The Aircraft Accident Investigation Bureau (AAIB) has attributed the September 2023 crash of a Learjet at Mumbai airport to the flight crew’s decision to continue an unstable approach in marginal weather conditions. Its final report has also highlighted shortcomings in pilot training, maintenance records and internal audits at VSR Ventures, the operator whose aircraft crashed at Baramati in January, killing Maharashtra Deputy Chief Minister Ajit Pawar and four others.
The report, made public on Friday, recommends tighter oversight of non-scheduled and general aviation operators, including a comprehensive review of fixed-wing pilots’ training records and verification that mandatory simulator exercises have been completed.
The AAIB has asked the Directorate General of Civil Aviation (DGCA) to introduce stall-recovery exercises in the landing configuration as part of recurrent pilot training. It has also called for operators to ensure that pilots complete all mandatory training, particularly exercises involving critical emergencies.
How the Mumbai Learjet crashed
The Learjet 45XR, registered as VT-DBL, was operating a non-scheduled flight from Visakhapatnam when it crashed while landing on runway 27 at Mumbai airport on September 14, 2023. All eight people on board were seriously injured.
According to the AAIB, the probable cause was the crew’s decision to continue an unstable approach in marginal weather, combined with inappropriate aircraft handling. This led to an aerodynamic stall at low altitude, from which the aircraft could not recover.
Investigators identified several contributing factors. The crew failed to monitor the aircraft’s airspeed against a rising low-speed warning cue, while the monitoring pilot called for a go-around too late. Rain reduced the crew’s visual references, and a high tailwind further complicated the approach.
The report also noted the crew’s “undue commitment” to landing before restrictions at Mumbai airport came into effect.
Both engines were functioning normally, and investigators found that the aircraft’s serviceability had not contributed to the accident.
Training and audit shortcomings at VSR
The investigation uncovered deficiencies in VSR Ventures’ recurrent training programme. During some Learjet pilots’ training cycles, skill checks covering critical emergency procedures were not completed in full over the required one-year period, including exercises that should have been conducted on simulators.
Investigators also found that technical and airframe logbooks had not been maintained properly. The company’s internal audits were not carried out diligently, according to the report.
Furthermore, the DGCA’s audit and surveillance reports examined during the investigation did not contain the findings subsequently identified by the AAIB.
The issue has drawn additional scrutiny because VSR operated the aircraft involved in the January crash at Baramati, which killed Ajit Pawar and four others. Following that accident, the civil aviation ministry said the DGCA’s most recent audit of VSR, conducted in February 2025, had recorded no Level-I findings, the most serious category of audit observations.
The Mumbai accident report was released more than three years after the crash, exceeding the 12-month period recommended under International Civil Aviation Organization norms. In January, following the Baramati crash, reports had highlighted that the Mumbai investigation was still pending. Aviation experts had said its findings could help establish whether VSR required stricter regulatory oversight.
DGCA asked to strengthen pilot oversight
The AAIB has recommended a one-time review of training records for all fixed-wing pilots, with particular attention to those employed by non-scheduled and general aviation operators. The exercise is intended to verify that pilots have completed all mandatory simulator sessions.
The bureau has also called for the DGCA to direct operators to ensure that pilots complete every prescribed training exercise, including critical emergency procedures. It recommended that pilots be required to execute a go-around whenever an approach is not stabilised.
To improve cockpit coordination, the report called for stronger crew resource management training, ensuring that monitoring pilots can confidently and promptly flag deviations and insist on corrective action.
For VSR specifically, the AAIB recommended introducing proper challenge-and-response checklists and improving the maintenance of technical and airframe records.
The regulator has also been asked to verify that operators’ manuals comply with applicable regulations and assess the effectiveness of their internal audits during inspections.
The recommendations seek to address both operational decision-making in the cockpit and shortcomings in the systems intended to ensure that pilots and operators meet aviation safety requirements.