The AAIB report on the September 2023 Learjet crash at Mumbai airport does more than identify an unstable approach in poor weather. Its findings point to a wider safety chain involving pilot decision-making, simulator training, operator records, internal audits and the regulator’s oversight of non-scheduled and general aviation companies.
According to the report cited by Navbharat Times, the Learjet 45XR, registered as VT-DBL, was flying from Visakhapatnam when it crashed while landing on runway 27 on 14 September 2023. All eight people on board were seriously injured, and a taxiway light was damaged. The AAIB identified the continuation of an unstabilised approach in adverse weather and the crew’s inability to control the aircraft adequately as the probable causes.
The report also found shortcomings at VSR Ventures, the company associated with the aircraft. These included deficiencies in pilot training, record-keeping and internal audits. The findings matter because aviation safety is not determined only by what happens in the cockpit during the final minutes of a flight. It also depends on whether an operator trains crews for foreseeable risks, maintains accurate technical records and detects unsafe practices before they become accident factors.
The report’s timing has added another institutional dimension. The final report was made public more than three years after the accident, although the source report notes that International Civil Aviation Organization rules provide for completion within 12 months. The Mumbai case was reportedly among pending investigations that came under attention after the January crash at Baramati, in which Maharashtra Deputy Chief Minister Ajit Pawar and four others died. The two incidents are separate, but their proximity in the public record has intensified scrutiny of safety oversight in private and non-scheduled aviation.
The central operational finding in the Mumbai case concerns the approach to landing. An approach is considered stabilised when the aircraft is properly configured, aligned, descending at the expected rate and travelling at an appropriate speed. If those conditions are not met by the prescribed stage of the approach, standard operating procedures generally require the crew to discontinue the landing and execute a go-around. The AAIB report, as described in the supplied account, found that the crew continued despite an unstable approach.
Several factors reportedly compounded that decision. The crew did not respond adequately to a low-speed warning, delayed the decision to go around and failed to maintain sufficient awareness of airspeed. Poor weather reduced external visibility, while a strong tailwind affected the aircraft’s approach. The report also cited pressure to land before a specified time at Mumbai airport. These factors placed the aircraft in a high-risk phase of flight, where a small deterioration in speed, configuration or control can quickly reduce the margin available for recovery.
The aircraft subsequently entered an aerodynamic stall at low altitude. A stall occurs when the wing no longer produces sufficient lift because the angle of attack has become too high. It is not simply an engine failure or a loss of power. Recovery requires the crew to recognise the condition, lower the aircraft’s nose as necessary, regain airspeed and manage altitude and configuration correctly. At low altitude during landing, the time and space available for recovery are sharply limited.
The AAIB recommendations show that the agency treated the crash as a training and systems issue as well as a crew-performance issue. One recommendation was for the Directorate General of Civil Aviation to consider including stall recovery in the landing configuration during simulator training. The proposed exercises would cover recovery from a full stall or from activation of a stall warning during climb, cruise, approach and landing configurations.
This recommendation is significant because training design determines which decisions crews practise under pressure. A pilot may know that an unstable approach should be abandoned, but safety depends on whether the crew can identify the warning signs quickly, communicate clearly and act according to procedure. The report’s recommendations therefore move beyond the question of individual error and towards the conditions under which crews are prepared to manage rapidly changing situations.
The proposed regulator-wide review of training records is another important element. The AAIB recommended that DGCA examine the training records of fixed-wing pilots, particularly those working for non-scheduled and general aviation organisations, to confirm that mandatory simulator exercises had been completed. The recommendation indicates that oversight must test not only whether a company has training requirements on paper, but also whether crews have completed the required exercises and whether those records can be reliably checked.
Non-scheduled aviation includes operations that do not follow the fixed timetable and network structure of scheduled airlines. The sector can include private, charter and other general aviation activity. That operating model does not reduce the need for formal safety systems. It can make consistent documentation, training supervision and regulatory visibility especially important because oversight must cover a range of operators, aircraft and operating patterns.
The report also directed attention to the internal systems of VSR Ventures. The company was advised to ensure that pilots understood and correctly followed challenge-and-response checklists with the cockpit crew. Such checklists require crew members to verify settings and confirm that aircraft systems are configured in accordance with standard operating procedures. The recommendation addresses the practical problem of a checklist becoming a routine formality rather than an active barrier against error.
Maintenance documentation was another area of concern. The company was advised to ensure that its maintenance and engineering staff maintained documents such as technical logbooks and airframe logbooks according to established procedures. These records are important because they provide continuity between flights, maintenance teams and oversight authorities. If information about an aircraft’s condition is incomplete or inconsistently recorded, the safety system loses an important source of early warning.
The recommendation on internal audits carries a similar message. DGCA was advised to direct non-scheduled and general aviation operators to implement internal audits seriously and effectively, and to examine the quality of those audits during inspections or surveillance. An audit system is useful only when it identifies deviations, assigns responsibility and confirms that corrective action has been completed. The AAIB findings suggest that the existence of an audit process cannot by itself be treated as proof of effective safety management.
The agency also recommended clearer instructions to operators on unstable approaches and go-arounds. Pilots should be encouraged to abandon an approach whenever the aircraft is not stabilised, regardless of how close it is to landing. This is an operational rule with a wider organisational implication: a go-around must be treated as a normal safety decision rather than as a failure to complete the flight as planned.
The airport system appears in the recommendations as well. The Airports Authority of India was advised to reinforce awareness among air traffic controllers about maintaining prescribed separation between aircraft to reduce the risk of wake turbulence. Wake turbulence consists of the air disturbance created behind an aircraft and can affect another aircraft following it. Although the report’s primary findings concerned the Learjet crew and operator systems, the recommendation shows that accident prevention also depends on air traffic management and the interaction between aircraft in the airport environment.
Taken together, the findings describe aviation safety as a layered system. Weather, wind, aircraft configuration, crew decisions, simulator preparation, checklist discipline, technical records, internal audits, regulator surveillance and air traffic control all form part of the chain. A failure in one layer may be recoverable if the others work properly. The risk becomes greater when several protections weaken at the same time.
The report also exposes the difference between regulatory compliance and operational safety. Training records may exist, audits may be conducted and procedures may be written, but the safety question is whether these controls influence decisions during a difficult approach. The recommendations on record reviews, simulator exercises and audit effectiveness are aimed at testing that practical connection.
What the supplied account establishes is that the AAIB attributed the crash primarily to the continuation of an unstable approach in poor weather, compounded by inadequate airspeed management, delayed go-around action, tailwind and other operational factors. It also establishes that the agency found deficiencies in the operator’s training, records and internal audit systems and proposed measures for DGCA, VSR Ventures and AAI.
What remains unresolved in the supplied material is how quickly the recommendations will be implemented, whether DGCA has completed the proposed review of fixed-wing pilot training records and whether the affected operator has corrected the deficiencies identified by the investigation. Those implementation steps will determine whether the report becomes a formal record of an accident or a trigger for measurable improvements in non-scheduled aviation oversight.
