AAIB Report Attributes April Goa Airport Runway Incursion to Crew Lapses and Communication Errors

A final report released by the Aircraft Accident Investigation Bureau (AAIB) has concluded that a runway incursion at Goa's Dabolim airport in April this year was likely caused by a failure of the Air India Express flight crew to adhere to air traffic controller instructions, alongside communication misinterpretations.

The incident occurred on the morning of April 3 involving an Air India Express Boeing 737-8 aircraft operating flight AXB 1109 from Dabolim to Delhi, and a single-pilot Indian Navy fighter jet that was taking off. The flight was carrying 171 people on board, and no injuries were reported.

At Dabolim airport, which functions as a civil enclave, air traffic services are managed by INS HANSA, with tower and approach controllers belonging to the Indian Navy. The Surface Movement Control (SMC) controller at the facility is provided by the Airports Authority of India (AAI).

According to the probe agency, the flight crew did not fully follow the SMC controller's taxi instructions to hold at the holding point and contact the Navy approach frequency. The report stated that positive communication with the Navy ATC before entering the active runway could have avoided the incident. The AAIB also noted that a radio telephony call of 'Expect back track' by the SMC controller was misinterpreted by the pilot flying as an entry clearance, shifting the crew's focus toward executing the runway entry without explicit clearance.

The investigation further identified contributing factors related to the flight deck crew. The pilot monitoring was a trainee who was overly reliant on the instructor and occupied with heads-down tasks to verify take-off values, preventing effective monitoring of radio calls or cautioning the pilot flying against unauthorized entry.

In its 35-page final report, the AAIB has issued several safety recommendations. The agency recommended that Dabolim airport's taxiway TWY N2 be considered a hotspot due to its proximity to civil apron bays and an increased risk of ground collisions and runway incursions. It also suggested that Air India Express issue a sensitisation circular, arrange counselling for the crew, and mandate specific training for the pilot-in-command.

For air traffic management, the AAIB recommended that the AAI issue a circular to emphasise standard radio phraseology, ensure controllers carefully listen to read-backs, and review phrases that can be easily misunderstood. Additionally, the report suggested establishing collaboration between the DGCA, AAIB, and defence authorities on a priority basis, while INS HANSA was advised to consider standardizing frequency change-over procedures for civil traffic.

Following the occurrence, naval and AAI authorities held a meeting to revise coordination procedures. The parties decided that the SMC controller will directly coordinate with Navy ATC via a hotline at the start of the day to confirm critical briefing elements, including the active runway and change-over frequency.

"Operational clarity and stringent communication protocols are non-negotiable in high-stakes environments like aviation, and the same principles apply to scaling businesses where process adherence prevents critical failures. This incident highlights how a combination of minor misinterpretations, training gaps, and procedural ambiguities can compound into significant operational risks. For growing enterprises, establishing clear lines of communication, robust internal controls, and continuous compliance monitoring are essential to mitigating unforeseen operational vulnerabilities." — Dr. Shishir Gupta, Founder & CEO, StartupLanes