FINAL INVESTIGATION REPORT ON RUNWAY EXCURSION INCIDENT TO

M/s. CHIMES AVIATION PVT LTD

CESSNA 172R AIRCRAFT, VT-CAG
ON 17.07.2021 AT DHANA AIRSTRIP, MADHYA PRADESH.

GOVERNMENT OF INDIA
OFFICE OF DIRECTOR OF AIR SAFETY (WR)
INTEGRATED OPERATIONAL OFFICE COMPLEX,
SAHAR ROAD, VILEPARLE (E), MUMBAI – 400099

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 Foreword

In accordance with Annex 13 to the Convention on International Civil Aviation Organization

(ICAO) and Rule 13(1) of Aircraft (Investigation of Accidents and Incidents), Rules 2017, the sole
objective of the investigation shall be the prevention of accidents and incidents and not
apportion blame or liability. The investigation conducted in accordance with the provisions of
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.

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 CONTENTS

Section Item Page No.

-- ABBREVIATIONS

-- GENERAL INFORMATION 01

-- SYNOPSIS 02

1.0 FACTUAL INFORMATION 02

1.1 History of Flight 02

1.2 Injuries to Persons 04

1.3 Damage to Aircraft 04

1.4 Other Damage 07

1.5 Personnel Information 08

1.6 Aircraft Information 09

1.7 Meteorological Information 11

1.8 Aids to Navigation 11

1.9 Communications 11

1.10 Aerodrome Information 12

1.11 Flight Recorders 12

1.12 Wreckage & Impact Information 13

1.13 Medical and Pathological Information 16

1.14 Fire 16

1.15 Survival Aspects 16

1.16 Tests and Research 16

1.17 Organizational and Management Information 16

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1.18 Additional Information 17

1.19 Useful or Effective Investigation Techniques 20

2.0 ANALYSIS 20

2.1 Operational Aspects 20

2.2 Weather Aspects 22

2.3 Engineering Aspects 22

3.0 CONCLUSION 23

3.1 Findings 23

3.2 Probable Causes 24

4.0 SAFETY RECOMMENDATIONS 24

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 ABBREVIATIONS

A/c Aircraft

AMSL Above Mean Sea Level

AOP Air Operator Permit

ARC Airworthiness Review Certificate

ASDA Accelerate -Stop Distance Available

ATC Air Traffic Control

CFT Crash Fire Tender

CSN Cycles Since New

CVR Cockpit Voice Recorder

FDR Flight Data Recorder

FRTO Flight Radio Telephony Operator

GPS Global Positioning System

IAS Indicated Air Speed

IFR Instrument Flight Rules

ILS Instrument Landing System

IR Instrument Rating

LDA Landing Distance Available

LHS Left Hand Side

MEL Minimum Equipment List

Operator AOP holder of the incident aircraft

PAPI Precision Approach Path Indicator

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PDR Pilot Defect Report

PIC Pilot in Command

QNH Pressure Setting to Indicate Elevation of Landing Aerodrome

QRH Quick Reference Handbook

RA Radio Altitude

RHS Right Hand Side

RWY Runway

SCT Scattered

SOP Standard Operating Procedure

SPL Student Pilot’s License

TO/GA Take-off/ Go-around

TODA Take-off Distance Available

TORA Take-off Run Available

TSN Time Since New

TWY Taxiway

UTC Coordinated Universal Time

VFR Visual Flight Rules

VOR Very high frequency Omni Range

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 FINAL INVESTIGATION REPORT ON RUNWAY EXCURSION INCIDENT TO
M/s. CHIMES AVIATION PVT LTD
CESSNA 172R AIRCRAFT VT-CAG AT DHANA, MADHYA PRADESH ON 17.07.2021

GENERAL INFORMATION

1. Aircraft Type : CESSNA

Model : 172R
Nationality : INDIAN
Registration : VT-CAG

2. Name of the Owner/Operator : M/s CHIMES AVIATION PVT LTD

3. Place of the incident : DHANA AERODROME, MADHYA PRADESH

4. Date and time of incident : 17.07.2021, approx. 0910UTC

5. Pilot in Command : STUDENT PILOT LICENSE HOLDER

Extent of Injuries : NIL

6. No. of Passengers onboard : NIL

Extent of Injuries : NIL

7. Geographical location of site : Lat 021 Deg 19’ 43” N

Of Occurrence (Lat. Long) : Long 074 Deg 57’ 40” E

8. Last point of Departure : Dhana Aerodrome

9. Point of intended landing : Dhana Aerodrome

10. Type of operation : TRAINING FLIGHT (SOLO)

11. Phase of operation : TAKE OFF

12. Type of occurrence : RE: RUNWAY EXCURSION (OVERRUN)

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 SYNOPSIS

Cessna 172R aircraft VT-CAG, belonging to M/s Chimes Aviation Pvt. Ltd was involved in a
Runway Excursion incident at Dhana aerodrome on 17.07.2021 during a training flight.

The student pilot was authorized for a general solo sortie flying (02 Circuits and Landings)
on 17.07.2021. After completing the first circuit and landing uneventfully, the student pilot
initiated the second takeoff on RWY 17 with ATC clearances. Crossing the middle markers,
after rotation, the student pilot felt that the aircraft was not climbing but shivering.
Considering that the Runway was consumed more than half length, and the aircraft not
gaining height, the student pilot got anxious and decided to abort the takeoff. During the
reject action, the power was reduced to idle and brakes were applied. The aircraft touched
down on Runway near Taxi link ‘B’ and continued rolling. The aircraft did not stop but
started drifting towards the right end of the Runway. The aircraft rolled further and moved
out of the Runway end into the soft ground area. During its movement, the aircraft came in
contact with one of the Runway end lights positioned on the right side of Runway. The
aircraft passed over a small ditch near the perimeter fence during which the nose landing
gear strut bent back. The aircraft came in contact with the metallic perimeter fence and
then moved out of the airport perimeter over the metal fence bending it down. Passing
down a small slope beyond the fence, the aircraft turned left and came to halt facing east.
The tail of the aircraft was on top of one of the notice boards placed on road side. The
Emergency services were activated and the student pilot rescued herself out of the aircraft
unhurt.

The incident was reported to DGCA and the investigation was instituted under Rule 13(1) of
Aircraft (Investigation of Accidents and Incidents) Rules 2017 by appointing Investigator-in-
Charge.

The incident occurred in day time. The investigation revealed that improper checklist
compliance by the student pilot to ensure the aircraft in takeoff configuration before
takeoff roll resulted in insufficient speed achieved for lift off and subsequent takeoff abort.
The speed at the time of touchdown and the shortage of remaining runway length
available caused the aircraft to overrun the runway.

1. FACTUAL INFORMATION:

1.1 History of Flight:

On 17.07.2021, a Cessna C172R aircraft, registration VT-CAG was scheduled for training
sorties at Dhana Airstrip in Madhya Pradesh. The preflight check including the ground run of

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the aircraft was carried out by an authorized engineer and no observations were made.
There were no pending snags or MEL invoked as per the records. The aircraft flew multiple
sorties with different crew before the incident sortie. All the sorties were uneventful with
nil sector snags.

On the day of incident, the student pilot reported to operations room of the academy at
0200UTC for the day’s training and completed the BA declaration at 0310UTC, and then
made entry in Authorization Book and dispatch documents. The authorization for flight to
the student pilot was given by Dy. Chief Flight Instructor, for two solo sorties on the day.
The first flight was on aircraft VT-CAC, a sortie of general flying which started at 0320UTC. A
total of 01hours 05minutes was the total flying time of the first sortie. After completing the
sortie successfully and uneventfully, the student pilot reported to the operations room for
the next planned sortie which was on aircraft VT-CAG.

Aircraft VT-CAG was already flown by other crew before it was allocated to the incident
involved student pilot. There were no snags entered in the Journey Log Book of aircraft VT-
CAG post its previous sorties. The second sortie for the student pilot was solo circuit and
landing including two takeoffs and landings. The preflight checks were carried out after
completion of entry in authorization book and submission of dispatch form. Total fuel
onboard before the flight was 122 liters. The preflight inspection was carried out by the
student pilot and the inspection was satisfactory with nil observations. The flight rule of VT-
CAG was VFR and the visibility recorded before the previous takeoff was 6000m. After
successful preflight checks, start up, taxi and line up, first take off, circuit and landing was
carried out.

During the landing roll, landing lights and fuel pumps were switched off by the student pilot
and the flaps were retracted up. Post landing, back tracking on RWY 17 was carried out as
per ATC instructions and thereafter lined up on RWY17 for the next takeoff. Upon lining up,
the student pilot checked the seats and seat belts and also locked the cabin doors and
windows. Upon receiving ATC clearance for takeoff, landing lights and fuel pumps were
switched ON, brakes were applied, power increased to 1800rpm, however the flaps were
not extended. Aircraft started rolling once brakes were released and once the aircraft
attained a speed of 57kts (IAS), the control column was pulled to rotate the aircraft. The
aircraft did not rotate as expected, instead started shivering upon crossing the middle
marker. As and when the student pilot observed that the nose wheel of the aircraft went up
in air, but aircraft was still rolling on main wheels and also when realizing that she doesn’t
have enough runway left, the take-off was aborted.

The student pilot dropped the nose slightly on the ground, followed by power to
idle. The aircraft touched back on runway surface near to Taxi link ‘B’ and continued rolling

3
further. As runway end was approaching she started applying brakes fully so as to stop the
aircraft on the runway itself. The aircraft did not stop on the runway but it kept rolling
towards the right edge of the runway and then further out of the runway into the soft
ground. There were runway end lights near to the right edge, one of which aircraft came
into contact with and got damaged. The aircraft then passed over the small ditch prior to
the perimeter fence which caused the nose landing gear strut to get bent backward. The
propeller also hit the ground and got damaged during this movement. Further moving
forward, aircraft came into contact with the metallic perimeter fence. The aircraft damaged
the fence and bent it down further moved out of the airport perimeter over it. The aircraft
passed down the small slope next to the fence and during its movement the horizontal
stabilizer of the aircraft came in contact with one of the metallic notice boards placed on
the road side. The aircraft tail got turned towards left with the tail pivoting on the board,
and finally came to halt facing east.

Once the aircraft came to complete stop, the student pilot received an RT call from ATC
advising to get out of the aircraft as soon as possible. The student pilot without any
communication or delay, removed her headsets, hanged them on control
column and tried to get out of the aircraft from left side of the aircraft However, as
obstructions were found near the left door, she exited the
aircraft via right door of the aircraft. The Emergency services were activated and the
student pilot rescued herself out of the aircraft unhurt.

1.2 Injuries to persons :

Injuries Crew Passengers Others

Fatal Nil Nil Nil
Serious Nil Nil Nil
Minor/None 01 Nil Nil

1.3 Damages to Aircraft :

The aircraft sustained following damages:-
i. RH main landing gear fairing assembly (Part no: 0541193-8), was damaged.
ii. RH wing leading edge skin and rib near wing tip (WS 208) damaged, RH wing
leading edge near WS 100 near wing strut attach point damaged.(Part no:-
0523029-4, 0523028-20 & 0523034-2).
iii. RH wing-NAV light cover broken (Part no: 0723205-10).
iv. Skin Aft Fuselage RH & Tail cone Fairing, (Part no. - 0512008-4 & 0530011-2)
were found bulged/damaged.
v. Fairing attachment point of vertical fin near FS 205.91 sheared-off (Part No-
0531012-2).

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 vi. Tail section at bottom between FS 205.81 TO FS 228.68 damaged.
vii. Bulging/damage on LH side aft fuselage skin (empennage area)-(Part no-
0512008-4 & 0530011-2).
viii. LH and RH angle (Part No. 0512001-7 & 0512001-8) was found damaged.
ix. LH side aileron skin upper and lower outboard (part no- 0523800-8 & 0523800-
12) damaged.
x. LH side NAV light cover and wingtip assembly (Part No- 0723206-1) was
damaged.
xi. LH wing skin leading edge outboard (Part no- 0523029-5) and 02 ribs at WS
172.00 & WS 190.00 (part no. 0523034-1 & 0523035-1) found damaged.
xii. LH Landing Gear Fairing Assembly (Part No- 0541193-7) found damaged.
xiii. Lower cowling (Part no- 0552242-7) found damaged.
xiv. Nose Landing Gear Lower & upper fittings (Part no- 0543016-1 & 0543013-1)
were found damaged.
xv. Nose landing gear lower portion (Part no- 0543062-20) was damaged.
xvi. Nose wheel LH and RH steering tube assembly (Part No.-MC0543022-1C &
MC0543022-1C) is damaged.
xvii. Shimmy Dampener is found damaged (Part No.- SE-1051-2)
xviii. Fuselage Skin Lower, LH & RH Angle. (Part no.-0513520-18 & 0513000-10 &
0513000-9) was damaged.
xix. Bottom side of Aircraft Firewall (Part No- 0553031-20) damaged.
xx. Lower firewall Reinforcement sheet (Part No- 0553046-1) found damaged.
xxi. Bulkhead Assembly LH & RH tunnel (Part No- 0513363-23 & 0513363-22) found
damaged.
xxii. Bracket Assembly Aft & LH & RH Angle, (Part no- 0513359-6 & 0513369-1 &
0513369-2) was damaged.
xxiii. Bulkhead Assembly LH & Anchor LH, (Part No- 0513053-5 & 0513488-11 &
071364-2.)
xxiv. Firewall Angle, (Part no.-0513577-1 & 0513577-2 & 0513109-9 & 0553006-4)
was damaged.
xxv. Angle LH & RH Center (Part No- 0513109-11 & 0513109-09 & 0513109-7) got
damaged.
xxvi. Weld Assembly & Bearing Assembly (Part No- 0411306-14 & 0411306-25 &
S1674-1 & S1675-1) was damaged.
xxvii. Aircraft Propeller (Part No- MTV-6A/187-129, S/N- 061157) and Propeller
Spinner (Part no.-B-426_P-1071) damaged.
xxviii. Engine (Part No- TAE-02-02-99, S/N- 02-02-04827) and engine mount (Part No-
20-7120-H008101) found damaged.

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Fig. 01 Damage to the starboard wing leading edge

Fig. 02 Damage to the port side wing leading edge

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Fig. 03 Bulging on LH side empennage area Fig. 04 Propeller damage

Fig. 05 Damage to bottom part of tail section Fig. 06 Damage to the bottom cowling

1.4 Other Damage :

1. Damage to 01 Runway end light (RWY 17 RH far end) due aircraft hit.

Fig. 07. Damage to RWY 27 end light

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1.5 Personnel Information :

The details of the licenses and ratings are as follows:-

1.5.1 Pilot in Command:

Pilot Student Pilot License Holder

Age 19 Years

Date of Issue License 11.03.2021 (SPL)

Licence Valid Upto 10.03.2026 (SPL)

Category Aeroplane

Class Single Engine Land

Endorsement as PIC C-172

Date of Medical Exam 18.12.2020

Medical Exam Valid up to 17.12.2022

FRTO Licence Date of issue of 10.05.2021

FRTO Licence Valid up to 09.05.2031

Total Flying Experience 55:00 hrs

Experience on type 55:00 hrs

Experience as PIC on type 18:05 hrs

Last flown on type 17 July 2021

Total Flying Experience during last 180 days 55:00 hrs

Total Flying Experience during last 90 days 36:35 hrs

Total Flying Experience during last 30 days 26:55 hrs

Total Flying Experience during last 07 days 10:55 hrs

Total Flying Experience during last 24 Hours 01:05 hrs

Upon scrutiny of the records, student pilot had her last flight on same day of incident (0320Z
departure) during which she flew 01:05hours in C-172 aircraft VT-CAC.

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 1.6 Aircraft Information :

Airframe details

Manufacturer CESSNA AIRCRAFT COMPANY

Type Cessna 172 R

Aircraft Registration VT-CAG

Manufacturer SI. No. 17281483

Year of Manufacturer 2007

Certificate of Registration No. 3728/2

Certificate of Airworthiness No. 4037

C of A issued on 08.04.2008

ARC issued on 07/07/2021

ARC Valid up to 08/07/2022

Category of C of A Normal

Subdivision category of C of A Passenger

Minimum Crew necessary 01

Aircraft Empty weight 831.25 Kg

Maximum all up weight 1111.00

Date of aircraft weighment 24/02/15

Last major Inspection P3-600 Hrs./01 Year Approved Inspection

Last major Insp. Carried out on 16/07/2021

Airframe hours Since New 10859:35 hours TSN

Airframe Hours Since last ARC 16:35 Hours

Aircraft usual station as per C of R Dhana Airport, Sagar (M P)

Aero mobile License No. A-043/003-RLO(NR)

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Engine details

Manufacturer Technify Motors GmbH

Type TAE 125

SI NO 02-02-04827

Engine hours Since New 600:55 hours

Engine hours Since O/H 600:55 hours

Date of O/H 18/12/2018

Last major Inspection P3-600 Hrs./01 Year Approved Inspection

Last major Inspection carried out on 16/07/2021

Average Fuel consumption as per fuel/oil 16.00 Ltr/Hrs.

register

Manufacturer specified Max. fuel Consumption 28.00 Ltr/Hrs.

Average Oil consumption as per fuel/oil register 0.10 Ltr/Hrs.

Propeller details

Manufacturer MT Propeller

Type MTV-6-A/187-129

SL. No 061157

Last major Inspection P3-600 Hrs./01 Year Approved Inspection

Last Major Insp. Carried out 16/07/2021

Total hours Since Overhaul 600:55 hours

Nil snags were reported by the previous sector crew on the aircraft and no snag was
pending for rectification. No DGCA mandatory modifications were pending. Also at the
time of incident there was no MEL invoked on this aircraft. The aircraft and its engine are
maintained as per the DGCA approved maintenance program. The inspection details as per
Aircraft Maintenance Program are as follows:

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 Sl.no Inspection Schedule Document Reference no.
1. P1‐50HRS/01 MONTH CAPL/CAMO/172R(STC)/ MCS‐001
2. P2‐100HRS/02 MONTHS CAPL/CAMO/172R(STC)/ MCS‐002
3. P3‐600HRS/01YEAR CAPL/CAMO/172R(STC)/ MCS‐003
4 ANNUAL RADIO INSP CAPL/CAMO/172R(STC)/ MCS-004

1.7 Meteorological Information:

Dhana aerodrome is equipped with an Automatic Weather Station setup at the ATC tower
which provides MET data from the internet. As per the predicted records maintained at
ATC, on 17.07.2021 for Dhana aerodrome for time 0830UTC, winds were 162/06kts,
visibility 6000m, clouds SCT060, QNH 1006 and temperature 36 degree Celsius. The METAR
register at the ATC shows that the met information is normally recorded every two hours
during the active hours. There is a wind measuring anemometer within the aerodrome
along with two windsocks. The forecasted weather at Dhana aerodrome for the incident
date as per METAR records is as follows:
Time 0600 0800 1000 1200 1400 1600 1800
(IST)
Wind 200/04 180/08 200/12 202/08 162/06 182/06 183/06

Visibility 6km 6km 6km 6km 6km 6km 6km

Clouds Fine Fine Cloudy SCT 040 Cloudy SCT SCT 070 SCT 080
BKN 060 SCT 050 060
Temp 250c 250c 280c 320c 360c 360c 330c

QNH 1008 1009 1009 1007 1006 1006 1006

As per the Garmin data, the average wind speed recorded during the second takeoff was
2.9knots.

1.8 Aids to Navigation :

Dhana aerodrome is not equipped with any navigational aids except windsock. All the flying
activities are based on Visual Flight Rules.

1.9 Communications :
At the time of incident, aircraft was having two way communications with the ATC
personnel at the tower frequency 122.60MHz. There is no recording facility available at the
ATC to record the communications. There was no snag reported in the communication
system of either the aircraft or the ATC.

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1.10 Aerodrome Information :

The Dhana Airstrip is located in Dhana, in Sagar District, Madhya Pradesh and is near to
Sagar, Damoh, Khurai and Bina. Dhana airport is the home base of Chimes Aviation
Academy (CAA). The aerodrome is situated at an elevation of 1709ft with coordinates of Lat
023 Deg 45’ 14” N and Long 078 Deg 51’ 21” E. It has a 3000*75 feet asphalt runway with
runway lights installed and a dedicated apron which can accommodate 10–12 small aircraft.
The Dhana airfield is not a critical airfield and is used for flying training by CAA. Other than
CAA, the airfield is often used by Madhya Pradesh Government Aviation and VIP charter
aircraft as well as Medical evacuation flights. There are no radio navigation aids available,
the runway orientation is 352–172 (35–17). The air traffic control (ATC) is staffed by the
academy during normal working hours. There are no facilities available for ATC tape
recording/SMGCS recording at the airport. Night operations are limited to local training
flights of CAA. Weather is usually stable, with strong cross winds.

1.11 Flight Recorders :

The aircraft is not equipped with either a Cockpit Voice Recording facility or a flight data
recorder. The aircraft is equipped with Garmin navigation system which records and stores
the basic flight parameters in a memory card.

Fig.08 Pitch degree vs relevant time

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Based on the data collected from the Garmin memory card, the following observations are
made.

The first takeoff and landing was uneventful and the aircraft after the first landing on RWY
17, back tracked from near the Taxiway ‘B’ and lined up for the second take off. The aircraft
started rolling for the second takeoff at 14:43:21hrs (local time) on RWY 17. The pitch angle
started increasing at a ground speed of around 60kts and reached a maximum pitch angle of
7.65 degrees. The maximum ground speed attained by the aircraft is 68.33kts during which
the pitch angle was 4.16degrees. The aircraft had a pitch angle of 4.19degrees near TXWY B
and 3.77degrees near to TXWY A.

Fig.09 Aircraft ground speed and pitch correlation

The aircraft exited the runway with a ground speed of 30.73kts and contacted the fence
with an approximate ground speed of 11.55kts.The average wind speed recorded by the
aircraft during the second takeoff roll was 2.9kts. The data of the Mean Sea Level Altitude
shows that the aircraft height had not increased more than 10ft from the ground surface.
The brake parameters are not recorded in the Garmin data.

1.12 Wreckage and Impact Information :

The actual location of touchdown could not be identified hence approximate touchdown
location was obtained from the witness statement. The aircraft made the touchdown on
RWY surface near to TXWY ‘B’ at around 2364ft from the RWY 17 beginning. The latitude
longitude positions extracted from the Garmin system shows the path followed by the
aircraft from the takeoff roll till halt. (Refer fig 13). The perimeter fencing of the airport is
located at a distance of 68ft (perpendicular distance) from Runway end. The road is at a
distance of 44ft from the fencing. The metallic sign board at the road side is at a
perpendicular distance of 16ft from the fencing. The aircraft while moving out of the soft
ground, came into contact with the metallic perimeter fence and damaged it and then

13
rolled over it towards the road. The aircraft passed down the small slope next to the fence
and during its movement the horizontal stabilizer of the aircraft came in contact with one of
the metallic notice boards placed on the road side. The aircraft got turned towards left with
the tail pivoting on the board. The final position of the aircraft was facing east with LH
horizontal stabilizer resting on the metal board and aircraft was at a distance of 82ft from
the Runway end, measured perpendicular. The flap lever in the cockpit (in-situ) was found
in Flaps 0 (UP) configuration. The engine controls were in switched off position and elevator
trim NOT in takeoff position.

Metallic notice
board

Fig. 10 Aircraft position after coming to halt (tail resting on notice board)

Fig. 11 Aircraft position after coming to halt (view from road side).

14
Fig.12.Aircraft position after coming to halt- aerial representation (not to scale)

Fig.13.path followed by the aircraft on the runway (aerial view)

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1.13 Medical and Pathological Information :

There was no injury to the trainee pilot and no injury to any person on ground. The student
pilot had submitted the self-declaration with regards to the non-consumption of alcohol
before undertaking the flight. The student pilot was subjected to medical checkup after the
incident and the doctor observed no injury and no sign of alcohol presence.

1.14 Fire :

There was no fire or smoke before or after the incident.

1.15 Survival Aspects :

The incident was survivable. The crash siren and fire alarm was activated by ATC.
Ambulance and Firefighting facilities reached the site however the student pilot came out of
the aircraft unhurt on her own.

1.16 Tests and Research :

The fuel and oil sample collected from the incident aircraft were sent to Aircraft
Engineering Directorate, O/o DGCA, New Delhi to check the quality on various
specifications. The samples were tested and found passed in the respective specification
tests. Also the aircraft engine was removed and send to its manufacturer, M/s Continental
Aerospace, Germany for detailed strip inspection along with FADEC data. As per the
inspection carried out, they concluded that the subject engine was not having any
abnormality and worked well within its specifications. From the parameters recorded in
FADEC system no warnings were generated from the engine during the flight.

1.17 Organizational and Management Information :

Chimes Aviation Academy (CAA), a division of Chimes Aviation Pvt Ltd, New Delhi is one of
the Flying Training Organizations (FTO) in India, set up in June 2008, at Dhana Airport, Sagar,
Madhya Pradesh. CAA is structured under the management of the Accountable Manager.
The FTO is approved by DGCA vide approval no. 04/2015 and had validity till 20.04.2022 (at
the time of incident). The academy uses DGCA approved Training and Procedure Manual for
carrying out flying training. Chimes Aviation Academy has been established primarily to
provide various flying and ground training to students.
The Engineering setup at the academy is under the approval system of DGCA and is an
“Approved Maintenance Organization” and an approved “Continuing Airworthiness
Management Organization” to cover maintenance and continuing airworthiness activities
of aircraft, engine, instruments, radio communication, navigation equipment and battery
installed on the aircraft operated by the academy.

16
1.18 Additional Information :

1.18.1 As per student pilot’s statement:

 The student pilot was authorized by Dy.CFI for two solo sorties on the day. First sortie of
solo general flying was conducted in aircraft VT-CAC uneventfully.
 Second sortie was planned in aircraft VT-CAG for solo circuit and landing.
 After successful preflight checks, start up, taxi and line up, first take off circuit and
landing was completed satisfactorily. During landing roll, landing lights and fuel pumps
were switched off and Flaps were made up. After landing, as per ATC instructions, back
tracking on RWY 17 was done and lined up for the next takeoff.
 On line up, checked whether seats and seat belts were correct and cabin doors and
windows were locked. Upon receiving ATC clearance, landing lights and Fuel pumps
were switched ON, brakes were applied, power increased to 1800rpm. At IAS 57kts, the
control column was pulled to rotate the aircraft but unexpectedly the aircraft didn’t
rotate. The whole aircraft started shivering after crossing the middle marker.
 As it was observed that nose wheel of the aircraft went up but aircraft was still rolling on
main wheels and also realizing that she don’t have enough of the runway available, the
take-off was aborted.
 The student pilot dropped the nose slightly on the ground, followed by power to Idle,
and started applying brakes. After aborting the take-off, while applying the brakes, she
could see the end of the runway, so applied brakes with all strength to make the aircraft
stop on the runway but it kept rolling and hit the fence. As she gained back senses,
aircraft was out of the fencing of academy perimeter.
 Once the aircraft came to complete stop, the student pilot could not complete the
aircraft shutdown procedures. She received an RT call from ATC advising to get out of
the aircraft as soon as possible. After listening to it, without any further communication,
the student pilot removed her headsets, hanged them on control column and tried to
get out of the aircraft from left side. However, she exited the aircraft via right door of
the aircraft as obstructions were found near the left door.
 The student pilot suffered no injury subsequent to incident.
 The student pilot had practiced flapless landings but no flapless takeoffs were practiced
during training.

1.18.2 As per Dy.Chief Flight Instructor’s Statement:

 The student pilot was authorized for her solo circuit and landing on 17 July 2021. Her
first circuit and landing was normal. The incident happened during the second sortie.

17
 After coming to full stop post first landing, she lined up for the second circuit and
landing. On the takeoff role she aborted the takeoff. She was unable to stop the aircraft
within the runway, hit to fence and came to a halt about 20 to 30 feet after the end of
the runway. She came out of the aircraft on her own and waited on the side.
 Dy. CFI came to know about the incident after hearing the emergency siren raised by the
ATC. He rushed to the aircraft site and observed that the student pilot was uninjured
and aircraft had come to a stop. The propeller and spinner was completely broken and
left with one blade, the a/c nose was toward East direction tilted downward with nose
strut bent backward, and the tail was in upward position. When the cockpit was checked
he observed that the Engine Master, Electrical Master were in OFF position, Fuel
selector in BOTH position, Flaps UP, Trim was not in Takeoff position. The student pilot’s
belongings were on the rear seat. There were damages on wings and fuel was leaking
from wing root position. The crash crew were already at the site. Then he along with
crash crew and maintenance team took charge of the scene of the incident.
 The student pilot joined Chimes Aviation Academy on 22 February 2021. SPL Classes was
conducted along with her batch and SPL was issued on 11 March 2021. She was assigned
to one of the instructors on 20 March 2021. She started flying on the same date and had
her Progress Check on 04 June 2021 and it was satisfactory. During the progress, the
instructor of student pilot requested Dy.CFI to fly with student pilot.
 Dy.CFI had flown with her for 03:20hrs and her solo check was conducted by him and
released for first solo on 23 June 2021. Her first solo was satisfactory. She was assigned
back to her instructor and continued her progress as per syllabus and her progress was
found satisfactory in dual and solo hours.

1.18.3 As per ATC controller’s statement (Witness):

 The Air traffic controller took over duties at ATC on 17 July 2021 from 0830UTC. Nothing
unusual was observed while the student pilot performed her first circuit.
 At about 0910 UTC, gave clearance for VT-CAG to take off from Runway 17. On take-off
roll as the aircraft approached abeam ATC, it was observed that aircraft was not getting
sufficient height at or after crossing middle marker. When the aircraft approached
tower, aircraft was in air and was almost parallel to Runway.
 Controller transmitted on RT to the aircraft to PULL-UP. But only “sir” was heard on RT
from the aircraft. Immediately after that the aircraft touched down on the Runway near
to B link. After the aircraft was on the Runway, white smoke was observed from main
landing gear. Shortly after that, the aircraft started drifting towards right end of the
Runway.
 At that time everybody concerned were alarmed by raising the siren and in that process
aircraft overrun the Runway and came to a stop. All the emergency vehicles rushed to

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 the aircraft site and reached the site in less than a minute and took charge at the scene
of incident.

1.18.4 Site visit observations:

The visit to the incident site was carried out along with the Dy.CFI on 30.07.2021. No
markings were available on the Runway or the soft ground at the end of Runway. It was
observed that the perimeter fence was of 06 feet height. The Runway end light which was
damaged during the incident was found replaced and was serviceable. The aircraft final
position was demarcated using chalk powder and stones. The damaged fence was found
restored. The Runway 17 end area near threshold markings were found degraded with loose
pebbles. There was no CCTV recording facility at both the Runway ends to capture the
approach and landing profile.

1.18.5 Progress of training:

The student joined the flying school in February 2021. First air experience was on
20.03.2021. The Progress check of the student pilot was carried out by the Dy.CFI after total
flying of 24hrs 05minutes only (as per syllabus generally after flying time of 11hrs, but as on
student improvement). The first solo check was carried out by CFI after a total flying time of
30hrs 10minutes only (as per syllabus after flying time of 15.45hrs), however the check was
satisfactory. Remarks of instructors and the time period taken by student pilot during
progress of training shows that the she had to concentrate more on takeoff and needed
consistence/confidence, as the improvement was slow.

The period of training during checks were found to be not in harmony with the approved
syllabus hours as in many cases according to the training records, the checks were
happening for less hours than required in the syllabus. (eg. First solo check circuits and
landings were done only for 30minutes whereas the syllabus mandates for 45min). The
student pilot was in the second phase of her training as per the syllabus. The solo checks
were satisfactory and no negative remarks were observed in the training records. During
the training progress, flapless landings were practiced however flapless takeoffs were not
practiced so far as the curriculum of training does not have flapless takeoffs to practice. The
instrument flying was started after completing 53hours of flying time on 15.07.2021. The
previous sortie before the incident sortie was carried out on same day on another aircraft
which was a general flying and was uneventful. The Flying Trainee’s progress as per the
records was found satisfactory and no history of any incidents were observed. As per the
statements recorded, at the time of incident, the instructor of the student pilot was in
classroom attending an online class.

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 1.18.6 POH and other SOPs:
- According to Pilot Operating handbook, as per the procedure for normal take off, the
wing flaps are preferred to be at 10 degrees. The wing flaps to be retracted at a safe
altitude. Also the elevator trim control to be set for takeoff.
- As per Chimes Aviation Academy SOP #10 (Issue 02 dated 15.06.2020), for normal
approach and landing, the pre landing checklist to be completed before reaching finals.
Thereafter landing checklist to be carried out. For normal landing, the wing flaps (below
85kts) to be selected from a range of 10 deg to FULL flaps as per the conditions. If flaps
are FULL, airspeed to be maintained between 60-70kts. The elevator trim control to be
adjusted as required.
- As per the same SOP, Post landing when clear of the active runway (aircraft tail past the
Holding point), the Pilot Flying is to STOP the aircraft and complete the after landing
checks. The after landing checklist requires the FLAPs to be made UP.
- According to the Flying Order Book of Academy, as per order 4/1 (Requirements of solo
flying) dated 01.07.2020, all solo flights to be carried out under the supervision of a
flying instructor.

1.19 Useful or Effective Investigation Techniques :

Nil

2. ANALYSIS :

2.1 Operational aspects:

On the day of incident, the student pilot was authorized to carry out 02 solo sorties by the
Dy.CFI. Enough rest was there for the student pilot before the first flight. The student pilot
reported to operations room at 0200UTC, and after finishing the briefing and
documentation work, reached the aircraft allotted to her i.e VT-CAC and carried out the
preflight checks. The sortie which was about 01hour 05minutes was completed
uneventfully. After the sortie she reported to operations room for her next planned solo
sortie. The aircraft allotted for the second sortie (02 circuits and landings) was VT-CAG.

After necessary documentation works, the student pilot carried out the preflight checks of
the aircraft. Upon successful completion of the preflight checks, the aircraft was taxied and
lined up on RWY 17 for first takeoff. After getting clearance from ATC, the takeoff was
carried out, completed the circuit and later landed back (Full stop landing) on RWY 17. The
first circuit was satisfactory and uneventful. During the landing roll, as part of the ‘after
landing checks’, the landing lights and fuel pumps were switched OFF by the student pilot.
Also the flaps were retracted to UP position.

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Thereafter, ATC was requested to permit for backtrack on RWY 17 and the same was
cleared by ATC. After lining up for RWY 17 for the next takeoff, permission for takeoff was
requested. The before takeoff checks were carried out partially during which, the elevator
trim was not kept in takeoff configuration and also the wing flaps were not extended to
10degrees. After getting the departure permission, the landing lights and fuel pumps were
switched ON, brakes were applied, increased the engine power for takeoff, as per the
takeoff checks. Once the brakes were released, the aircraft started rolling forward.

The student pilot didn’t realize that the takeoff configuration was not set as required, and
continued to takeoff. The student pilot was expecting the aircraft to behave as in normal
takeoff configuration, but the aircraft was not responding as expected at the rotation
speed. The student pilot rotated the aircraft at the usual rotation speed, however since the
takeoff configuration was not normal, the aircraft was not acquiring sufficient lift at that
speed and was not gaining height after lifting off the ground. Instead aircraft started
shivering due to the insufficient generation of lift. As the student pilot felt the same, she
decided to reject the takeoff immediately.

The speed at which the rotation initiated was 60kts. The ground speed at the time of
maximum pitch attitude achieved (7.650) was 64.67kts. As part of rejecting the takeoff, the
aircraft nose was dropped down and throttle was reduced. The aircraft after gaining a little
height from ground, landed back and continued rolling. By the time the aircraft started
rolling on ground with a ground speed of 63.66kts (near to TXWY ‘B’ link), remaining RWY
length available was nearly 800ft. Seeing the RWY end the student pilot applied brakes with
full strength however, she could not stop the aircraft within the available RWY length and
continued rolling further. The aircraft then moved out of RWY along the right edge of RWY
and ran over one of the RWY end lights and further moved towards the perimeter fencing,
passing over a small ditch. The nose landing gear collapsed when the aircraft came in touch
with the banks of the ditch. The propeller and spinner cone got damaged during the
aircraft’s movement. The aircraft moved over the fence out of airport perimeter and came
to complete stop with its nose facing east and the tail resting on the notice board. After
hearing the RT call from ATCO, the student pilot managed to come out of the aircraft unhurt
through the RH door. The emergency services and Dy. CFI reached immediately at the site
and took over the control of the site. The student pilot was immediately taken to hospital
for preliminary analysis and no injury observed. Presence of alcohol was not observed
during the checks.

From the incident site photographs it is observed that the engine controls were in switched
off position, throttle was in ‘IDLE’. Flaps were in ‘Flaps 0’ configuration and elevator trim
was NOT in takeoff position. From the Flying Trainee’s Progress Records and the previous
flying training school records, no incident history was observed during the student pilot’s

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training period. The instructor of the student pilot was at the classroom during the time of
incident flight and hence it is clear that he was not monitoring his student’s flight which is
against the requirements of solo flying as per Flying Order Book of the academy (order 4/1
Requirements of solo flying, dated 01.07.2020). Also from the progress training records it is
observed that, though as per the approved syllabus the first solo check (circuit and landing)
need to be for a time period of 45minutes, the actual time completed by the student pilot
during her first solo check was only 30 minutes.

As per the statements collected and the in-situ condition of the aircraft, it is evident that
noncompliance of before takeoff checklist and aircraft handling by the student pilot was the
prime factor to the incident.

2.2 Weather aspects:

The incident occurred in day time with visibility of 6000m. The records available in METAR
register also shows that the weather parameters were conducive for general flying. Hence
weather is not considered a factor to the incident.

2.3 Engineering aspects:

All the maintenance/airworthiness documents pertaining to the aircraft VT-CAG was valid
at the time of incident. No scheduled inspection was found due on the aircraft before the
incident flight. The engine run up and the daily inspection as per schedule performed by
approved engineer was satisfactory. No snags were reported by the crew who operated the
aircraft before the incident sortie and no snag was pending for rectification before the
incident sortie. No DGCA mandatory modification was due on this aircraft and no MEL was
invoked at the time of incident.

The aircraft had 122 litres of fuel in tanks and 5.5litres of oil in sump before the chocks off.
The fuel and oil samples collected from the aircraft post incident was tested and found
within the specification criteria limits. The brake pads were normal and within limits and
the brakes were working at the time of incident. The tires were not damaged during the
braking and found without any wear. There were no snags reported to the brake system of
the aircraft in the near past. No leakage or damage to the brake units were observed after
the incident. However, the effectivity of application of brakes by the student pilot could not
be verified from Garmin data as the brake parameters are not recorded. The movement of
flap system was checked and was found satisfactory. The engine was removed and send to
manufacturer for detailed strip inspection. As per the strip inspection carried out by M/s
Continental Aerospace and the analysis of FADEC data, the subject engine worked well
within its specifications and there were no warnings reported from the engine.

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 Therefore, the aircraft was considered airworthy before the incident flight and the
maintenance factor is ruled out.

3. CONCLUSION:
3.1 Findings:

i. The aircraft was having valid Certificate of Airworthiness (CoA) and Airworthiness
Review Certificate (ARC) as on date of incident. The serviceability factor of the
aircraft was not a contributory factor to the incident.
ii. Licenses, medical fitness and currency on Cessna 172R of the student pilot were
valid at the time of incident.
iii. The student pilot had authorization from Dy.Chief Flight Instructor to carry out
general solo flying of circuits and landings and had sufficient rest before the first
flight of the day.
iv. The first flight of the day was carried out in another aircraft and was uneventful.
v. Sufficient quantity of fuel and oil of correct specifications was available in the
aircraft VT-CAG.
vi. The incident happened during day time and visibility was favorable for general
flying.
vii. The aircraft operated within its Center of Gravity and weight limits. The first takeoff
and landing of the sortie prior to incident was uneventful.
viii. The student pilot before the second takeoff, did not complete the before takeoff
checklist actions. As a result, the flaps were remained in zero position (not
extended) and the elevator trim was not set to takeoff configuration. The student
pilot continued to takeoff without realizing that the flaps and elevator trim were not
set, as done normally.
ix. The aircraft was not gaining height as expected by the student when pitch attitude
was increased for takeoff. The aircraft started vibrating due insufficient speed
achieved for lifting up, as the configuration set was not.
x. The incorrect aircraft configuration was not realized by the student pilot. The
inadequate height gain (as expected) along with vibration, made the student pilot to
abort the takeoff even after the rotation speed.

xi. The flapless takeoff was not practiced by the student pilot before, as it was not
mandated in the syllabus. Only briefing on flapless takeoff was provided during the
progress of training.

xii. The student applied brakes upon touchdown to stop the aircraft on the RWY
however the aircraft did not stop within RWY length limits. The available runway

23
 length after touchdown considering the flaps up configuration was marginal to stop
within the limits.

xiii. There was no damage to the tires due braking. The brake pads were found normal
and within limits and the brakes were working at the time of incident. There were no
snags reported on brake system in the near past as per records.

xiv. The damage to the RWY end light assembly was due to the aircraft overrun during
its exit out of the RWY.

xv. The runway 17 end portion was found degraded with loose pebbles during site
inspection.

xvi. The monitoring the student’s flight was not carried out by the instructor from either
ATC or apron area as he was in the classroom at the time of subject flight, which was
against the procedure.

xvii. The first solo check of the student pilot was only for a period of 30minutes instead
of 45minutes which is not in accordance with the approved flying syllabus.

xviii. There was no injury to neither the student pilot nor any other person outside the
aircraft.

xix. There was no fire or smoke during or after the incident.

3.2 Probable Cause:

The student pilot’s decision to abort the takeoff above rotation speed with marginal
runway available caused the aircraft to overrun the runway. The non-adherence to before
takeoff checklist items leading to incorrect aircraft configuration was a contributory factor.

4. SAFETY RECOMMENDATIONS:

 Action as deemed fit by DGCA-HQrs in view of the findings viii, xv, xvi and xvii.
 DGCA-HQrs may review the syllabus of flying training with respect to emergency
practices and consider to include the flapless takeoffs as part of it, in view of the
above findings.
VINEETH VINEETH SREEKUMAR
SREEKUM your signing location here
2022.12.28 13:05:
28+05'30'
Date: 28.12.2022 AR
(Vineeth S)
Place: Mumbai Investigation-In-Charge, VT-CAG

----End of report—

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