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00:02Landing at Calicut Airport.
00:05Speed break up.
00:08The pilots of Air India Express Flight 1344 run out of tarmac to stop.
00:15Oh, crap!
00:2321 people are killed.
00:28Start up the hydraulics.
00:31Did the brakes malfunction?
00:33No sign of fluid leak.
00:36The brakes didn't feel?
00:39When investigators listen to the cockpit voice recorder...
00:43Put the wipers on.
00:45...they discover a malfunction of an entirely different nature.
00:51What's happened to him?
00:55So, was this crash caused by a faulty windshield wiper?
01:03Me, me, me, me!
01:07Oh, crap!
01:25It's monsoon season in India.
01:29Air India Express Flight 1344 is on approach to Calicut International Airport.
01:38The pilot flying is Captain Deepak Satay.
01:41He's a highly experienced 59-year-old commercial pilot.
01:46Visibility is just above minimum, so he can make an attempt.
01:50Okay?
01:51Check.
01:53The captain had flown in and out of Calicut a number of times.
01:57So he was very familiar with the airfield, the terrain around, and the weather conditions.
02:05The runway is wet.
02:07The runway is wet.
02:07Expect turbulence.
02:08Expect weather.
02:09All precautions.
02:12First officer Akilesh Kumar is aged 32.
02:16He joined Air India Express three years ago and has almost 2,000 flying hours.
02:22He has less experience navigating through monsoons than the captain.
02:28That area experiences very heavy showers along with reduced visibility and strong winds.
02:37In addition to the five crew, there are 184 Indian nationals on board.
02:44All are being repatriated amid the ongoing COVID-19 outbreak.
02:49It's one of more than 2,000 flights into India to date, bringing home thousands of workers stranded abroad
02:57when flights were grounded due to COVID restrictions.
03:01So the passengers on these flights were mostly blue-collar workers, people who had flown to Dubai to work in
03:08malls, in small restaurants.
03:13About 50 miles from the airport, Captain Satay begins his approach briefing.
03:19For a go-around, wind shear on approach, approach to stall, and recovery on go-around, as briefed in the
03:27first sector.
03:28Check.
03:31Approach briefing is basically one pilot communicating to the other what his plan of action is.
03:38Any doubts?
03:41No.
03:43Any questions?
03:47No questions.
03:52Today's flight from Dubai to Calicut takes just under four hours.
04:00Calicut Tower, Express India 1344 on ILS runway 28.
04:0812 miles from the airport.
04:10Any change in the visibility?
04:13The captain wants a weather update.
04:17Any change in the visibility? Express India 1344.
04:21Uh, stand by.
04:24Air India, Express 1344.
04:26Latest visibility is 2,000 meters and light rain.
04:31Copy, Express India 1344.
04:352,000 meters visibility on a tricky airport with light rain.
04:41And the pilots are basically a bit more anxious than a normal approach.
04:50Calicut's runway is built on a tabletop plateau.
04:54There are steep drop-offs at both ends.
04:58There is no margin of error.
05:00If you exceed the landing limit, you go straight down into a valley.
05:07The pilots are flying a Boeing 737-800, specially modified for difficult landings.
05:15It has modified spoilers and braking performance and allows it to stop faster than other models of the 737-800.
05:26Just two minutes from Calicut airport, the crew gets ready for landing.
05:32Put the wipers on.
05:38Lead-in lights in sight?
05:40Yep.
05:46What's happened to it?
05:49Oh crap.
05:51Wiper's gone.
05:53What a day for the wiper to go.
05:58With decreased visibility hindering their approach, the pilots must make a crucial decision.
06:07If they do not have the runway or any of the elements in sight, at that point they have to
06:13take a decision to continue or to go around.
06:21Approaching minimums, 500. Minimums.
06:29Let's go around.
06:35A half mile from the airport, Captain Sate aborts the landing and decides to try it again.
06:50Express India 1344, request reason for go around.
06:56When pilots go missed on an approach, it's important information to share with air traffic control because that can help
07:02other pilots who are coming into the airport anticipate any hazards that may be there.
07:07Due to weather, Express India 1344, heavy rain.
07:12Uh, Roger.
07:18While flight 1344 completes its go around, a crew waiting to take off contacts the tower.
07:28Calicut Air India 425, we're ready for taxi and we appreciate if you can give us 1-0 for departure.
07:37The departing crew wants to switch runways.
07:42Runway 2-8 and Runway 1-0 are the same strip of runway, but they're in the opposite directions.
07:50Roger.
07:51Expect 1-0. Taxi via Charlie, enter backtrack, line up Runway 1-0.
07:56Via Charlie, enter backtrack, line up 1-0.
07:59Air India 425. Thank you, sir.
08:02Typically, departure aircraft want to taxi the least time and get airborne as soon as possible.
08:10Runway 1-0 is closest to the apron.
08:13To accommodate the departing aircraft, controllers change the active runway from 2-8 to 1-0.
08:22Express India 1344, wind is now 270 degrees, 0-8 knots.
08:27Confirm you'd like to make an approach for Runway 1-0?
08:32Yeah, we'd like to try if you can give us an update on the visibility for Runway 1-0.
08:40Visibility is the same, sir, at 2,000 meters and we'll notify you of any improvement.
08:44And now wind is 260 degrees, 0-5 knots.
08:49Okay. Set up for 1-0. Let's try.
09:02Localizer alive.
09:05Check.
09:08The localizer is part of the ILS, or instrument landing system.
09:14That provides lateral guidance to the runway's centerline.
09:24Cabin crew, landing stations.
09:29Flight 1344 is now only six miles from the runway.
09:35Shall we do it?
09:37Captain Sate tries the wipers again.
09:40Just a sec.
09:44What is this?
09:47The captain's wiper is working more slowly than it should.
09:51I guess this is the fastest it'll go.
09:54Okay. Glide slope captured.
09:59The glide slope is also part of the instrument landing system and guides the plane on a three-degree slope
10:06to the runway threshold.
10:12Flaps 25.
10:14Flaps 25 selected.
10:16Theانficovir.
10:19Kalika Tower, Express India.
10:221344.
10:23On ILS runway, 1, 0.
10:27Express India, 1, 3, 4, 4.
10:29Roger.
10:29Bright rain over the field runway, surface.
10:31Wet.
10:32Wind 250 degrees.
10:340-8 knots.
10:34runway one zero cleared to land four miles from the runway the crew receives clearance to land
10:45okay runway in sight runway in sight check this time the pilots can see the runway
11:00as a pilot when you're coming in for landing where there's weather and visibility just above
11:06minimums you're keeping a sharper eye because things could change at a moment's notice
11:13flight 1344 crosses the runway threshold
11:30speed break up the speed brakes are deployed to help slow the plane
11:38auto brake disarm
11:44but the plane isn't stopping fast enough
11:56the 737 falls off the end of the runway
12:03and breaks apart rescuers rush to save the 190 people on board as every second could mean
12:15the difference between life and death in driving rain and darkness surviving passengers begin to
12:27emerge from the wreckage of air India Express flight 1344 the heavy rain benefits the rescue it was very
12:37helpful in fact for dowsing the post crash fire it ultimately helped us save lives 169 people
12:47survive the crash 59 walk away without injuries
13:03but 21 of those on board are dead
13:08captain Deepak Satay and first officer Akilesh Kumar are among them
13:25investigators from India's aircraft accident investigation bureau the AAIB arrive on the scene
13:33this was the first accident which AAIB would have been investigating on its own so it was really an
13:42acid test for AAIB to prove its mettle the first question investigators must answer did something break
13:51off from the airplane before the landing making it impossible for the plane to stop
14:01I've got the next batch downloaded looking at them now this was the second wave of
14:10COVID which was the most dangerous so there was an embargo as to how many people could sit in a
14:16room and conduct a meeting investigators examine dozens of photos from the crash scene you agree it's all
14:26here they conclude all of the wreckage is contained within the crash site the wreckage was not very spread out
14:38it
14:39was concentrated over a radius of about 200 feet let's regroup in a bit all the damage was caused when
14:50the plane overran the runway
14:55so we wanted to come out with the probable reasons as to what has led the aircraft to exit the
15:02runway
15:13only slightly off center but at least they were lined up with the runway properly to better understand why the
15:23plane overran the runway
15:24investigators try to determine where it initially touched down so where do the marks start
15:36on a dry runway it is very very easy to find the touchdown points because the tires they leave some
15:44rubber
15:44deposit on the point of touchdown they work their way back along the runway
16:18beyond 5000 feet we were not able to locate any touch tire marks
16:23the tire marks have been washed away due to heavy rain unable to determine where the plane touched down investigators
16:34examine the runway itself did rubber deposits make the runway too slippery they perform a test to determine if the
16:44runway surface provided enough friction or grip for the plane to decelerate properly
16:51our experience shows that a aircraft of 737 class it leaves a rubber deposit and over a period of time
16:59it becomes difficult for the tire to grip
17:08friction test results just came in
17:10coefficient of friction ranges from 0.63 to 0.72 that's within standard
17:31we were quite satisfied with the condition of the paved surface of calicut airport there were no major rubber deposits
17:41with the runway surface ruled out investigators consider if the plane's tires were too worn causing it to hydroplane on
17:51the wet runway
17:53the grooves on the grooves on the tires like on a car channels for water to drain off and if
17:59the tire is bald basically the grooves are worn out that will cause the aircraft to slip
18:08202 202 psi right in the required pressure range
18:15no skid burn
18:16no skid burn
18:18or bald spots
18:20just like the others
18:23if there was a case of hydroplaning
18:25there would be white marks on the runway and that portion of the tires would have been burned and here
18:36we didn't find either of these
18:40what about the brakes
18:44did the brakes malfunction causing the plane to overrun the runway
18:51some corrosion
18:55nothing out of the ordinary
18:59let's check the hydraulics
19:05we wanted to ascertain the serviceability of hydraulics
19:09because this is the braking system
19:13start up the hydraulics
19:15yes
19:22no sign of fluid leak
19:25no sign of fluid leak
19:25the brakes didn't feel
19:27no
19:33i can see that there was no abnormality in the deceleration devices
19:42okay
19:46good
19:50so did the plane touch down within the touchdown zone
19:57investigators try to determine if the crew of flight 1344 gave themselves enough space to stop
20:04thank you
20:14they found an image
20:23from a closed circuit camera located here
20:30looks like they're still about 15 feet above the runway and they're past the touchdown zone
20:40we could see clearly the aircraft floating but unfortunately we couldn't see the exact
20:46touchdown point so that means they flew well past the touchdown area before putting the plane down
20:56that's right
21:06why would the pilots land so far past the touchdown zone
21:12and risk the lives of everyone on board
21:24i have the atc recordings
21:29let's hope we get some answers
21:33investigators turn to conversations between air india express flight 1344 and the controller
21:41to learn why the plane over flew the touchdown zone
21:48calicut tower express india 1344 on ils runway 28
21:56okay sounds like they initially planned to land on runway 28
22:00so why did they land on 10 instead
22:06the winds will be from your front you'll be landing into the wind that creates more lift
22:17but three and a half minutes later the crew changes their plans
22:21tower express india 1344 going around
22:27roger
22:33so they called a go around
22:41during monsoon season it is not very uncommon uh to see a go around because uh of the low ceiling
22:48and uh showers of rain which suddenly reduce visibility
22:55express india 1344 request a reason for go around
22:58due to weather express india 1344 heavy rain
23:04uh roger
23:07they probably couldn't see the runway
23:09sounds about right
23:13the crew realized that the runway was not in sight
23:16so they took a call to go around so that was absolutely in order
23:21calicut air india 425
23:23we're ready for taxi and we appreciate if you can give us one zero for departure
23:29then investigators hear another plane asking to swap the active runway
23:35and the controller advising flight 1344 of the change
23:41express india 1344 wind is now 270 degrees 08 knots confirm you'd like to make an approach for runway one
23:48zero
23:50so the controller asks them to use one zero
23:53so the controller asks them to use one zero
24:00calicut express india 1344
24:04go ahead
24:05go ahead
24:05how's the visibility on runway one zero
24:09before accepting the new runway the pilots request clarification of weather conditions
24:16both runways at 2 000 meters with light rain
24:20and how are the surface winds
24:24surface winds now 260 degrees 05 knots
24:295 knots
24:32is that within limits
24:34let's check
24:4210 knots is the limit
24:45okay so landing on one zero safely is technically possible even if they'd be landing in a tailwind
24:57just ten and a half minutes later investigators hear the last communication with the tower
25:07express india 1344 on ils runway one zero
25:15express india 1344 roger light rain over the field runway surface wet wind 250 degrees 08 knots
25:23runway one zero cleared to land
25:25runway one zero cleared to land and what's the visibility
25:33they're asking about visibility again
25:37seems to be an issue
25:43visibility is the same sir at 2 000 meters
25:45copied sir express india 1344
25:51two and a half minutes later
25:53they overfly the landing zone
26:00an eight knot tailwind i mean it's still within limits
26:04despite missing the touchdown zone could the crew have safely stopped their plane on the runway
26:12speed brake
26:13speed brake up
26:23investigators examined the flight parameters of air india express flight 1344
26:30the data could shed light on precisely where the aircraft landed after cctv footage captured it passing the touchdown zone
26:41can you isolate the weight on wheels perimeter
26:50weight on wheels is a sensor which indicates to the fdr the moment weight comes on the wheels
26:59that's what we're looking for
27:00the plane touchdown at 1900 hours 40 minutes and 25 seconds so how far down the runway is that
27:09using the ground speed of the aircraft investigators calculate how far the plane flew over the runway
27:194438 feet from threshold
27:22in the distance
27:23it became very clear to us as to where the aircraft had exactly touchdown
27:31he overshot the touchdown zone by nearly 1500 feet
27:38leaving less than half the runway for stopping
27:42can the plane even stop on half a runway in a tailwind
27:47Let me calculate the actual landing distance.
27:52The actual landing distance is the distance required from touchdown to stop.
27:58Weight.
28:0263,000 kilos.
28:05Wind.
28:06Last reported tailwind before flight 1344 began its approach was actually 10 knots.
28:13Flaps.
28:1430.
28:197,803 feet.
28:21So according to the information they had before accepting the approach,
28:26they needed to touchdown here to have any chance of stopping before the end of the runway.
28:34Flight 1344 should have touchdown 3,000 feet earlier in order to stop safely.
28:41So why did the pilots not give themselves enough runway to stop the plane?
28:52When the aircraft touches down, you experience harsh braking, reverse thrust, more noise.
28:58But here it was totally silent and the passengers, they would be wondering, why is the aircraft not touching down?
29:10Investigators check the transcripts of the cockpit voice recording for something that might explain why the pilots carried out the
29:18landing without enough runway.
29:22The flight data gives us what happened, but why it happened comes from the CVR.
29:30theabulator.
29:31During the first approach, the windshield wipers are on.
29:37And look what happens afterwards.
29:45lead in lights in sight yep 27 seconds after starting the wiper what's happened to it
29:57oh crap wiper's gone it malfunctions what a day for the wiper to go
30:12maybe that explains why he was so worried about visibility
30:17according to rules for landing at Calicut during monsoon season it is mandatory for
30:23pilots to divert to an alternative airport if the wipers malfunction so was this crash
30:31caused by a faulty windshield wiper unserviceability of a wiper in rainy conditions is a no-go item the
30:43crew pressed on to land at Calicut we couldn't fathom the reason let's see if the wiper was
30:53working on the second approach heading to course so good just a sec what is this I guess that's the
31:10fastest it'll go so the wiper is working just not as fast as it should despite the slow wiper the
31:21pilots continue the approach okay runway in sight runway in sight check so less than a mile from the
31:36airport both pilots can see the runway the faulty wiper doesn't seem to have prevented the pilots from
31:44seeing the runway and so far they are still on the glide slope but it looks like they deviate below
31:55and
31:57then above it the approach became unstabilized and the actions on the part of the crew to continue with
32:07the approach really shocked us so if they were above the glideslope that means when they cross the runway
32:16threshold they were 40 feet too high the tailwind less than ideal
32:27if you fly off of the glide slope this close to the runway it is unsafe for you to continue
32:33yet this
32:33crew did continue their landing did the pilots believe they could recover from an unstabilized approach
32:42and land safely auto brake disarm oh crap
33:05looks like the captain increases engine power to stabilize the landing
33:12investigators search the FDR parameters to explain how the pilots of flight 1344 dealt with their
33:20unstabilized approach in order to have a smooth landing pilots typically add a bit of thrust just before
33:29touchdown which is probably what the captain was trying to do he's pushing throttles well beyond 80%
33:46the captain adds so much power the plane floats down the runway
33:57the plane floats over the runway for more than 3000 feet why wouldn't the captain just put the plane down
34:10his wiper was barely working it's night weather is marginal what if he lost track of where he was along
34:19the runway
34:22so when you approach an airfield like Calicut there are no lights surrounding the runway you just see
34:29the runway lights so in case you have light rain but low cloud ceiling that is a very unnerving feeling
34:41the captain didn't know where to put the plane down because of his slow wiper and the heavy rain which
34:48reduced his vision
34:58they still could have done a go around
35:02the plane can carry out the go around from any point of time even after touchdown
35:08so long the thrust reversers are not deployed
35:13so why didn't they
35:28just check it put the plane down
35:34the captain captain yeah go around
35:38go around
35:42the first officer called for a go around and the captain ignored him
35:49why would such an experienced captain not listen to his first officer at such a critical moment
35:56that was fatal if the captain would have gone around the result could have been different
36:10okay
36:12i appreciate your assistance thanks
36:17investigators interview other pilots who flew with captain satay to determine how he worked with
36:24others in the cockpit that was the last pilot on the list and here's some of the ways they described
36:32him
36:33cognitive rigidity goal oriented tendency towards perfectionism
36:38sounds more like an air force pilot than a civilian one which is what he was for 21 years at
36:44the start of his career
36:51the military aviators are trained to be goal oriented because for them the
36:55success of a mission is the most important criteria
37:00there's another reason the captain may have been determined to land in calicut
37:06the crew were now making a second approach into calicut and if they had to go around from this approach
37:15they would by the operating procedures be required to divert
37:21did the captain resist a second go around so that he wouldn't be forced to divert
37:34here's something
37:36investigators focus on the captain's flight schedule before and after the day of the accident
37:42take a look captain satay was scheduled to be on standby the day after the accident august 8th
37:50but the day before the accident there was a scheduling change and captain satay had to pick up an additional
37:57flight
38:00he was the only captain who could fly out of calicut remember a tricky airport
38:06and only captains can operate flights in and out of a tabletop airport
38:14so if he had diverted to another airport instead of landing the flight to doha the next day would have
38:20to be cancelled
38:25he was committed to land because he knew that there was no one else to undertake the flight
38:32but even if the captain forced the landing the first officer could still have taken over the controls
38:38and diverted so why didn't he if the captain does not carry out to go around the co-pilot is
38:45expected to
38:46take over in the safety of the flight that is a must captain go around
39:01investigators examine the cvr transcripts of flight 1344
39:06to determine why the first officer failed to take control they discover a pattern emerging
39:13rate of a dismissive captain yeah yeah correcting correcting correcting and a first officer who didn't
39:25assert himself right close right close check captain go around
39:38the captain uses his authority to dictate what he wants and the co-pilot is too submissive to call out
39:45what he sees as i'm safe
39:49was this type of behavior common at the airline investigators examine air india express's operations
39:57manual
40:01it would be very important to understand how teamwork is encouraged in the cockpit of an air india express
40:07aircraft
40:12it says captains need to approve flight data presented by first officers
40:19i would certainly promote a definite hierarchy in the cockpit
40:25maybe that's why the first officer didn't feel empowered enough to grab the controls and do the go-around
40:32we realized that the language used amounted to the first officer is subservient to the captain
40:44despite the captain's rigidity one simple procedure could have saved the passengers and crew
40:54i don't recall them ever calculating their landing distance
41:01because they were now coming in with a tailwind onto runway one zero the conditions
41:06had changed entirely from the headwind on runway two eight and they needed to do a landing distance calculation
41:17you're right he didn't do the calculation
41:25they missed critical decisions on the tailwind the wet runway and potential diversion options
41:32in addition to calculating landing distance
41:37if they had done any of these it would have helped them understand there was too little margin of error
41:41to conduct this approach
42:10different airport different outcome
42:13the captain would have been able to pass controls to the first officer
42:17who had a fully working wiper to land the plane
42:23they just diverted to another airport they'd all be alive today
42:37there were so many opportunities the crew had to conduct a missed approach during this landing but the crew took
42:43none of them
42:50in their final report investigators recommend expanding simulator training for unstabilized approaches
42:59stressing that the first officer should assertively assume control
43:02and initiate a go-around if the pilot flying fails to respond
43:14simulator training with an emphasis on assertiveness would go a long way in allowing first officers to
43:19take all appropriate actions up to and including taking control of the aircraft when the pilot in command does not
43:26respond appropriately
43:37this accident is avoidable
43:40this accident is avoidable
43:56they do not see the consequences of their actions that is a key point in any accident
44:07to are
44:32the
44:32main
44:32learn
44:32to
44:32we want to
44:32to see
44:32it
44:32see
44:40You
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