Air India Express Flight 1344

Air India Express Flight 1344 was a scheduled international flight on 7 August 2020 from Dubai, United Arab Emirates, to Kozhikode, India, landing at Calicut International Airport. The flight was part of the Vande Bharat Mission to repatriate Indian nationals stranded due to the COVID-19 pandemic. The flight crew aborted two landing attempts because of heavy rain and tailwind. On the third landing attempt, the aircraft touched down on runway 10, but skidded off the end of the tabletop runway and slid down a slope, killing 19 passengers and both pilots. The four cabin crew members and 165 passengers survived, of whom all but two were injured. This was the second fatal accident involving Air India Express, after the 2010 Mangalore crash.
Background
Airport
Calicut International Airport in Karipur, Malappuram, is considered one of the most dangerous airports in India, according to India's Directorate General of Civil Aviation (DGCA). It has a tabletop runway, a runway that is located on the top of a plateau or hill with one or both ends adjacent to a steep precipice which drops into a gorge. The DGCA designated Calicut Airport as a "critical airfield", which means that only the captain (and not the first officer) can perform takeoffs and landings there. The Airports Authority of India says that the airport is licensed for use in all weather conditions under instrument flight rules, but that the pilots operating flights to and from Calicut Airport (both day and night) should have sufficient flying hours at night to handle the dangerous conditions.
Captain Mohan Ranganathan, a member of a safety advisory committee of the Ministry of Civil Aviation, said in 2011 that Calicut Airport is "unsafe". He recommended that Calicut Airport not be used for landing during wet weather. He observed that the airport had a tabletop runway with a steep down-slope from one-third of the runway 10 and inadequate "buffer zones", referring to the runway end safety areas (RESA) at both ends of the runway. Instead of the recommended safety area, it had only . The width of runway 10 is only half of the minimum width that existing regulations require, with very little buffer zone on either side, whereas the recommended width is . Calicut Airport also lacked an engineered materials arrestor system (EMAS), which could have prevented the accident. He also reported that there were heavy rubber deposits on the runway. Calicut Airport's management ignored several warnings about the dangerous conditions at Calicut Airport, especially during wet conditions. Many international airlines stopped landing wide-body aircraft at Calicut because of the dangerous conditions. Ranganathan said "The warnings were ignored... in my opinion, it is not an accident but a murder. Their own audits have had flagged safety issues".
Conditions at Calicut Airport were investigated in 2019, following a tailstrike during the landing of Air India Express aircraft. The investigation revealed several safety hazards, including multiple cracks in the runways, pools of stagnant water, and excessive rubber deposits. In July 2019, the DGCA issued a show-cause notice to the director of Calicut Airport because of these hazards.
Aircraft and crew
The accident involved a Boeing 737-800 with a short-field performance package, registered as VT-AXH, manufacturer's serial number 36323 and line number 2108. The aircraft, that first flew on 15 November 2006, was operated by Air India Express and had a tail livery with India Gate on the left and Gateway of India on the right. The crew consisted of Captain Deepak Sathe (59), first officer Akhilesh Kumar (32); and four flight attendants. Sathe had landed successfully at Calicut airport at least 27 times, including more than ten times in 2020. He had 10,000 hours of flying experience on the Boeing 737, including 6,662 as commander.
Crash
The aircraft departed stand E6 and took off from runway 30R at Dubai International Airport on 7 August 2020, at 14:14 GST (7 August 2020, 10:14 UTC) and was scheduled to arrive at Calicut International Airport at 19:40 IST (7 August 2020, 14:10 UTC), covering a distance of . It was a repatriation flight for people who had been stranded abroad due to the COVID-19 pandemic, under the Vande Bharat Mission.
The aircraft reached the airport on schedule. The approach was for runway 28, but two landings were aborted due to tailwind and the aircraft circled, waiting for clearance before making a landing on runway 10. At around 19:37 IST (14:07 UTC), they were given clearance to land on runway 10. Due to the monsoon and floods in Kerala at the time, inclement weather conditions reduced visibility at the time of landing to . Runway 28 was operational and in the first landing attempt, the pilot could not see the runway thus requested for runway 10. On the second attempt on runway 10, the aircraft touched down near taxiway ''C'', which is approximately beyond the runway threshold. The aircraft failed to stop before the end of the tabletop runway and plunged into a gorge, splitting the fuselage into two sections upon impact. The accident site was around from the airport terminal. No post-crash fire was reported. It was suggested that the crew shut off the engines on landing, which may have saved lives by preventing a fire. According to a CISF officer, the aircraft did not slide into the gorge. It took off from the cliff and then collapsed.
The accident was the second fatal accident of Air India Express and was similar to Air India Express Flight 812 which also overran the runway 10 years earlier at Mangalore International Airport, killing 158 people on board.
Victims
A total of 184 passengers, four cabin crew and two cockpit crew were on board, all Indian. Seventeen people died on the spot from the crash, including both pilots. Later the death toll rose to twenty-one people on 24 August. and more than 100 people were injured. The chief minister of Maharashtra, Uddhav Thackeray, announced a state funeral for late Wing commander Captain Deepak Vasant Sathe in Mumbai.
Compensation
The Government of India and Kerala each announced an interim compensation of for the families of the deceased above the age of 12 years, for below the age of 12 years, for seriously injured, and for those who sustained minor injuries. It was also announced that the medical expenses of the injured would be borne by the state government.
Air India Express completed the disbursement of interim compensation to all passengers and next of kin of the deceased passengers soon after the accident.
Interim compensation of was paid to the next of kin of 15 deceased passengers who were above the age of 12, to the next of kin of 4 deceased passengers who were below the age of 12, each to 92 passengers and 2 crew members who were critically injured, and each to 73 passengers who suffered minor injuries.
Aftermath
Rescue and response
Following the incident, local people from the surrounding Karipur village rushed to the crash site to rescue trapped victims from the aircraft, followed by 40 Central Industrial Security Force (CISF) personnel who were guarding the perimeter of the airport, a quick reaction team and the Chief Airport Security Officer. Family members of the CISF personnel living nearby also joined. Police and firefighters were also deployed for the initial rescue operations. All passengers were evacuated in about three hours and taken to various hospitals in Kozhikode and Malappuram districts. Emergency response team, GO Team and special assistance team of Air India (officially known as 'Angels of Air India') from Kochi, Mumbai and Delhi were sent to the accident site. Three CISF officers were awarded Director General commendation disc for their rescue efforts after the mishap. The accident is predicted to cost the insurers and their reinsurers , which includes aircraft or hull and liability for third party and passengers. It is around 90 per cent of the insured value and Air India will recover this amount since the aircraft has been totally damaged. The insurer is an Indian insurance consortium led by New India Assurance. Claim settlement survey has already started. The airline had engaged a US-based firm, Kenyon International, to recover the baggage along with Angels of Air India.
COVID-19 infection
Two passengers on the flight who survived tested positive for COVID-19, after arriving at a hospital after the accident. To check the spread among other passengers and rescue personnel, CISF and Kerala Health Department asked their personnel and other passengers who were on the flight to undertake testing and quarantine. One week later, 24 officers involved in the rescue operation tested positive. Kondotty municipality, the place where the airport is located, was subsequently declared as a containment zone.
Pilots associations' response
The International Federation of Air Line Pilots' Associations (IFALPA) tightly monitored the actions after the accident and responded "Our thoughts are with the families of the pilots, crew members, and passengers who lost their lives aboard the aircraft. We send support and wishes to all the survivors, many of them injured and in hospital in critical condition." They got in touch with the Indian association, Air Line Pilots’ Association-India (ALPA-India) and the Aircraft Accident Investigation Bureau (AAIB) for technical expertise and assistance in investigation.
Following the accident, many pilot associations in the country soared up against the director of the DGCA, Arun Kumar, and wanted him to be replaced with someone more technically sound in aviation, after he referred to the late pilots as "fellows" and also said, "...and the landing it seems was not appropriate...", "The landing was not smooth". The pilot associations said that these comments from the director were amateurish and made them "the laughing stock of the aviation world".
Public interest litigation
According to Yeshwant Shenoy, a lawyer fighting for safer airports in India, the DGCA should have put restrictions on conditions when airlines could land or take off. He blamed the DGCA for being incompetent and negligent after the 2010 crash in Mangalore, and called it a state-run syndicate. He filed a Public Interest Litigation (PIL) in the Kerala High Court after the crash, to shut down operations of Calicut airport as it is not compliant with air regulations. Shenoy demanded an open inquiry by a Court of Inquiry instead of a closed one by AAIB. He also demanded that the investigation should be conducted by the Central Bureau of Investigation, as local police weren't experienced in these.
Ban on wide-body aircraft
Shortly after the crash, operations of wide-body aircraft at Kozhikode were put on hold. As a result, Air India and Saudia removed their widebody services to Calicut.
Investigation
The Directorate General of Civil Aviation (DGCA) and Flight Safety Departments investigated the accident. The cockpit voice recorder and flight data recorder were recovered the next day and sent to Delhi for analysis. Boeing was to send its investigation team to examine the debris of the aircraft for defects and assist the probe.
Initial findings suggested that at the time of landing, the tailwind was around . The aircraft was at at an altitude of approximately above the surface of runway 10, which is not considered ideal for short finals during poor weather conditions. The throttle was found to be in a fully forward position (takeoff or go-around position) and the spoilers were retracted from the position of the speed brake lever, which indicates that the pilots might have tried for a go-around. The tailwind, rubber deposits and wet runway affecting the braking performance of the aircraft are thought to be contributory factors to the accident. Civil Aviation Minister, Hardeep Puri, in a press conference at Kozhikode on 8 August, said that there had been sufficient fuel onboard for the aircraft to have flown to a diversion airport. The possibility of pilot error as a cause of the accident was suggested by DGCA's Arun Kumar.
Several concerns were raised on the inquiry on this incident, by Captain Mohan Ranganathan, Yeshwant Shenoy and others, that it might get covered up and the truth would never surface. Royal Aeronautical Society fellow and aviation safety expert Amit Singh alleged that evidence in the crash site was being tampered, as few unidentified people were spotted near the wreckage, thus asked for an open investigation. He also pointed out that investigations were flawed and instead of punishing real culprits, actions were taken against the pilots.
Aircraft Accident Investigation Bureau (AAIB)
The AAIB team in Kozhikode probed the incident with the assistance of Airports Authority of India officials, air traffic control, ground staff, CISF, the fire team and the rescue team. It found evidence of waterlogging of the runway at the time of landing. It also checked whether ATC was aware of waterlogging and whether the pilots adhered to rules. The preliminary investigation report was expected to be ready in a week after the accident, however this did not happen.
The United States National Transportation Safety Board (NTSB) also sent a member to assist the AAIB.
A five-member committee was set up by AAIB on 13 August, to investigate the incident, with the final report to be submitted on 13 January 2021. The committee headed by Captain S.S. Chahar, former designated examiner on Boeing 737 Next Generation, was to also provide recommendations to avoid such accidents in future.
The civil aviation ministry cited delays due to the COVID-19 pandemic and granted a two-month extension to the AAIB to submit its draft final probe report on the crash.
Final report
On 11 September 2021 the final report was released by the Indian Aircraft Accident Investigation Bureau (AAIB) stated that the probable cause was:
The pilot flying did not adhere to the Standard Operating Procedures (SOP) of the company, despite this, he continued the unstabilazed approach and landed over the touchdown zone, halfway down the runway, despite the pilot monitoring called for a Go-around which would have permitted a necessary Go-around but the pilot monitoring failed to take the control of the airpane and making a Go-around by himself.
Contributory Factors
According to the investigative team a contributory factor was a role of some systemic factors that are failed to be noticed in this accident. Similar incidents/accidents will be continue to appened mostly of this appened in AIXL, This has reinforced these systemic failures in the aviation sector. This usually happened due to this prevailing safety culture that create rise of this errors, mistakes and violations of routine duties performed by people operating within the system. Consequently, the contributory factors which were found below include both the immediate causes and the deeper or systemic causes.
The actions and decisions by the pilot in command are justified by a misplaced motivation to land back at Kozhikode motivated because the PIC wanted to operate flight 1373 the next morning. The lack of a sufficient number of Captains stationed at Kozhikode was the result of faulty AIXL HR policy which does not take into account operational requirement while assigning a permanent base to its Captains. There was only 01 Captain against 26 First Officers on the posted force at Kozhikode;
The PIC have a great experience with the landing at Kozhikode in adverse weather conditions. This experience by the pilot in command make him overconfident, this overconfidence leading to self-approval and a state of reduced conscious attention that would have seriously affected his actions, decision making as well as Crew Resource Management (CRM);
The pilot in command was taken various anti-diabetics drugs that are unprescribed, that have propably caused an indistinct cognitive deficits due to mild hypoglycaemia which likely contributed to errors in performing complex decision making and also sensitivity to noncognitive errors;
Visual illusions are probably caused in the distance and depth perception cannot be excluded due to the degradation of visual signs of orientation due to low visibility and negligible performance of the PIC’s windshield wiper in rain;
Insufficient Crew Resource Management was a major contributory factor in the accident. The lack of firmness and extreme authority gradient in the cockpit, the first officer do not takeover the controls despite he was aware of the complicated situation. The lack of effective CRM training resulted in poor Crew Resource Management and steep cockpit gradient;
High-level management policies of Air India Express have leading to a lack of supervision in the training, operations and safety practices are the results of deficiencies at various level causing this accidents in AIXL due to human error;
Lack of effectiveness and the not imposing of the requisite skills for performance enhancement by the Air India Express pilot training program. One of the weakness in the training was inadequate maintenance and lack of periodic systems of the flight simulator. Frequently recurring major issues resulting in negative training. Furthermore, pilots were often not checked for all the mandatory flying exercises during simulator check sessions by the examiners;
The unavailability of Optional Practical Training made difficult for the pilots to quickly calculate accurate landing data in poor weather conditions. Quick and accurate calculations would help the pilots anticipates the extreme low margin of error, allowing them to opt in different solutions for other safer alternatives;
The analysis of the Tech Logs and Maintenance Records showed an evidence of nonstandard practices of reporting certain obstacles through verbal briefing instead of a writed briefing. There was no entry about windshield wiper fault in the Tech log of the flight. Though it could not be verified, but a verbal briefing regarding this issue is highly probable;
The Air Traffic Control Operator on duty, changed the runway in use in a hurry to accommodate the departure of another flight without understanding the repercussions on recovery of flight 1344 in tail winds over a wet runway in rain. He did not advice the flight of prevailing strong tail winds and also did not dispatch the updated QNH settings on the altimeter;
Accuracy on reporting surface wind on runway 10 was affected by the installation of a wind sensor in violation to the laid down criteria present in the CAR. Aggraveted frequent failure due to poor maintenance;
The Tower Met Officer (TMO) was not present in the control tower during the accident. The airport was under two concurrent weather warnings and it is obbligatory for the TMO to be in site to update and inform the fast changing weather conditions to enhance air safety. During adverse meteorologic conditions the presence of the TMO in the ATC tower was even more fundamental;
The Airports Authority of India (AAI) as managed to fulfil the certifications requirements at Kozhikode aerodrome made byInternational Civil Aviation Organization (ICAO) and Directorate General of Civil Aviation (DGCA) about certain critical areas like the Runway End Safety Area (RESA), runway and approach lights. Each of these, individually fulfills the safety however, taken in consideration entirely, this left the pilots of flight 1344 with a little or none margin of error. Despite not having contributed to the causes of the accident, availability of runway centreline lights would have certainly favored and enanched the spatial orientation of the Pilot in command;
The absence of a detailed dynamic policy clear cut guidelines by the Regulator on monitoring of Long Landings at the time of the accident was another contributory factor in this runway overrun accidents. A Long Landing has always been major factor in various accidents and incidents involving runway excursion since 2010 and has not been addressed in CAR Section 5, Series F, Part II;
DGCA did not make an exhaustive revising on CAR Section 5, Series F, Part II Issue I, dated 30 Sep 99 (Rev. on 26 Jul 2017) on Monitoring of DFDR/QAR/PMR Data for Accident/Incident Prevention to address the recommendations of the COI from the Air India Express Flight 812 crash occurred in 2010 at Managlore Airport regarding the exceedance limits, resulting in the persisting ambiguities about this matter;
DFDR data monitoring for prevention of accidents/incidents is mede by Air India Express. However 100% of this DFDR monitoring is not being made, despite the resources laided down in the relevant CAR and repeated probe observations by DGCA. The DFDR data monitoring is the most effective tool to identify overshoot and provide suitable corrective training in order to prevent runway accidents like the crash of flight 1344. However, the Annual Technical Reports submitted by the company on the aforementioned findings were accepted by DGCA year after year without establish its implementation or giving the proper importance to its adverse implications.
In popular culture.
Vande Bharat Flight IX 1344: Hope to Survival is a 2021 Discovery+ original documentary based on the crash. The 45-minute documentary creates graphical simulations of the accident.
See also
Air India Express Flight 812 another Boeing 737-8NG(SFP), which overshot the runway at Mangalore International Airport, Mangalore, India
List of accidents and incidents involving commercial aircraft
List of accidents and incidents involving the Boeing 737
Pegasus Airlines Flight 2193 a Boeing 737-86J, which overran the runway at Istanbul Sabiha Gökçen International Airport, Pendik, Istanbul, Turkey. Three died.
TAM Airlines Flight 3054 an Airbus A320, which overshot the runway at Congonhas Airport, situated in Brazil
Air France Flight 358 an Airbus A340, which overran the runway at Toronto Pearson International Airport in August, 2005
Explanatory notes
References
External links
IX 1344 incident at Kozhikode – UPDATES —Air India Express
Accident Bulletin: AIXL Flight IX-1344—Air India
2020 disasters in India
Accidents and incidents involving the Boeing 737 Next Generation
Express Flight 1344
August 2020 events in India
Aviation accidents and incidents in 2020
Aviation accidents and incidents in India
Airliner accidents and incidents caused by pilot error
Airliner accidents and incidents involving runway overruns
COVID-19 pandemic in India
COVID-19 pandemic in the United Arab Emirates
Evacuations of Indians
History of Kozhikode
Transport in Kozhikode