursatganj
Airport. Following METARs for Fursatganj airport were issued between 0400
UTC to 0600 UTC.

Time Winds Visibility Weather Clouds QNH Temp/

(UTC) (o/Knots) (Meters) (HPa) DP (oC)
0400 VRB/02 5000 Haze FEW 2000 FT 1000 35/26
(HZ)
0500 VRB/02 5000 Haze FEW 2000 FT 1000 35/27
(HZ)
0600 070/02 5000 Haze FEW 2000 FT 1015 31/27
(HZ) SCT 2500 FT

The aircraft was under the jurisdiction of Varanasi Airport at the time of
accident. The weather (METAR) MET Report for Varanasi Airport from 0500
UTC to 0700 UTC.

Time Wind Wind Vis Clouds Temp/ QNH TREND

in Dir Speed (m) Dew hPa
UTC (KT) Point
(℃)
0500 170 06 3500 FEW 2000 FT 32/26 1000 TEMPO
FEW CB 1500 IN
3000FT HVY
SCT 10000 FT TSRA
0506 120 15 --- SCT 2000FT 30/26 1001 NOSIG
FEW CB CB over
3000FT head
OVC 8000 FT
0530 060 07 2500 SCT 2000FT 31/26 1000 BECMG
FEW CB 3000 IN
3000FT TSRA
OVC 9000 FT

12
 0600 230 03 3000 SCT 2000FT 28/27 1000 NOSIG
FEW CB
3000FT
BKN 10000 FT
0630 360 04 3500 SCT 2000FT 28/27 1000 NOSIG
FEW CB
3000FT
BKN 10000 FT
0700 VRB 02 4000 SCT 2000FT 28/25 999 TEMPO
FEW CB 3000 RA
3000FT OVH
BKN 8000

1.8 Aids to Navigation

The aircraft was fitted with ILS, DME, VOR DME, RNAV transponder and GPS .
There was no defect reported and all navigational equipment were in
serviceable condition.

1.9 Communication
There was always two-way communication between the aircraft and ATC. The
recording of the communication between the aircraft and ATC was mostly clear
except when the aircraft was in contact with ATC, Lucknow. It was informed
that the reception from the aircraft departing from Fursatganj towards Mau,
Azamgarh, Gazipur, etc. are generally very poor due to low altitude maintained
by the training aircraft and VHF coverage.
At the time of accident, the aircraft was on Varanasi Approach Control
Frequency. The last communication made by the trainee pilot was “Sir leaving
3500 for flight level 55” when the trainee pilot was reading back the approval
given by Controller to the request made by him for climb to 5500 ft. The trainee
pilot did not report any operational difficulty at any stage of the flight.
It was observed that when the aircraft was under the control of Area
Surveillance Control, Lucknow all communication/RT call outs with the aircraft
was given by the planning controller.

1.10 Aerodrome Information

Not relevant. The accident occurred while the aircraft was enroute.

13
1.11 Flight Recorders
Cockpit Voice Recorder (CVR) and Digital Flight Data Recorder (DFDR) were
neither fitted nor required on this aircraft as per existing Civil Aviation
Requirements.

1.12 Wreckage & Impact Information

The aircraft was destroyed during the accident. The aircraft wreckage was
scattered in an area of radius of about 5 Kms from the point where the main
aircraft wreckage (Forward portion of cockpit along with wings and engine) was
found. The wings were found attached to the forward portion of the fuselage.
The main wreckage impacted the paddy field (soft ground) in nose down
attitude which was evident from the fact that the engine (which was intact with
the structure) along with front instrument panel were found buried
approximately 3 feet under soft ground.
When the investigation team reached the accident site, the local police
authorities informed that other aircraft wreckage parts fell in different areas of
the village. The villagers took these aircraft parts to their home which were later
recovered by the local police authorities. The investigation team with the help
of local police authorities interacted with the villagers/eyewitnesses to identify
the approximate position of each aircraft part from where it was picked up by
the villagers.
Following information was revealed from the interaction with villagers &
eyewitnesses: -
• The aircraft empennage along with rear seat were found approximately 5
Kms (In another village) away from the main wreckage on a terrace of a
house.
• The rear fuselage portion was found 500 meters away from the main
wreckage.
• The cockpit door along with attached frame was found on top of a tree,
however, the exact location of the tree could not be ascertained.
• The body of the deceased trainee pilot was found approximately 300 meters
away from the main wreckage. As per the eyewitnesses the trainee pilot fell
from the aircraft main wreckage before it impacted the paddy field.

14
 From the interaction with villagers/eyewitnesses and analyzing the wreckage
distribution pattern it is quite evident that the aircraft got disintegrated in flight.
The main wreckage along with parts recovered from the villagers were later
shifted to IGRUA hangar at Fursatganj. The aircraft wreckage was re-
constructed and it was found that most of the parts were recovered. The
wreckage was destroyed to an extent that some of the small parts could not be
recovered.

1.13 Medical & Pathological Information

The trainee pilot did not undergo pre-flight Breath Analyzer (BA) test before the
flight. As per order No. DGCA-15031/4/2020 issued by DGCA, for all domestic
operations only 10% random pre-flight BA examination is to be done. Therefore,
on the day of accident three trainees carried out BA test randomly, which didn’t
include the deceased trainee pilot.
The trainee pilot received fatal injuries.

1.14 Fire
There was no fire.

1.15 Survival Aspects

The accident was not survivable.

1.16 Test and Research

Nil

1.17 Organizational & Management Information

1.17.1 Indira Gandhi Rashtriya Uran Akademi (IGRUA)
Indira Gandhi Rashtriya Uran Akademi (IGRUA) is a flying training Organization
located at Fursatganj, Dist. Raebareli U.P. It was set up in 1985 as an
autonomous body under the Ministry of Civil Aviation. The chief executive of
the organization is the Director who is the Accountable Manager having both
the administrative and financial control in the organization. The flying training
operations at IGRUA commenced in Oct 1986. As per the Certificate of
Approval of FTO, the organization has approval for conducting flying training
courses for CPL, PPL, SPL, IR, FIR(A) training, etc. The FTO has fleet of
Trinidad TB-20, Zlin 242L, Diamond DA-40 and Diamond DA-42 aircraft.

15
 The Organisation Chart as per the Manual of the FTO is as shown below:

FIG. 1 - ORGANIZATION CHART

As on the day of accident, the flying training academy had one CFI, two Dy.CFI,
three FI and 06 AFI for imparting training to the student pilots. The FTO has in-
house maintenance setup as per CAR 145 which is approved by DGCA and
was valid on the day of accident.

1.17.2 Training and Procedure Manual (TPM) of the Organization

1.17.2.1 Duties & Responsibilities of CFI
The salient portion of duties & responsibilities of CFI as mentioned in the
TPM is reproduced below.

FIG.2 - SALIENT PORTION OF DUTIES & RESPONSIBILITIES OF CFI

16
1.17.2.2 Procedure regarding Weather
The investigation team perused the TPM of the organisation approved by
DGCA and it was observed that there was no specific procedure laid down
in the TPM for weather such as from where the weather/Forecast will be
taken, how the current weather and forecast will be informed to the
trainees/instructors for imparting flying training, who is responsible for
obtaining weather and maintaining weather watch all the time during flying
training exercise, etc. Also, there is no specific requirement/guidelines by
DGCA in this regard for FTOs.
However, it was informed to the investigation team that there is a settled
practice wherein the instructors conduct three briefings in a day for flying
training in batches. This also includes following Met Briefings: -
• Latest METARs of Fursatganj, Lucknow, Prayagraj and Varanasi.
• Current Weather Conditions: Satellite images and radar images are
displayed along with any weather warnings or cautions.
• Weather forecast Local & Neighboring Airfields: Max/Min temperature
of the day for base, chances of precipitation and winds at different
altitudes.
Post briefing the trainees report to their individual flying instructor for their
planned exercise briefing. Thereafter, the respective flying instructor briefs
the solo trainee as per their planned profile for navigation profile briefing
consists of Nav log briefing, route briefing, VFR Map briefing, fuel planning,
Local & Enroute weather briefing and few contingencies are discussed.
On the day of accident, the morning briefing was conducted at around 07:15
IST by one of the Dy.CFI as the CFI was on leave. As per the Dy.CFI, he
authorized the flying training exercise after ensuring that the current weather
and the weather forecast shown till 09:30 IST was fine for local & enroute
(for cross country). The deceased trainee pilot was briefed by one of the AFI
who stated that local & enroute weather was fine for solo navigation.

17
1.18 Additional Information

1.18.1 Wind Shear

Wind shear is a rapid change in wind speed or direction over a relatively short
distance in the atmosphere. This shear can be both either vertical or horizontal.
Vertical wind shear is a change in wind speed or direction with change in
altitude. Horizontal wind shear is a change in wind speed with change in lateral
position for a given altitude.

Wind shear conditions can occur at low as well as high altitudes. Horizontal
wind shear is most frequently experienced when crossing fronts or flying in the
vicinity of mountainous areas. Vertical wind shear can be experienced
anywhere from the surface to upper Flight Levels (FLs) – particularly it is
associated to thunderstorm conditions. The most dangerous conditions are
when flying at lower levels.

FIG. 3 - WIND SHEAR REPRESENTATION

Wind shear codes for speed, direction, temperature clouds, dew point etc. are
shown in the above figure. Wind shear measured in knots, is either positive or
negative. Increment in wind shear value are positive numbers, while decrement
is noted as negative values. When operating in the upper atmosphere, wind
shear value is almost always positive. Closer to the ground, one may
experience negative wind shear values.

18
 Symbols used for the quantum of wind shear are shown below.

FIG. 4 - WIND SHEAR CODES

Wind shear has significant affects on control of an aircraft. It causes rapid

change in lift, and thus the altitude, of the aircraft. Strong outflow from
thunderstorms causes rapid changes in the three-dimensional wind velocity just
above ground level. Initially, this outflow causes a headwind that increases
airspeed, which normally causes a pilot to reduce engine power if they are
unaware of the wind shear.

1.18.2 Weather Trend from MET Office, Lucknow

In addition to the general MET information provided by IMD (Refer Para 1.7),
weather trend with respect to change in altitude from time 0530 UTC to 0635
UTC was obtained from MET office, Lucknow to study the prevailing weather
conditions in the area which the aircraft could have encountered during flight.
The weather trend provided by IMD (reflectivity Index v/s height) is as given
below:

19
FIG. 5 - REFLECTIVITY INDEX WITH HEIGHT FROM TIME 0500 UTC TO 0600 UTC

The above graph shows reflectivity index (in dBZ) viz-a-viz height (altitude in
Kms) from time 0500 to 0600 UTC.
The aircraft was maintaining altitude of approximately 5500 feet (1676 meters)
when it disappeared from the radar. At that time as per the above graph there
was no precipitation. The wind shear symbol was indicating wind shear of 3-7
knots just prior to accident.

FIG. 6 - WEATHER RADAR IN AND AROUND LUCKNOW (UPTO 500 KM)

AT 05:40:14 UTC
20
 Areas of heavy precipitation (with big raindrops or snowflakes) return a lot of
power to the radar and appear as brighter colors in reflectivity images. In this
reflectivity image, the heaviest precipitation is in red, while lighter precipitation
is in blue and green. The colours - yellow, orange and white shows moderate
precipitation.

It is evident from the Radar image (Refer image above) that the weather was
building up in the area between Fursatganj (FSG) and Mau (MAU) i.e., enroute
the flight path followed by the trainee pilot where the accident occurred.

1.18.3 Recent occurrences of similar nature involving flying training aircraft

There have been similar occurrences in the recent past wherein the trainee
aircraft had encountered weather enroute during the cross-country flight.
Circumstances of one such occurrence is discussed below: -

• Accident to M/s Wings Aviation Pvt. Ltd. Cessna 172 aircraft VT-RGF at
Sultanpur Village, Telangana on 06.10.2019.
In the above occurrence also, the aircraft was operating solo cross country flight
when it encountered sudden adverse weather. At that time the precipitation was
moderate with downward wind shear of 3-7 knots. This was further confirmed
when, the trainee pilot requested ATC for descent due to heavy rain and return
to base. The request was approved by ATC. The aircraft during descent
encountered wind shear, during which the speed of the aircraft got reduced.
There was sudden increase in its sink rate due to sudden reduction in lift. As
the aircraft was low, there was no time/ height available for the trainee pilot to
affect a recovery, and the aircraft impacted the ground at high vertical speed
resulting into aircraft disintegrating into pieces and leading to the accident.

1.19 Useful and Effective Techniques

NIL

21
2. ANALYSIS
2.1 Serviceability of aircraft
The aircraft was manufactured in the year 1999. It was having a valid Certificate
of Registration (C of R) at the time of accident and holding a valid Indian
Certificate of Airworthiness (C of A) under Normal category and Passenger
Sub-Division. Airworthiness Review Certificate (ARC) was valid at the time of
accident. There was no snag reported before the accidented flight.
All concerned Airworthiness Directives, mandatory Service Bulletins, DGCA
Mandatory Modifications on this aircraft and its engine were complied with as
on the date of accident. The CG of the aircraft was within limits.

2.2 Weather

The weather reported at and around Fursatganj airport at the time of accident
was visibility 5000 meters, with winds VRB/02 knots. Weather as per this
information and observations made by Dy. CFI in the morning was found
suitable for carrying out the cross-country flight. At the time of accident, the
aircraft was under Varanasi control and the weather in and around Varanasi
just before the accident was HVY TSRA with cloud SCT 2000 FT, FEW CB
3000 FT, OVC 8000 FT, winds changing from 170/06 kt to 120/15 kt and
visibility dropping to 2500 meters from 3500 meters.

During investigation, weather trend (variation) with altitude was obtained from
MET Office, Lucknow, which revealed that at the time of accident at an altitude
of 5500 feet (1676 meters) there was a wind shear of 3 to 7 knots with no
precipitation. The same was also corroborated from the radar image (Refer FIG.
6 above) that the weather was building up in the area between Fursatganj
(FSG) and Mau (MAU) i.e., enroute the flight path followed by the trainee pilot
where the accident occurred.

It was also evident from the extent of damage to the aircraft and scatter of the
wreckage which confirmed that the aircraft encountered very bad weather such
that it disintegrated in air. The eyewitnesses (Villagers) also confirmed that they
heard a bang noise just after thunderstorm when they saw the damaged aircraft
which was losing height.

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 In view of the above it can be concluded that the aircraft had encountered
sudden adverse weather with severe wind shear which gave no time for the
trainee pilot to take any corrective action to avoid the same.

2.3 Organizational Aspect

2.3.1 Weather monitoring in the organisation

The investigation team perused the TPM of the organisation approved by

DGCA and it was observed that there was no specific procedure laid down in
the TPM for weather monitoring. Also, there is no specific
requirement/guidelines by DGCA in this regard for FTOs. However, it was
informed to the investigation team that there is a settled practice in the
organisation where they conduct mass briefing to the trainee pilots three times
a day during which they cover weather briefings also. On the day of accident,
the mass briefing was conducted in the morning at around 07:15 IST by one of
the Dy.CFI in the absence of the CFI who was on leave that day. As per the
Dy.CFI, he authorized the flying training exercise after ensuring that the current
weather and the weather forecast shown till 09:30 IST was fine for local &
enroute (for cross country). The deceased trainee pilot was briefed by one of
the AFI who stated that local & enroute weather was fine for solo navigation.

The deceased trainee pilot was enroute to MAU when the aircraft encountered
sudden severe adverse weather which led to the accident. There were other
trainee pilots who were also authorized for cross country flight on aircraft VT-
FGK & VT-FGF. VT-FGF was authorized for the same route after the departure
of VT-IGE and VT-FGK was authorized for Fursatganj – Ghazipur-Fursatganj
which departed before VT-IGE. Both these trainee pilots were en-route (near
Varanasi) when they observed developing weather ahead in their respective
path. Both the trainee pilots decided to set course back to Fursatganj after
taking necessary approval from ATC, Varanasi.

It is, therefore, quite evident that even though the weather in the morning was
fine for local and cross-country exercise, the weather started deteriorating
afterwards at around 0500 UTC when these aircraft were enroute in their
respective flight path.

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 This was quite obvious as the accident occurred during monsoon. Monsoon
season activities/period in India begins from starting June and continues till mid-
October. Monsoon period /season is mostly a four-month period, when a
massive convective thunderstorm dominates India’s weather. The weather
tends to change suddenly during monsoon.

This was also the case in a similar occurrence which was discussed earlier
(refer para 1.18.3) wherein the trainee aircraft encountered sudden severe
weather enroute the flight path which led to the accident.

These accidents could have been avoided if there was proper monitoring of
current and weather trends which seems to be lacking during the conduct of
flying training exercises. Although there are certain existing practices like MET
register and scheduled briefings, etc. but these are not sufficient and not
monitored continuously as most of the instructors are busy imparting flying
training during which it is not possible to monitor weather continuously. Had the
enroute weather/weather trend been monitored continuously these cross-
country exercises could have been cancelled or the trainee pilots could have
been asked to come back.
This may be achieved by dedicated weather monitoring system and a
procedure in this regard should be developed wherein the current and weather
trends are monitored continuously during the time of flying training exercise
especially monitoring of en-route weather for cross country flights. This will help
in conducting safe flying training exercise where the trainee pilots and
instructors will be provided with latest weather and can plan the flying training
exercises accordingly.

2.4 Circumstances Leading to the Accident

On the day of accident after the mass briefing the trainee pilot was detailed for
“solo cross country” exercise by one of the AFI as the local & enroute weather
was fine at that time for solo navigation.
The AFI carried out pre-flight inspection and did not find any abnormality in the
aircraft. The weather at the time of take-off from Fursatganj was visibility 5000
meters with winds VRB/02 kts. After take-off, the aircraft was handed over to
ATC, Lucknow and thereafter to ATC, Varanasi. The aircraft was cleared for

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 climb to 5500 ft (outbound operating altitude for cross country as per flight plan)
and was maintaining 5500 ft. Thereafter it was observed on the radar that while
enroute the aircraft, was observed to have climbed to 6000 ft followed by a
descent to 5200 ft. This implies that the aircraft had encountered inclement
weather. At that time there was wind shear of 3-7 knots at altitude of 5500 feet.
This was further confirmed from the radar images that the weather was building
up in the area between Fursatganj (FSG) and Mau (MAU) i.e., enroute the flight
path followed by the trainee pilot. When the aircraft was around 36 NM North
of BBN (Varanasi) at a radial of 30o, the Radar and VHF contact were lost and
a synthetic radar position symbol appeared. The controller gave many calls to
the aircraft including calls on emergency frequency, through other IGRUA
aircraft and airlines aircraft operating under the jurisdiction of ATC Varanasi,
however, there was no response. The aircraft could have encountered sudden
adverse weather (Thunderstorm) with severe wind shear which gave no time
for the trainee pilot to take any corrective action during which the aircraft
disintegrated in air and lost control. The aircraft structural parts such as
empennage, fuselage section was found in different areas which were around
5 km away from the final resting position of the main wreckage (Forward cabin
with wings & engine).

3. CONCLUSION
3.1 Findings
3.1.1 The aircraft was having valid C of R, C of A & ARC on the day of accident.

3.1.2 The aircraft and its engine were being maintained as per continuous
maintenance programme approved by DGCA.

3.1.3 No inspection/Maintenance action was due on the aircraft & its engine as on
date of accident.

3.1.4 All concerned Airworthiness Directives, mandatory Service Bulletins, DGCA

Mandatory Modifications on this aircraft and its engine had been complied with
as on date of event.

3.1.5 Scrutiny of the Flight Release Book (FRB) revealed that, there was no snag
pending on the aircraft prior to the accidented flight.

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3.1.6 The deceased trainee pilot was having a valid student pilot license and was
certified & qualified for the flight.

3.1.7 On the day of accident, the flying training exercises were authorized by one of
the Dy. CFI in the absence of CFI who was on leave.

3.1.8 The AFI who briefed the deceased trainee pilot for solo cross country
navigational exercise carried out the pre-flight inspection of the aircraft and did
not find any abnormality.

3.1.9 The weather at the time of take-off at Fursatganj was fine with visibility 5000
meters with winds VRB/02 kts. After take-off, the aircraft was handed over to
ATC, Lucknow and thereafter to ATC, Varanasi.

3.1.10 The RT call outs during that time at Lucknow Area Control were given by
planning controller which is in contravention to the relevant SOPs.

3.1.11 The trainee pilot was cleared and was maintaining altitude of 5500 feet as per
plan for outbound leg.

3.1.12 After some time, it was observed on RADAR that the aircraft climbed to 6000 ft
and then descended to 5200 ft indicative of aircraft encountering severe
adverse weather.

3.1.13 At that time there was wind shear of 3-7 knots at altitude of 5500 feet. This was
further confirmed from the radar images that the weather was building up in the
area between Fursatganj (FSG) and Mau (MAU) i.e., enroute the flight path
followed by the trainee pilot.

3.1.14 When the aircraft was around 36 NM North of BBN (Varanasi) at a radial of 30 o,
the Radar and VHF contact were lost and a synthetic radar position symbol
appeared.

3.1.15 The controller gave many calls to the aircraft including calls on emergency
frequency, through other IGRUA aircraft and airlines aircraft operating under
the jurisdiction of ATC Varanasi, however, there was no response. The trainee
pilot did not give any call out for emergency.

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3.1.16 The aircraft could have encountered sudden adverse weather (Thunderstorm)
with severe wind shear which gave no time for the trainee pilot to take any
corrective action during which the aircraft disintegrated in air and lost control.

3.1.17 The aircraft wreckage was scattered in an area of radius of about 5 Kms from
the point where the main aircraft wreckage (Forward portion of cockpit along
with wings and engine) was found.

3.1.18 The TPM of the organisation approved by DGCA did not have any specific
procedure laid down for weather monitoring. Also, there is no specific
requirements/guidelines by DGCA in this regard for FTOs.

3.1.19 It was informed to the investigation team that there is a settled practice in the
organisation where they conduct mass briefing to the trainee pilots three times
a day during which they cover weather briefings also.

3.1.20 On the day of accident, the mass briefing was conducted in the morning at
around 07:15 IST by one of the Dy.CFI. As per the Dy.CFI, he authorized the
flying training exercise after ensuring that the current weather and the weather
forecast shown till 09:30 IST was fine for local & enroute (for cross country).

3.1.21 There was other two trainee pilots of the organisation who were also authorized
for solo cross-country flight during that time. Both these trainee pilots set course
back to Fursatganj when they observed developing weather ahead in their
respective path.

3.1.22 The weather in the morning was fine for local and cross-country exercise, when
the weather started deteriorating afterwards. The weather around Varanasi at
the time of accident was HVY TSRA with cloud SCT 2000 FT, FEW CB 3000
FT, OVC 8000 FT, winds changing from 170/06 kt to 120/15 kt and visibility
dropping to 2500 meters from 3500 meters.

3.1.23 The present accident and accidents of similar nature in pasts could have been
avoided if there was proper monitoring of current weather and weather trends
which seems to be lacking in most of the FTOs during the conduct of flying
training exercises.

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3.1.24 Although there are certain existing practices like MET register and scheduled
briefings, etc. but these are not sufficient and not monitored continuously as
most of the instructors are busy imparting flying training during which it is not
possible to monitor weather continuously.

3.2 Probable Cause of the Accident

The accident occurred as the aircraft encountered sudden inclement weather
(Thunderstorm) with wind shear during which it disintegrated in air and lost
control wherein trainee pilot had no time to take corrective action.

In-adequate weather monitoring was a contributory factor to the accident.

4 Safety Recommendations

4.1 It is recommended that DGCA may formulate requirements/guidelines

regarding weather monitoring such that the current weather and weather tends
are being monitored continuously by FTOs and same is communicated to
instructors & trainee pilots during flying training exercise especially in case of
development of any adverse weather. The compliance of the same may be
ensured during audits/surveillance of FTOs.
4.2 It is recommended that DGCA may advise all flying training organizations to
develop a full proof system of 100% supervision of the training sorties by CFI
or Dy.CFI as stipulated in the DGCA CAR on the subject.
4.3 It is recommended that AAI may advise all controllers to strictly adhere to the
laid down SOPs to ensure that the RT calls are made by the responsible
controller only.

(K. Ramachandran) (Amit Kumar)

Investigator- In-Charge Investigator

Date: 15.02.2022
Place: New Delhi

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