- vor 13 Stunden
On 7 August 2020, Air India Express Flight 1344 plunges down a gorge after overrunning the runway at Kozhikode International Airport in poor weather, killing 21 of the 190 people on board. The captain continued the unstabilized approach and landed too far down the runway.
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00:06Oh
00:07Landing at Calicut Airport
00:09Speedbrake up
00:12The pilots of Air India Express flight 1344 run out of tarmac to stop
00:19Oh crap
00:2621 people are killed
00:31Start up the hydraulics
00:34Did the brakes malfunction?
00:36No sign of fluid leak
00:38The brakes didn't feel?
00:42When investigators listen to the cockpit voice recorder
00:45Put the wipers on
00:48They discover a malfunction of an entirely different nature
00:53What's happened to it?
00:57So was this crash caused by a faulty windshield wiper?
01:05D D D D
01:26It's monsoon season in India
01:30Air 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 we can make an attempt
01:50Okay
01:50Check
01:51D D D D
01:54He had flown in and out of Calicut a number of times
01:56So he was very familiar with the airfield, the terrain around and the weather conditions
02:04Runway is wet, expect turbulence, expect weather, all precautions
02:11First officer Akilesh Kumar is age 32
02:15First officer Akilesh Kumar is age 32
02:15He joined Air India Express three years ago and has almost 2,000 flying hours
02:21He has less experience navigating through monsoons than the captain
02:26That area experiences very heavy showers along with reduced visibility and strong winds
02:35In addition to the five crew, there are 184 Indian nationals on board
02:41All are being repatriated amid the ongoing COVID-19 outbreak
02:46It's one of more than 2,000 flights into India to date
02:50Bringing home thousands of workers stranded abroad when flights were grounded due to COVID restrictions
02:58So the passengers on these flights were mostly blue collar workers
03:02People who had flown to Dubai to work in malls, in small restaurants
03:10About 50 miles from the airport, Captain Satay begins his approach briefing
03:16For a go-around, wind shear on approach, approach to stall and recovery on go-around
03:21As briefed in the first sector
03:24Check
03:26Approach briefing is basically one pilot communicating to the other what his plan of action is
03:34Any doubts?
03:36No
03:38Any questions?
03:43No questions
03:47Today's flight from Dubai to Calicut takes just under 4 hours
03:55Calicut Tower, Express India 1344 on ILS runway 28
04:0212 miles from the airport
04:04Any change in the visibility?
04:07The captain wants a weather update
04:11Any change in the visibility? Express India 1344
04:15Uh, standby
04:17Air India, Express 1344
04:19Latest visibility is 2,000 metres and light rain
04:23Copy, Express India 1344
04:282,000 metres of visibility on a tricky airport with light rain
04:34The pilots are basically a bit more anxious than a normal approach
04:42Calicut's runway is built on a tabletop plateau
04:46There are steep drop-offs at both ends
04:50There is no margin of error
04:52If you exceed the landing limit, you go straight down into a valley
04:59The pilots are flying a Boeing 737-800 specially modified for difficult landings
05:06It has modified spoilers and braking performance
05:09And allows it to stop faster than other models of the 737-800
05:17Just two minutes from Calicut airport, the crew gets ready for landing
05:22Put the wipers on
05:28Lead in lights in sight
05:31Yep
05:37What's happened to it?
05:39Oh crap
05:41Wiper's gone
05:43What a day for the wiper to go
05:47With decreased visibility hindering their approach, the pilots must make a crucial decision
05:56If they do not have the runway or any of the elements in sight
06:00At that point they have to take a decision to continue or to go around
06:10Approaching minimums, 500
06:13Minimums
06:17Let's go around
06:23A half mile from the airport, Captain Sate aborts the landing and decides to try it again
06:38Express India 1344, request a reason for go around
06:43When pilots go missed on an approach, it's important information to share with air traffic control
06:48Because that can help other pilots who are coming into the airport anticipate any hazards that may be there
06:54Due to weather, Express India 1344, heavy rain
06:59Roger
07:05While flight 1344 completes its go around
07:09A crew waiting to take off contacts the tower
07:14Calicut Air India 425, we're ready for taxi and we appreciate if you can give us 1-0 for departure
07:23The departing crew wants to switch runways
07:27Runway 28 and runway 1-0 are the same strip of runway, but they're in the opposite directions
07:35Roger, expect 1-0, taxi via Charlie, enter backtrack, line up runway 1-0
07:43Air India 425, thank you sir
07:48Typically, departure aircraft want to taxi the least time and get airborne as soon as possible
07:54Runway 1-0 is closest to the apron
07:57To accommodate the departing aircraft, controllers change the active runway from 28 to 1-0
08:05Express India 1344, wind is now 270 degrees, 08 knots
08:10Confirm you'd like to make an approach for runway 1-0?
08:16Yeah, we'd like to try if you can give us an update on the visibility for runway 1-0
08:23Visibility is the same, sir, at 2,000 meters and we'll notify you of any improvement
08:27And now wind is 260 degrees, 05 knots
08:32Okay, set up for 1-0, let's try
08:44Localizer alive?
08:46Check
08:50The localizer is part of the ILS, or instrument landing system
08:55That provides lateral guidance to the runway's center line
09:06Cabin crew, landing stations
09:10Flight 1344 is now only 6 miles from the runway
09:16Shall we do it?
09:18Captain Sate tries the wipers again
09:20Just a sec
09:25What is this?
09:27The captain's wiper is working more slowly than it should
09:31I guess this is the fastest it'll go
09:34Okay, glide slope captured
09:39The glide slope is also part of the instrument landing system
09:43And guides the plane on a 3-degree slope to the runway threshold
09:51Flaps 25
09:53Flaps 25 selected
09:55Moving
09:58Calica Tower, Express India 1344
10:02On ILS runway 1-0
10:05Express India 1344, roger
10:08Light rain over the field, runway surface wet, wind 250 degrees, 08 knots
10:13Runway 1-0 cleared to land
10:17Four miles from the runway, the crew receives clearance to land
10:23Okay, runway in sight
10:24Runway in sight, check
10:28This time the pilots can see the runway
10:33Approaching minimums
10:36Five hundred
10:38As a pilot, when you're coming in for landing where there's weather and visibility just above minimums
10:44You're keeping a sharper eye because things could change at a moment's notice
10:50Flight 1344 crosses the runway threshold
10:5830
10:5830
10:5920
10:5930
11:0420
11:06Speedbrake up
11:08The speed brakes are deployed to help slow the plane
11:14Auto brake disarm
11:19But the plane isn't stopping fast enough
11:24Oh crap!
11:31The 737 falls off the end of the runway
11:37And breaks apart
11:43Rescuers rush to save the 190 people on board
11:47As every second could mean the difference between life and death
11:56In driving rain and darkness, surviving passengers begin to emerge from the wreckage of Air India Express Flight 1344
12:05The heavy rain benefits the rescue
12:09It was very helpful, in fact, for dousing the post-crash fire
12:14It ultimately helped us save lives
12:19169 people survive the crash
12:2159 walk away without injuries
12:34But 21 of those on board are dead
12:39Captain Deepak Satay and First Officer Akilesh Kumar are among them
12:56Investigators from India's Aircraft Accident Investigation Bureau, the AAIB, arrive on the scene
13:04This was the first accident which AAIB would have been investigating on its own
13:10So it was really an acid test for AAIB to prove its mettle
13:16The first question investigators must answer
13:19Did something break off from the airplane before the landing, making it impossible for the plane to stop?
13:31I've got the next batch downloaded
13:35Looking at them now
13:37This was the second wave of COVID, which was the most dangerous
13:41So there was an embargo as to how many people could sit in a room and conduct a meeting
13:48Investigators examined dozens of photos from the crash scene
13:53Do you agree it's all here?
13:57They conclude all of the wreckage is contained within the crash site
14:03The wreckage was not very spread out
14:06It was concentrated over a radius of about 200 feet
14:12Let's regroup in a bit
14:15All the damage was caused when the plane overran the runway
14:22So we wanted to come out with the probable reasons as to what has led the aircraft to exit the
14:29runway
14:40Only slightly off centre
14:43But at least they were lined up with the runway properly
14:46To better understand why the plane overran the runway
14:51Investigators try to determine where it initially touched down
14:55So where do the marks start?
15:02On a dry runway, it is very, very easy to find the touchdown points
15:06Because the tyres, they leave some rubber deposit on the point of touchdown
15:15They work their way back along the runway
15:39They work their way back along the runway
15:41Beyond 5000 feet, we were not able to locate any touched tyre marks
15:47The tyre marks have been washed away due to heavy rain
15:53Unable to determine where the plane touched down, investigators examine the runway itself
16:00Did rubber deposits make the runway too slippery?
16:04They perform a test to determine if the runway's surface provided enough friction or grip
16:10For the plane to decelerate properly
16:13Our experience shows that an aircraft of 737 class
16:17It leaves a rubber deposit
16:19And over a period of time
16:21It becomes difficult for the tyre to grip
16:29Friction test results just came in
16:32Friction test results just came in
16:33Coefficient of friction ranges from
16:370.63
16:40To 0.72
16:43That's within standard
16:52We were quite satisfied with the condition of the
16:56Paved surface of Calicut Airport
16:59There were no major rubber deposits
17:03With the runway surface ruled out
17:05Investigators consider if the plane's tyres were too worn
17:09Causing it to hydroplane on the wet runway
17:13The grooves on the tyres, like on a car
17:16The channels for water to drain off
17:18And if the tyre is bald, basically the grooves are worn out
17:22That will cause the aircraft to slip
17:28202 PSI
17:29Right in the required pressure range
17:34No skid burn
17:37Or bald spots
17:39Just like the others
17:42If there was a case of hydroplaning
17:44There would be white marks on the runway
17:47And that portion of the tyres would have been burnt
17:53And here we didn't find either of these
17:58What about the brakes?
18:01Did the brakes malfunction, causing the plane to overrun the runway?
18:08Some corrosion
18:13But nothing out of the ordinary
18:16Let's check the hydraulics
18:22We wanted to ascertain the serviceability of hydraulics
18:26Because this is the braking system
18:30Start up the hydraulics
18:38No sign of fluid leak
18:41No sign of fluid leak
18:41No sign of fluid leak
18:42The brakes didn't feel?
18:43No
18:48I can say that there was no abnormality in the deceleration devices
18:57Okay
19:00Okay
19:01Good
19:05So
19:06Did the plane touch down within the touchdown zone?
19:12Investigators try to determine if the crew of Flight 1344 gave themselves enough space to stop
19:19Thank you
19:20Thank you
19:28They found an image
19:37From a closed circuit camera
19:39Located
19:40Located
19:40Up here
19:43Looks like they're still about 15 feet above the runway
19:46And they're past the touchdown zone
19:53We could see clearly the aircraft floating
19:57But unfortunately we couldn't see the exact touchdown point
20:01So that means they flew well past the touchdown area before putting the plane down
20:08That's right
20:17That's right
20:18Why would the pilots land so far past the touchdown zone?
20:24And risk the lives of everyone on board?
20:35I have the ATC'd recordings
20:40Let's hope we get some answers
20:44Investigators turn to conversations between Air India Express Flight 1344 and the controller
20:51To learn why the plane over flew the touchdown zone
20:58Calicut Tower Express India 1344 on ILS runway 28
21:06Okay, sounds like they initially planned to land on runway 28
21:10So why did they land on 10 instead?
21:15Landing on runway 28 the winds will be from your front
21:19You'll be landing into the wind
21:21That creates more lift
21:26But three and a half minutes later the crew changes their plans
21:30Tower Express India 1344 going around
21:35Roger
21:37Roger
21:42So they called a go around
21:49During monsoon season it is not very uncommon to see a go around
21:52Because of the low ceiling and showers of rain which suddenly reduce visibility
22:02Express India 1344 request a reason for go around
22:06Due to weather Express India 1344 heavy rain
22:11Roger
22:14They probably couldn't see the runway
22:15Sounds about right
22:19The crew realized that the runway was not in sight
22:22So they took a call to go around
22:24So they took a call to go around
22:24So that was absolutely in order
22:27Calicut Air India 425
22:28We're ready for taxi and we appreciate if you can give us one zero for departure
22:35Then investigators hear another plane asking to swap the active runway
22:41And the controller advising flight 1344 of the change
22:46Express India 1344 wind is now 270 degrees 08 knots confirm you'd like to make an approach for runway one
22:53zero
22:55So the controller asked them to use one zero
23:03So the controller asked them to use one zero
23:04Calicut Express India 1344
23:08Go ahead
23:09How's the visibility on runway one zero
23:14Before accepting the new runway the pilots request clarification of weather conditions
23:19Both runways at 2,000 meters with light rain
23:23And how are the surface winds?
23:27Surface winds now 260 degrees 05 knots
23:32Five knots
23:36Is that within limits?
23:37Let's check
23:45Ten knots is the limit
23:47Okay, so landing on one zero safely is technically possible even if they'd be landing in a tailwind
24:00Just ten and a half minutes later
24:03Investigators hear the last communication with the tower
24:09Express India 1344 on ILS runway one zero
24:16Express India 1344 Roger
24:19Light rain over the field runway surface wet
24:21Wind 250 degrees 08 knots
24:25Runway one zero clear to land
24:26Runway one zero clear to land
24:29And what's the visibility?
24:34They're asking about visibility again
24:37Seems to be an issue
24:43Visibility is the same, sir, at 2,000 meters
24:46Copied, sir. Express India 1344
24:51Two and a half minutes later
24:53They overfly the landing zone
24:59An eight knot tailwind, I mean it's still within limits
25:04Despite missing the touchdown zone, could the crew have safely stopped their plane on the runway?
25:11Speed break up
25:12Speed break up
25:22Investigators examined the flight parameters of Air India Express flight 1344
25:27The data could shed light on precisely where the aircraft landed after CCTV footage captured it passing the touchdown zone
25:38Can you isolate the weight on wheels perimeter?
25:47Weight on wheels is a sensor which indicates to the FDR the moment weight comes on the wheels
25:55That's what we're looking for
25:57The plane touched down at 1900 hours 40 minutes and 25 seconds
26:02So how far down the runway is that?
26:05Using the ground speed of the aircraft
26:08Investigators calculate how far the plane flew over the runway
26:154,438 feet from the threshold
26:18It became very clear to us as to where the aircraft had exactly touchdown
26:26He overshot the touchdown zone by nearly 1,500 feet
26:33Leaving less than half the runway for stopping
26:37Can the plane even stop on half a runway in a tailwind?
26:42Let me calculate the actual landing distance
26:46The actual landing distance is the distance required from touchdown to stop
26:52Weight
26:5663,000 kilos
26:59Wind
27:00Last reported tailwind before flight 1344 began its approach was actually 10 knots
27:07Flaps?
27:0830
27:127,803
27:137,803 feet
27:15So according to the information they had before accepting the approach
27:19They needed to touchdown here to have any chance of stopping before the end of the runway
27:26Flight 1344 should have touched down 3,000 feet earlier in order to stop safely
27:33So why did the pilots not give themselves enough runway to stop the plane?
27:44When the aircraft touches down you experience harsh braking, reverse thrust, more noise
27:49But here it was totally silent and the passengers, they would be wondering why is the aircraft not touching down
28:01Investigators check the transcripts of the cockpit voice recording
28:05For something that might explain why the pilots carried out the landing without enough runway
28:13The flight data gives us what happened
28:15But why it happened comes from the CVR
28:21Hey
28:22During the first approach
28:25The windshield wipers are on
28:27And look what happens afterwards
28:35Bleeding lights in sight?
28:37Yep
28:3927 seconds after starting the wiper
28:43What's happened to it?
28:46Oh crap, wiper's gone
28:49It malfunctions
28:51What a day for the wiper to go
29:01Maybe that explains why he was so worried about visibility
29:06According to rules for landing at Calicut during monsoon season
29:10It is mandatory for pilots to divert to an alternative airport if the wipers malfunction
29:17So was this crash caused by a faulty windshield wiper?
29:24Unserviceability of a wiper in rainy conditions is a no-go item
29:29The crew pressed on to land at Calicut
29:34We couldn't fathom the reason
29:39Let's see if the wiper was working on the second approach
29:44Heading to course
29:46Shall we do it?
29:48Just a sec
29:52What is this?
29:55I guess that's the fastest it'll go
30:00So the wiper is working, just not as fast as it should
30:05Despite the slow wiper, the pilots continue the approach
30:10Okay, runway in sight
30:12Runway in sight check
30:19So, less than a mile from the airport
30:22Both pilots can see the runway
30:25The faulty wiper doesn't seem to have prevented the pilots from seeing the runway
30:31And so far they are still on the glide slope
30:38But it looks like they deviate below
30:41And then above it
30:45The approach became unstabilized
30:48And the actions on the part of the crew to continue with the approach really shocked us
30:56So if they were above the glide slope
30:57That means when they crossed the runway threshold
31:00They were 40 feet too high
31:03The tailwind less than ideal
31:10If you fly off of the glide slope this close to the runway
31:13It is unsafe for you to continue
31:16Yet this crew did continue their landing
31:20Did the pilots believe they could recover from an unstabilized approach and land safely?
31:31Auto brake disarm
31:35Oh crap
31:46Looks like the captain increases engine power to stabilize the landing
31:53Investigators search the FDR parameters to explain how the pilots of flight 1344 dealt with their unstabilized approach
32:04In order to have a smooth landing
32:05Pilots typically add a bit of thrust
32:09Just before touchdown
32:12Which is probably what the captain was trying to do
32:17He's pushing throttles well beyond 80%
32:2230
32:2320
32:26The captain adds so much power
32:28The plane floats down the runway
32:36The plane floats over the runway for more than 3,000 feet
32:40The plane floats over the runway for more than 3,000 feet
32:41Why wouldn't the captain just
32:44Put the plane down?
32:48His wiper was barely working
32:52It's night, the weather is marginal
32:55What if he lost track of where he was along the runway?
33:00So when you approach an airfield like Calicut
33:02There are no lights surrounding the runway
33:05You just see the runway lights
33:08So in case you have light rain but low cloud ceiling
33:13That is a very unnerving feeling
33:19The captain didn't know where to put the plane down
33:22Because of his slow wiper and the heavy rain which reduced his vision
33:34They still could have done a go around
33:39The plane can carry out a go around from any point of time
33:42Even after touchdown
33:44So long the thrust reversers are not deployed
33:49So why didn't they?
34:03Just check it, put the plane down
34:10Captain
34:10Yeah?
34:12Go around
34:16The first officer called for a go around
34:20And the captain ignored him
34:23Why would such an experienced captain not listen to his first officer at such a critical moment?
34:31That was fatal
34:33If the captain would have gone around
34:36The result could have been different
34:45Cap, I appreciate your assistance
34:48Thanks
34:51Investigators interview other pilots who flew with Captain Satay
34:55To determine how he worked with others in the cockpit
34:59That was the last pilot on the list
35:02And?
35:03Here's some of the ways they described him
35:05Cognitive rigidity
35:07Goal-oriented
35:09Tendency towards perfectionism
35:11Sounds more like an Air Force pilot than a civilian one
35:14Which is what he was for 21 years at the start of his career
35:23The military aviators are trained to be goal-oriented
35:26Because for them the success of a mission is the most important criteria
35:32There's another reason the captain may have been determined to land in Calicut
35:38The crew were now making a second approach into Calicut
35:42And if they had to go around from this approach
35:45They would by the operating procedures be required to divert
35:52Did the captain resist a second go around so that he wouldn't be forced to divert?
36:04Here's something
36:07Investigators focus on the captain's flight schedule before and after the day of the accident
36:12Take a look
36:14Captain Satay was scheduled to be on standby the day after the accident, August 8th
36:20But the day before the accident, there was a scheduling change
36:24And Captain Satay had to pick up an additional flight
36:30He was the only captain who could fly out of Calicut
36:33Remember a tricky airport
36:35And only captains can operate flights in and out of a tabletop airport
36:42So if he had diverted to another airport instead of landing
36:46The flight to Doha the next day would have to be cancelled
36:53He was committed to land because he knew that there was no one else to undertake the flight
37:00But even if the captain forced the landing
37:03The first officer could still have taken over the controls and diverted
37:07So why didn't he?
37:10If the captain does not carry out to go around, the co-pilot is expected to take over
37:14In the safety of the flight, that is a must
37:19Captain, go around
37:27Investigators examine the CVR transcripts of flight 1344
37:31To determine why the first officer failed to take control
37:35They discover a pattern emerging
37:39Rate of descent, Captain
37:42Of a dismissive captain
37:43Yeah, yeah, correcting, correcting, correcting
37:47And a first officer who didn't assert himself
37:51Right, look
37:53Right, look
37:54Check
37:56Captain
37:58Go around
38:03The captain uses his authority to dictate what he wants
38:07And the co-pilot is too submissive to call out what he sees as unsafe
38:14Was this type of behaviour common at the airline?
38:18Investigators examine Air India Express's operations manual
38:24It would be very important to understand how teamwork is encouraged in the cockpit of an Air India Express aircraft
38:36It says captains need to approve flight data presented by first officers
38:42I would certainly promote a definite hierarchy in the cockpit
38:48Maybe that's why the first officer didn't feel empowered enough to grab the controls and do the go around
38:55We realised that the language used amounted to the first officer is subservient to the captain
39:06Despite the captain's rigidity, one simple procedure could have saved the passengers and crew
39:16I don't recall them ever calculating their landing distance
39:22Because they were now coming in with a tailwind onto runway one zero
39:26The conditions had changed entirely from the headwind on runway two eight
39:31And they needed to do a landing distance calculation
39:37You're right
39:39He didn't do the calculation
39:45They missed critical decisions on the tailwind, the wet runway and potential diversion options
39:52In addition to calculating landing distance
39:56If they had done any of these, it would have helped them understand there was too little margin of error
40:01to conduct this approach
40:28different airport different outcome
40:30different airport different outcome
40:32have been able to pass controls to the first officer who had a fully working wiper to land
40:37the plane.
40:41If they had just diverted to another airport, they'd all be alive today.
40:55There were so many opportunities the crew had to conduct a missed approach during this
40:59landing, but the crew took none of them.
41:07In their final report, investigators recommend expanding simulator training for unstabilized
41:14approaches, stressing that the first officer should assertively assume control and initiate
41:20a go-around if the pilot flying fails to respond.
41:30Simulator training with an emphasis on assertiveness would go a long way in allowing first officers to
41:35take all appropriate actions, up to and including taking control of the aircraft, when the pilot
41:40in command does not respond appropriately.
41:56Simulator training with an officer, Madrid, and South北, in the critical detail.
41:57We see the number of risks at every stage the crew had taken, which were unnecessary risks.
42:04There was a human factor which came into play.
42:10They do not see the consequences of their actions.
42:14That is a key point in any accident.