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Air Crash Investigation S26E09 Monsoon Approach
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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?
00:34No 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?
01:07Oh, 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 we can make an attempt, okay?
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.
02:05Runway is wet.
02:07Expect turbulence.
02:08Expect weather.
02:09All precautions.
02:12First officer Akilesh Kumar is age 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,
03:05people who had flown to Dubai to work in malls, in small restaurants.
03:13About 50 miles from the airport, Captain Satay begins his approach briefing.
03:19For a go-around, windshield on approach, approach to stall, and recovery on go-around,
03:26as briefed in the first sector.
03:28Check.
03:29Check.
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?
04:19Any change in the visibility?
04:19Express India 1344.
04:22Stand by.
04:25Air India Express 1344.
04:26Latest visibility is 2,000 meters and light rain.
04:41The 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.
05:01If 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
05:21So 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,
06:01the pilots must make a crucial decision.
06:07If they do not have the runway or any of the elements in sight,
06:11at that point they have to take a decision to continue or to go around.
06:21Approaching minimums.
06:22500.
06:25Minimums.
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.
07:37The departing crew wants to switch runways.
07:42Runway 28 and runway 10 are the same strip of runway, but they're in the opposite directions.
07:50Roger.
07:51Expect 1-0.
07:52Taxi via Charlie.
07:53Enter backtrack.
07:54Line up runway 1-0.
07:56Via Charlie.
07:57Enter backtrack.
07:58Line up 1-0.
07:59Air India 425.
08:00Thank you, sir.
08:03Typically, 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.
08:50Set up for 1-0.
08:52Let's try.
09:02Localizer alive.
09:04Check.
09:08The localizer is part of the ILS, or instrument landing system,
09:13that provides lateral guidance to the runway's centerline.
09:25Cabin crew, landing stations.
09:28Flight 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.
09:45What 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.
09:55Glide slope captured.
09:59The glide slope is also part of the instrument landing system,
10:04and guides the plane on a three-degree slope to the runway threshold.
10:12Flaps 25.
10:14Flaps 25 selected.
10:17Moving.
10:19Kalika Tower, Express India 1344.
10:23On ILS, runway 1-0.
10:27Express India 1344, Roger.
10:29Light rain over the field, runway surface wet.
10:32Wind 250 degrees, 0-8 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 minimums,
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.
11:32The speed brakes are deployed to help slow the plane.
11:38Auto brake disarmed.
11:44But the plane isn't stopping fast enough.
11:49Oh, crap!
11:56The 737 falls off the end of the runway.
12:03And breaks apart.
12:09Rescuers rush to save the 190 people on board.
12:13As 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.
12:41It ultimately helped us save lives.
12:46169 people survive the crash.
12:4959 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.
13:26Investigators 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.
13:49Did something break off from the airplane before the landing, making it impossible for the plane to stop?
14:01I've got the next batch downloaded.
14:06Looking at them now.
14:09This 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.
17:07And over a period of time, it becomes difficult for the tire.
17:08Friction test results just came in.
17:11Coefficient of friction ranges from 0.63 to 0.72.
17:22That's within standard.
17:32We were quite satisfied with the condition of the paved surface of Calicut Airport.
17:38There 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, are 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.
18:09202 PSI.
18:10Right in the required pressure range.
18:15No skid burn.
18:19Or bald spots.
18:20Just like the others.
18:23If there was a case of hydroplaning, there would be white marks on the runway and that portion of the
18:32tires would have been burned.
18:35And here we didn't find either of these.
18:41What 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.
19:05We 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?
19:27No.
19:33I can say that there was no abnormality in the deceleration devices.
19:42Okay.
19:45Good.
19:49So, 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.
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 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 ATZ 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
21:44touchdown zone.
21:48Calicut Tower, Express India 1344 on ILS runway 28.
21:56Okay, sounds 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.
22:55Express India 1344, request a reason for go around.
22:59Due to weather, Express India 1344, heavy rain.
23:04Roger.
23:05Roger.
23:07Roger.
23:13The crew realized that the runway was not in sight.
23:16So they took a call to go around.
23:18So that was absolutely in order.
23:21Calicut Air India 425.
23:23We're ready for taxi and we appreciate if you can give us 1-0 for departure.
23:30then investigators hear another plane asking to swap the active runway and the controller
23:37advising flight 1344 of the change express India one three four four wind is now two seven zero
23:44degrees zero eight knots confirm you'd like to make an approach for runway one zero so the
23:52controller asked them to use one zero Calicut Express India one three four four go ahead
24:05how's the visibility on runway one zero before accepting the new runway the pilots request
24:13clarification of weather conditions both runways at 2,000 meters with light rain and how are the
24:21surface winds surface winds now two six zero degrees zero five knots five knots is that within limits
24:34let's check ten knots is the limit okay so landing on one zero safely is technically possible even if
24:49they'd be landing in a tailwind just ten and a half minutes later investigators hear the last
25:03communication with the tower Express India one three four four on ILS runway one zero
25:15Express India one three four four Roger light rain over the field runway surface wet wind two five zero
25:22degrees zero eight knots runway one zero clear to land runway one zero clear to land and what's the visibility
25:33they're asking about visibility they're asking about visibility again seems to be an issue
25:43visibility is the same sir at 2,000 meters
25:51two and a half minutes later they overfly the landing so an eight knot tailwind I mean it's still within
26:02limits
26:04despite missing the touchdown zone could the crew have safely stopped their plane on the runway
26:12speed break up
26:23investigators examine the flight parameters of air India Express flight 1344 the data could shed light on
26:32precisely 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 that's
26:59what we're looking for the plane touchdown at 1900 hours 40 minutes and 25 seconds so how far down the
27:07runway is
27:07that using the ground speed of the aircraft investigators calculate how far the plane flew over the runway
27:194,438 feet from threshold it became very clear to us as to where the aircraft had exactly touched down
27:31he overshot the touchdown zone by nearly 1500 feet
27:38leaving less than half the runway for stopping can the plane even stop on half a runway in a tailwind
27:48let me calculate the actual landing distance
27:51the actual landing distance is the distance required from touchdown to stop weight
28:0263,000 kilos
28:05wind
28:06last reported tailwind before flight 1344 began its approach was actually 10 knots
28:12flaps
28:1430
28:1730
28:187,803 feet
28:22so 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 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 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
29:30hey
29:31during the first approach
29:34the windshield wipers are on
29:36and look what happens afterwards
29:45lead in lights in sight
29:47yep
29:5027 seconds after starting the wiper
29:53what's happened to it
29:57oh crap
29:58wiper's gone
30:01it 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
30:22it is mandatory for pilots to divert to an alternative airport if the wipers malfunction
30:30so 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
30:59shall we do it?
31:01just a sec
31:06what 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
31:25runway in sight check
31:34so
31:34less than a mile from the airport
31:37both 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
31:56and 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
32:14that means when they crossed the runway threshold
32:16they were 40 feet too high
32:19the tailwind less than ideal
32:27if you fly off of the glide slope this close to the runway
32:30it 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
32:53oh 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
33:25pilots typically add a bit of thrust
33:28just 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
34:05put the plane down
34:10his wiper was barely working
34:14it's night, weather is marginal
34:17what if he lost track of where he was along the runway
34:22so when you approach an airfield like Calicut
34:25there are no lights surrounding the runway
34:28you just see the runway lights
34:31so in case you have light rain
34:33but low cloud ceiling
34:35that is a very unnerving feeling
34:41the captain didn't know where to put the plane down
34:45because of his slow wiper and the heavy rain which reduced 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
35:29just check it, put the plane down
35:35captain
35:36yeah
35:37go around
35:42the first officer called for a go around
35:45and 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
35:59that was fatal
35:59if the captain would have gone around
36:02the result could have been different
36:10okay
36:12I appreciate your assistance
36:15thanks
36:18investigators interview other pilots who flew with Captain Satay
36:22to 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
36:34goal-oriented
36:36tendency 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
36:54because for them the success 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
37:10and if they had to go around from this approach
37:14they 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 flight
37:40after the day of the accident
37:42take a look
37:44Captain Satay was scheduled to be on standby the day after the accident
37:48August 8th
37:50but the day before the accident there was a scheduling change
37:55and Captain Satay had to pick up an additional flight
38:01he was the only captain who could fly out of Calicut
38:04but remember a tricky airport and only captains can operate flights in and out of a tabletop airport
38:14so if he had diverted to another airport instead of landing
38:18the flight to Doha the next day would have to 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
38:35the first officer could still have taken over the controls and diverted
38:39so 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
39:05to determine why the first officer failed to take control
39:09they discover a pattern emerging
39:14rate of descent captain
39:15of a dismissive captain
39:19yeah, yeah, correcting, correcting, correcting
39:22and a first officer who didn't assert himself
39:26right foot
39:28right foot
39:29check
39:31captain
39:33go around
39:38the captain uses his authority to dictate what he wants
39:42and the co-pilot is too submissive to call out what he sees as unsafe
39:50was this type of behaviour common at the airline?
39:54investigators examine Air India Express's operations manual
40:01it would be very important to understand how team work 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 realise that the language used amounted to the first officer is subservient to the captain
40:44despite the captain's rigidity
40:46one 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
41:05the conditions had changed entirely from the headwind on runway two eight
41:10and they needed to do a landing distance calculation
41:17you're right
41:19he didn't do the calculation
41:25they missed critical decisions on the tailwind
41:28the wet runway and potential diversion options
41:32in addition to calculating landing distance
41:36if they had done any of these it would have helped them understand
41:40there was too little margin of error to 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
42:42but the crew took none of them
42:50in their final report
42:52investigators recommend expanding simulator training for unstabilized approaches
42:58stressing that the first officer should assertively assume control
43:03and initiate a go around if the pilot flying fails to respond
43:14simulator training with an emphasis on assertiveness would go a long way
43:17in allowing first officers to 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
43:42we see the number of risks at every stage the crew had taken
43:47which were unnecessary risks
43:50there was a human factor
43:52which came into play
43:56they do not see the consequences of their actions
44:00that is a key point in any accident
44:02that is a key point
44:40You
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