Investigation Summary
The flight was scheduled as a routine transport mission carrying two pilots and eight technicians. During taxi, the crew requested a 10-minute delay for administrative reasons before proceeding to Runway 28. Meteorological conditions at the time included a visibility of 800 meters with shallow fog. Data from the investigation revealed that shortly after rotation at 110 knots, the aircraft reached approximately 400 feet AGL before beginning a progressive left turn. The Pilot Monitoring (PM) noticed the aircraft was not following the intended path and realized the autopilot's heading mode was not engaged. Although the PM attempted to take manual control 21 seconds before impact, the aircraft had already entered a steep bank. A series of automated warnings followed, including autopilot disengage, bank angle, and stall warnings. The aircraft completed a nearly 180-degree turn, struck trees and a perimeter wall, and came to rest in a water holding tank. The investigation highlighted significant human factors, noting that both pilots were relatively inexperienced on the type and had been flying together without the supervision of a senior pilot, contrary to internal BSF directives.
Final Conclusions
The AAIB India final report concluded the accident was caused by the flight crew's premature engagement of the autopilot without a selected heading mode during the initial climb. This error, compounded by poor visibility and the crew's failure to recognize and correct the increasing left bank, resulted in a loss of altitude and impact with terrain. The report also cited a lack of safety culture and inadequate supervision within the BSF Air Wing, as the two low-experience pilots were permitted to fly together despite orders requiring an experienced pilot to be on board.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain (Pilot Flying)
Experience includes 77:00 hours as PIC on type. Released as PIC after 620:35 hours as co-pilot on type.
First Officer (Pilot Monitoring)
Experience includes 196:35 hours as PIC on type. Released as PIC after 183 hours as co-pilot on type.
Systems & Failure Modes
Autopilot
The crew engaged the autopilot shortly after liftoff but failed to select a lateral navigation mode (Heading), causing the aircraft to drift into an uncommanded bank.
EGPWS
The Enhanced Ground Proximity Warning System provided bank angle and altitude alerts in the final 17 seconds of flight.
Stall Warning System
The stall warning alarm activated 8 seconds prior to impact as the aircraft lost lift during the steep bank.
Interesting Facts
- 01The aircraft was 22 years old at the time of the accident.
- 02The actual takeoff weight was 5668.85 kg, just 1.05 kg below the maximum takeoff weight (99.9% MTOW).
- 03Tools and equipment carried for helicopter maintenance weighed at least 63 kg, contributing to the high takeoff weight.
- 04The Pilot Flying had only 77 hours of experience as PIC on the B200 type.
- 05The aircraft performed a 180-degree turn from its departure heading before impact.
- 06Post-impact fire destroyed the portions of the aircraft that did not submerge in the water tank.
Safety Actions & Advisories
BSF Air Wing Overhaul
The inquiry recommended a complete overhaul of the BSF Air Wing, citing a non-existent safety culture and lack of operational supervision.
Safety Management System Implementation
Investigators recommended the formal establishment of Safety Management Systems (SMS) to monitor and report unsafe acts and flying expertise deficiencies.