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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.
10:16Stay with they headed.
10:16Moving.
10:20Kellika Tower, Express India 1344.
10:23On ILS.
10:24Runway 1-0.
10:27Express India 1344.
10:29Roger.
10:29Light, rain over the field.
10:30Runway surface.
10:31Wet.
10:32Wind 250 degrees, 08 knots.
10:35Runway 1-0 cleared to land.
10:39Four miles from the runway, the crew receives clearance to land.
10:45Okay, runway in sight.
10:47Runway in sight, check.
10:51This time, the pilots can see the runway.
10:56Approaching minimums.
10:59500.
11:01As a pilot, when you're coming in for landing where there's weather and visibility just above minimum,
11:07you're keeping a sharper eye because things could change at a moment's notice.
11:13Flight 1344 crosses the runway threshold.
11:2130, 20.
11:30Speed brake up.
11:33The speed brakes are deployed to help slow the plane.
11:38Auto brake disarm.
11:44But the plane isn't stopping fast enough.
11:49Oh, crap!
11:56The 737 falls off the end of the runway and breaks apart.
12:08Rescuers rush to save the 190 people on board, as every second could mean the difference between life and death.
12:22In driving rain and darkness, surviving passengers begin to emerge from the wreckage of Air India Express Flight 1344.
12:32The heavy rain benefits the rescue.
12:36It was very helpful, in fact, for dousing the post-crash fire.
12:40It ultimately helped us save lives.
12:46169 people survive the crash.
12:4959 walk away without injuries.
12:5159 walk away without injuries.
13:26Investigators from India's Aircraft Accident Investigation Bureau, the AAIB, arrive on the scene.
13:34This was the first accident which AAIB would have been investigating on its own.
13:40So it was really an acid test for AAIB to prove its mettle.
13:46The first question investigators must answer, did something break off from the airplane before the landing, making it impossible for
13:54the plane to stop?
14:01I've got the next batch downloaded.
14:06Looking at them now.
14:08This was the second wave of COVID, which was the most dangerous.
14:12So there was an embargo as to how many people could sit in a room and conduct a meeting.
14:19Investigators examine dozens of photos from the crash scene.
14:25Do you agree it's all here?
14:28They conclude all of the wreckage is contained within the crash site.
14:35The wreckage was not very spread out.
14:38It was concentrated over a radius of about 200 feet.
14:44Let's regroup in a bit.
14:48All the damage was caused when the 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.
15:20To better understand why the plane overran the runway, investigators try to determine where it initially touched down.
15:28So 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 deposit on the point of touchdown.
15:50They work their way back along the runway.
16:18Beyond 5,000 feet, we were not able to locate any touch tire marks.
16:23The tire marks have been washed away due to heavy rain.
16:30Unable to determine where the plane touched down, investigators examine the runway itself.
16:37Did rubber deposits make the runway too slippery?
16:41They perform a test to determine if the runway's surface provided enough friction or grip for the plane to decelerate
16:49properly.
16:51Our experience shows that an aircraft of 737 class, it leaves a rubber deposit.
16:57And over a period of time, it 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.
17:21That's within standard.
17:31We were quite satisfied with the condition of the paved surface of Calicut Airport.
17:39There were no major rubber deposits.
17:42With 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 tires, like on a car, channels for water to drain off.
17:59And if the tire is bald, basically the grooves are worn out.
18:03That will cause the aircraft to slip.
18:08202 PSI, right in the required pressure range.
18:15No skid burn.
18:18Or bald spots.
18:20Just like the others.
18:23If there was a case of hydroplaning, there would be white marks on the runway.
18:29And that portion of the tires would have been burned.
18:35And here we 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.
18:55But nothing out of the ordinary.
18:59Let's check the hydraulics.
19:06We wanted to ascertain the serviceability of hydraulics, because this is the braking system.
19:13Start up the hydraulics.
19:22No sign of fluid leak.
19:25The brakes didn't feel?
19:26No.
19:33I can say 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.
20:13They found an image from a close-circuit camera located in the pier.
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 touchdown point.
20:48So, 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, and risk the lives of everyone on board?
21:24I have the ATC's heat recordings.
21:29Let's hope we get some answers.
21:34Investigators turn to conversations between Air India Express Flight 1344 and the controller to learn why the plane overflew the
21:43touchdown zone.
21:48Calicut Tower, express India 1344, on ILS runway 28.
21:56Okay.
21:57Sounds like they initially planned to land on runway 28.
22:01So, why did they land on 1-0 instead?
22:06Landing on runway 28, the winds will be from your front.
22:11You'll be landing into the wind.
22:12That creates more lift.
22:17But three and a half minutes later, the crew changes their plans.
22:22Tower Express, India 1344, going around.
22:27Roger.
22:34So, they called a go around?
22:41During monsoon season, it is not very uncommon to see a go around, because of the low ceiling and showers
22:50of rain, which suddenly reduce visibility.
23:07They probably couldn't see the runway.
23:09They probably couldn't see the runway.
23:10Sounds about right.
23:13The crew realized that the runway was not in sight.
23:16So, they took a call to go around.
23:17So, that was absolutely in order.
23:21Calicut Air, India 425.
23:23We're ready for taxi.
23:24And we appreciate if you can give us 1-0 for departure.
23:29Then, investigators hear another plane asking to swap the active runway.
23:34And the controller advising flight 1344 of the change.
23:41Express India 1344, wind is now 270 degrees, 08 knots.
23:46Confirm you'd like to make an approach for runway 1-0?
23:50So, the controller asked them to use 1-0.
23:54So, the controller asked them to use 1-0.
23:59So, the controller asked them to use 1-0.
24:00Calicut, express India 1344.
24:04Go ahead.
24:05How's the visibility on runway 1-0?
24:10Before accepting the new runway, the pilots request clarification of weather conditions.
24:15Both runways at 2,000 meters.
24:18With light rain.
24:20And how are the surface winds?
24:24Surface winds now 260 degrees, 05 knots.
24:295 knots.
24:33Is that within limits?
24:34Let's check.
24:4210 knots is the limit.
24:45Okay.
24:46So, landing on 1-0 safely is technically possible, even if they'd be landing in a tailwind.
24:58Just ten and a half minutes later, investigators hear the last communication with the tower.
25:07Express India 1344 on ILS, runway 1-0.
25:15Express India 1344, roger.
25:18Light rain over the field, runway surface wet.
25:21Wind 250 degrees, 08 knots.
25:24Runway 1-0 cleared to land.
25:28And 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.
25:45Copy, sir.
25:46Express India 1344.
25:51Two and a half minutes later, they overfly the landing zone.
26:00An eight-knot tailwind.
26:02I 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 break 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 touched down at 1900 hours, 40 minutes and 25 seconds.
27:06So 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.
27:194,438 feet from the threshold.
27:22It became very clear to us as to where the aircraft had exactly touched down.
27:31He overshot the touchdown zone by nearly 1,500 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.
28:22So according to the information they had before accepting the approach, they needed to touch down here to have any
28:30chance of stopping before the end of the runway.
28:33Flight 1344 should have touched down 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.
29:00And 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.
29:25But why it happened comes from the CVR.
29:30Hey.
29:32During the first approach, the windshield wipers are on.
29:37And look what happens afterwards.
29:45Bleeding lights in sight.
29:47Yep.
29:4927 seconds after starting the wiper.
29:53What's happened to it?
29:57Oh, crap.
29:58Wiper's gone.
30:00It malfunctions.
30:02What 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 pilots to divert to an alternative
30:25airport if the wipers malfunction.
30:29So was this crash caused by a faulty windshield wiper?
30:37Unserviceability of a wiper in rainy conditions is a no-go item.
30:42The crew pressed on to land at Calicut.
30:47We couldn't fathom the reason.
30:52Let's see if the wiper was working on the second approach.
30:57Heading to course.
30:59Showed you.
31:00Good.
31:01Just a sec.
31:05What is this?
31:08I guess that's the fastest it'll go.
31:13So the wiper is working, just not as fast as it should.
31:18Despite the slow wiper, the pilots continue the approach.
31:24Okay, runway in sight.
31:26Runway in sight, check.
31:34So, less than a mile from the airport, both pilots can see the runway.
31:40The faulty wiper doesn't seem to have prevented the pilots from seeing the runway.
31:46And so far they are still on the glide slope.
31:53But it looks like they deviate below and then above it.
32:01The approach became unstabilized.
32:04And the actions on the part of the crew to continue with the approach really shocked us.
32:12So if they were above the glide slope, that means when they crossed the runway threshold, they were 40 feet
32:17too high.
32:19A 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 crew did continue their landing.
32:38Did the pilots believe they could recover from an unstabilized approach and land safely?
32:49Auto brake, disarm.
32:54Oh 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 unstabilized approach.
33:23In order to have a smooth landing, pilots typically add a bit of thrust just before touchdown.
33:32Which is probably what the captain was trying to do.
33:37He'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 3,000 feet.
34:02Why wouldn't the captain just put the plane down?
34:10His wiper was barely working.
34:14It's night, weather's marginal.
34:17What if he lost track of where he was along the runway?
34:22So when you approach an airfield like Calicut, there are no lights surrounding the runway.
34:28You just see the runway lights.
34:31So 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 a 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.
35:35Captain.
35:36Yeah.
35:37Go 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.
35:59If the captain would have gone around, the result could have been different.
36:10Okay.
36:12I appreciate your assistance.
36:15Thanks.
36:18Investigators interview other pilots who flew with Captain Satay to determine how he worked with others in the cockpit.
36:26That was the last pilot on the list.
36:29And?
36:30Here's some of the ways they described him.
36:33Cognitive rigidity, goal-oriented, tendency towards perfectionism.
36:39Sounds more like an Air Force pilot than a civilian one.
36:42Which is what he was for 21 years at the start of his career.
36:51The military aviators are trained to be goal-oriented because for them the success of a mission is the most
36:57important 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.
37:10And if they had to go around from this approach, they 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?
37:33Here's something.
37:36Investigators focus on the captain's flight schedule before and after the day of the accident.
37:42Take a look.
37:44Captain Sethay 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.
37:54And Captain Sethay had to pick up an additional flight.
38:00He was the only captain who could fly out of Calicut, remember, a tricky airport, and only captains can operate
38:08flights 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 and diverted.
38:40So why didn't he?
38:42If the captain does not carry out to go around, the co-pilot is expected to take over.
38:47In the safety of the flight, that is a must.
38:51Captain.
38:53Go around.
39:01Investigators examine the CVR transcripts of flight 1344 to determine why the first officer failed to take control.
39:10They discover a pattern emerging.
39:14Rate of descent, Captain.
39:16Of a dismissive captain.
39:18Yeah, yeah, correcting, correcting, correcting.
39:22And a first officer who didn't assert himself.
39:26Flight book.
39:28Flight book.
39:29Check.
39:32Captain.
39:33Go 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 unsafe.
39:49Was this type of behavior common at the airline?
39:54Investigators examine Air India Express's operations manual.
40:01It would be very important to understand how teamwork is encouraged in the cockpit of an Air India Express aircraft.
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 1-0, the conditions had changed entirely from the
41:08headwind on runway 2-8, and they needed to do a landing distance calculation.
41:16You're right.
41:18He didn't do the calculation.
41:29You're right.
41:33He didn't do the calculation.
41:37He didn't do the calculation.
41:37If they had done any of these, it would have helped them understand there was too little
41:40margin of error to conduct this approach.
42:09It's not much.
42:10Different airport, different outcome.
42:13The captain would have been able to pass controls
42:15to the first officer,
42:17who had a fully working wiper to land the plane.
42:23If they had just diverted to another airport,
42:24they'd all be alive today.
42:37There were so many opportunities the crew had
42:40to conduct a missed approach during this landing,
42:43but the crew took none of them.
42:50In their final report,
42:52investigators recommend expanding simulator training
42:56for unstabilized approaches,
42:58stressing that the first officer
43:00should assertively assume control
43:02and initiate a go-around
43:04if the pilot flying fails to respond.
43:14Simulator training with an emphasis on assertiveness
43:16would go a long way in allowing first officers
43:19to take all appropriate actions
43:21up to and including taking control of the aircraft
43:24when the pilot in command does not respond appropriately.
43:37This accident is avoidable.
43:41We see the number of risks at every stage the crew had taken,
43:47which were unnecessary risks.
43:50There was a human factor which came into play.
43:56They do not see the consequences of their actions.
44:00That is a key point in any accident.
44:05Size of respect points
44:05S sync and string and enormity
44:05Some warnings many times
44:10from the University of Ohio
44:10Part 7
44:11Student
44:11Sam collection
44:11Delivery
44:22State
44:32Inspector
44:32Tom
44:40You
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