All language subtitles for Mayday.S26E09.Monsoon.Approach.2160p.CRAV.WEB-DL.DDP5.1.H.265-Kitsune_track3_[eng]

Landing
at Calicut Airport...

Speed brake up.

...the pilots
of Air India Express

Flight 13-44 run out
of tarmac to stop.

Oh, crap!

Twenty-one
people are killed.

Start up the hydraulics.

Did the brakes
malfunction?

No sign of fluid leak.

The brakes didn't fail.

When investigators
listen to the Cockpit

Voice Recorder...

Put the wipers on.

...they discover
a malfunction

of an entirely different nature.

What's happened to it?

So was this crash caused by
a faulty windshield wiper?

Mayday! Mayday!

Pull up!

It's monsoon
season in India.

Air India Express,
Flight 13-44

is on approach to
Calicut International Airport.

The pilot flying
is Captain Deepak Sathe.

He's a highly experienced
59-year-old commercial pilot.

Visibility is
just above minimums

so we can make
an attempt. Okay?

Check.

The captain had flown
in and out of Calicut

a number of times.

So he was very familiar
with the airfield,

the terrain around,
and the weather conditions.

The runway is wet,
expect turbulence,

expect weather,
all precautions.

First Officer
Akhilesh Kumar is aged 32.

He joined Air India Express
three years ago and has almost

2000 flying hours.

He has less experience
navigating through monsoons

than the Captain.

That area experiences
very heavy showers

along with reduced visibility
and strong winds.

In addition to the 5 crew,

there are 184
Indian nationals onboard.

All are being repatriated amid
the ongoing COVID-19 outbreak.

It's one of more than 2,000
flights into India to date,

bringing home thousands
of workers stranded abroad

when flights were grounded
due to COVID restrictions.

So the passengers
on these flights were mostly

blue-collar workers,

people who had flown
to Dubai to work in malls,

in small restaurants.

About 50 miles from
the airport, Captain Sathe

begins his approach briefing.

For a go-around, wind shear
on approach, approach to stall

and recovery on go-around as
briefed in the first sector.

Check.

Approach briefing is basically
one pilot communicating

to the other what his
plan of action is.

Any doubts?

No.

Any questions?

No questions.

Today's flight
from Dubai to Calicut

takes just under 4 hours.

Calicut tower,
Express India 1-3-4-4

on ILS runway 2-8.

Twelve miles
from the airport...

Any change in the visibility?

...the Captain wants
a weather update.

Any change in the visibility,
Express India 1-3-4-4?

Uh, standby.

Air India Express 1-3-4-4,

latest visibility is 2,000
meters and, uh, light rain.

Copy.
Express India 1-3-4-4.

Two thousand metres visibility
on a tricky airport

with light rain,
the pilots are basically

a bit more anxious
than a normal approach.

Calicut's runway
is built on a tabletop plateau.

There are steep drop-offs
at both ends.

There is no margin of error.
If you exceed the landing limit,

you go straight down
into a valley.

The pilots are flying
a Boeing 7-37-800

specially modified
for difficult landings.

It has modified spoilers
and braking performance

and allows it to stop

faster than other models
of the 7-3-7-800.

Just two minutes from
Calicut Airport,

the crew gets ready for landing.

Put the wipers on.

Lead in lights
in sight.

Yeah.

What's happened to it?

Oh, crap. The wiper is gone.

What a day for the wiper to go.

With decreased visibility
hindering their approach,

the pilots must make
a crucial decision.

If they do not have the runway
or any of the elements in sight,

at that point,
they have to take a decision

to continue or to go around.

Approaching minimums.
500. Minimums.

Uhhh...

let's go around.

A half mile from
the airport, Captain Sathe

aborts the landing
and decides to try it again.

Express India 1-3-4-4,
request reason for go-around.

When pilots go missed on
an approach, it's important

information to share with
air traffic control because

that can help other pilots
who are coming into the airport

anticipate any hazard
that may be there.

Due to weather,
Express India 1-3-4-4.

Heavy rain.

Uh, roger.

While Flight 13-44
completes its go-around,

a crew waiting to take-off
contacts the tower.

Calicut, Air India
4-2-5, we are ready for taxi

and we appreciate if you can
give us one-zero for departure.

The departing crew
wants to switch runways.

Runway 2-8 and runway 1-0
are the same strip of runway

but they are in
the opposite directions.

Roger, expect 1-0.

Taxi via Charlie, enter back
track, line up runway 1-0.

Via Charlie,
enter backtrack, line up 1-0,

Air India 4-2-5.
Thank you, sir.

Typically, departure
aircraft want to taxi

the least time and get
airborne as soon as possible.

Runway 1-0 is closest
to the apron.

To accommodate the departing
aircraft, controllers change

the active runway
from 2-8 to 1-0.

Express India 1-3-4-4,
wind is now 2-7-0 degrees,

zero eight knots, confirm
you'd like to make an approach

for runway 1-0?

Yeah, we'd like to try
if you can give us an update

on the visibility
for runway 1-0.

Visibility is the same,
sir, at 2,000 meters,

and we'll notify you
of any improvement.

And now wind is
2-6-0 degrees, 0-5 knots.

Okay. Set up for 1-0.
Let's try.

Localizer alive.

Check.

The localizer
is part of the I-L-S,

or Instrument Landing System,

that provides lateral guidance
to the runway's centreline.

Cabin crew, landing stations.

Flight 13-44 is now
only 6 miles from the runway.

Shall we do it?

Captain Sathe tries
the wipers again.

Just a sec.

What is this?

The Captain's wiper is working
more slowly than it should.

I guess this is
the fastest it'll go.

Okay, glide slope captured.

The glide slope is also part
of the instrument landing system

and guides the plane
on a 3-degree slope

to the runway threshold.

Flaps 25.

Flaps 25 selected.
Moving.

Calicut tower, Express India
1-3-4-4,

on ILS runway 1-0.

Express India
1-3-4-4, roger.

Light rain over the field.
Runway surface wet.

Wind 2-5-0 degrees, 0-8 knots.
Runway 1-0 cleared to land.

Four miles from the runway,

the crew receives
clearance to land.

Okay, runway in sight.

Runway in sight, check.

This time, the pilots
can see the runway.

Approaching minimums.

500.

As a pilot, when you're coming
in for a landing where there's

weather and visibility
just above minimums,

you're keeping a sharper eye
because things could change

at a moment's notice.

Flight 13-44 crosses
the runway threshold.

30... 20.

Speed brake up.

The speed brakes are deployed
to help slow the plane.

Auto brake disarm.

But the plane isn't
stopping fast enough.

Oh, crap!

The 7-37 falls off
the end of the runway...

...and breaks apart.

Rescuers rush to save
the 190 people onboard,

as every second
could mean the difference

between life and death.

In driving
rain and darkness,

surviving passengers begin
to emerge from the wreckage

of Air India Express
Flight 13-44.

The heavy rain
benefits the rescue.

It was very helpful in fact
for dousing the post-crash fire.

It ultimately
helped us save lives.

169 people survive the crash.

59 walk away without injuries.

But 21 of those
onboard are dead.

Captain Deepak Sathe
and First Officer Akhilesh Kumar

are among them.

Investigators from India's

Aircraft Accident
Investigation Bureau

the A-A-I-B,
arrive on the scene.

This was the first accident
which AAIB would have been

investigating on its own.

So it was really an acid test
for AAIB to prove its mettle.

- The first question
investigators must answer -

did something break off from
the airplane before the landing,

making it impossible
for the plane to stop?

I've got the
next batch downloaded...

Looking at them now.

This was the second wave
of COVID,

which was the most dangerous,
so there was an embargo

as to how many people could sit
in a room and conduct a meeting.

Investigators examine dozens
of photos from the crash scene.

You agree it's all here?

They conclude all
of the wreckage is contained

within the crash site.

The wreckage was not very
spread out. It was concentrated

over a radius of about 200 feet.

Let's regroup in a bit.

All the damage was caused when
the plane over ran the runway.

So we wanted to come out
with the probable reasons

as to what has led the aircraft
to exit the runway.

Only slightly off center...

But at least they were lined up
with the runway properly.

To better understand why
the plane overran the runway,

investigators try to determine
where it initially touched down.

So where do the marks start?

On a dry runway it is very,
very easy to find the touchdown

points because the tires,

they leave some rubber deposit
on the point of touchdown.

They work their way back
along the runway.

Beyond 5,000 feet

we were not able to locate
any touch tire marks.

The tire marks had been washed
away due to heavy rain.

Unable to determine where
the plane touched down,

investigators examine
the runway itself.

Did rubber deposits make
the runway too slippery?

They perform a test

to determine if the runway's
surface provided enough friction

or grip for the plane
to decelerate properly.

Our experience shows that
a aircraft of 7-3-7 class,

it leaves a rubber deposit.

And over a period of time
it becomes difficult

for the tire to grip.

Friction test results
just came in.

Co-efficient of friction
ranges from...

...6-3 to. 7-2.

That's within standard.

We were quite satisfied
with the condition

of the paved surface
of Calicut Airport.

There were no major
rubber deposits.

With the runway surface ruled
out, investigators consider

if the plane's tires
were too worn,

causing it to hydroplane
on the wet runway.

The grooves
on the tires, like on a car,

are channels for water
to drain off.

And if the tire
is bald, basically,

the grooves are worn out.

That will cause
the aircraft to slip.

202 psi.

Right in the required
pressure range.

No skid burn...

or bald spots.

Just like
the others.

If there was a case
of hydroplaning there would be

white marks on the runway and
that portion of the tires

would have been burnt.

And here we didn't find
either of these.

What about the brakes?

Did the brakes malfunction

causing the plane
to overrun the runway?

Some corrosion...

but nothing out of the ordinary.

Let's check the hydraulics.

We wanted to ascertain the
serviceability of hydraulics

because this is
the braking system.

Start up the hydraulics.

No sign of fluid leak.

The brakes didn't fail.

No.

I can say that there was

no abnormality in
the deceleration devices.

Okay...

good.

So, did the plane touchdown
within the touchdown zone?

Investigators try to determine
if the crew of flight 13-44

gave themselves
enough space to stop.

Thank you.

They have found an image...

...from a closed circuit camera
located here.

Looks like they're still about
15 feet above the runway,

and they're past
the touchdown zone.

We could see clearly
the aircraft floating

but, unfortunately, we couldn't
see the exact touchdown point.

So that means they flew
well past the touchdown area

before putting the plane down.

That's right.

Why would the pilots land so
far past the touchdown zone

and risk the lives
of everyone on board?

I have the ATC recordings.

Let's hope we get
some answers.

Investigators turn
to conversations between

Air India Express Flight 13-44
and the controller

to learn why the plane
overflew the touchdown zone.

Calicut tower,
Express India 1-3-4-4

on ILS runway 2-8.

Okay, it sounds like
they initially planned

to land on runway 2-8.

So why did they
land on 1-0 instead?

Landing on runway 2-8 the
winds will be from your front.

You'll be landing into the wind.
That creates more lift.

But three-and-a-half
minutes later,

the crew changes their plans.

Tower, Express India
1-3-4-4, going around.

Roger.

So they called a go-around.

During monsoon season,
it is not very uncommon

to see a go-around because,

of the low ceiling
and showers of rain,

which suddenly
reduce visibility.

Express India 1-3-4-4,
request reason for go-around.

Due to weather,
Express India 1-3-4-4.

Heavy rain.

Uh, roger.

Hmm. They probably
couldn't see the runway.

Sounds about right.

The crew realized that
the runway was not in sight,

so they took
a call to go around,

so that was absolutely in order.

Calicut, Air India 4-2-5,

we're ready for taxi

and we appreciate if you can
give us 1-0 for departure.

Then, investigators
hear another plane

asking to swap the active runway

and the controller advising
Flight 13-44 of the change.

Express India 1-3-4-4,
wind is now 2-7-0 degrees,

0-8 knots, confirm you'd
like to make an approach

for runway 1-0?

So, the controller
asked them to use 1-0.

Calicut,
Express India 1-3-4-4.

Go ahead.

How's the
visibility on runway 1-0?

Before accepting
the new runway,

the pilots request clarification
of weather conditions.

Both runways at 2,000 meters
with, uh, light rain.

And how are
the surface winds?

Surface winds now
2-6-0 degrees, 0-5 knots.

Five knots.

Is that within limits?

Let's check...

10 knots is the limit.

Okay. So landing on 1-0 safely
is technically possible

even if they'd be landing
in a tailwind.

Just ten-and-a-half
minutes later,

investigators hear the last
communication with the tower.

Express India
1-3-4-4, on ILS runway 1-0.

Express India
1-3-4-4, roger.

Light rain over
the field, runway surface wet.

Wind 2-5-0 degrees, 0-8 knots.
Runway 1-0 cleared to land.

Runway 1-0
cleared to land,

and what's the visibility?

They're asking
about visibility again.

It seems to be an issue.

Visibility is the same,
sir, at 2,000 meters.

Copy sir,
Express India 1-3-4-4.

Two-and-a-half minutes later,
they overfly the landing zone.

An 8 knot tailwind.
I mean it's still within limits.

Despite missing
the touchdown zone,

could the crew have
safely stopped their plane

on the runway?

Speed brake up.

Investigators
examine the flight parameters

of Air India Express
Flight 13-44.

The data could shed light

on precisely where
the aircraft landed,

after CCTV footage captured
it passing the touchdown zone.

Can you isolate the
weight on wheels parameter?

Weight on wheels is a sensor
which indicates to the FDR

the moment weight
comes on the wheels.

That's what we're looking for.

The plane touched down
at 19:40:25

So how far down
the runway is that?

Using the ground speed
of the aircraft, investigators

calculate how far the plane
flew over the runway.

4,438 feet
from the threshold.

It became very clear to us
as to where the aircraft

had exactly touched down.

He overshot the touchdown zone
by nearly 1500 feet...

...leaving less than
half the runway for stopping.

Can the plane even stop on half
a runway in a tailwind?

Let me calculate
the actual landing distance.

The actual landing distance
is the distance required

from touchdown to stop.

Weight?

63000 kilos.

Wind?

Last reported tailwind
before Flight 1-3-4-4

began its approach
was actually 10 knots.

Flaps?

30.

7,803 feet.

So according
to the information they had

before accepting the approach,

they needed to touchdown here

to have any chance of stopping
before the end of the runway.

Flight 13-44 should have
touched down 3,000 feet earlier

in order to stop safely.

So why did the pilots
not give themselves

enough runway to stop the plane?

When the aircraft
touches down,

you experience harsh braking,

reverse thrust, more noise.

But here, it was totally silent.

And the passengers,
they would be wondering,

why is the aircraft
not touching down?

Investigators check
the transcripts

of the cockpit voice recording

for something that might explain

why the pilots
carried out the landing

without enough runway.

The flight data gives us
what happened.

But why it happened
comes from the CVR.

Hey.

During the first approach,

the windshield wipers are on.

And look what
happens afterwards.

Lead-in lights in sight.

Yeah.

27 seconds after
starting the wiper ...

What's happened to it?

Oh, crap. The wiper's gone.

...it malfunctions.

What a day
for the wiper to go.

Maybe that explains why he
was so worried about visibility.

According to rules
for landing at Calicut

during monsoon season,

it is mandatory
for pilots to divert

to an alternative airport
if the wipers malfunction.

So was this crash caused
by a faulty windshield wiper?

Unserviceability of a wiper
in rainy conditions

is a no-go item.

The crew pressed on
to land at Calicut.

We couldn't fathom the reason.

Let's see if the wiper was
working on the second approach.

Heading to course.

Shall we do it?

Just a sec.

What is this?

I guess that's
the fastest it'll go.

So the wiper is working,
just not as fast as it should.

Despite the slow wiper,

the pilots continue
the approach.

Okay, runway in sight.

Runway in sight, check.

So, less than a mile
from the airport,

both pilots can see the runway.

The faulty wiper doesn't
seem to have prevented

the pilots from seeing
the runway.

And so far they are
still on the glide slope...

But it looks like they deviate
below and then above it.

The approach
became un-stabilized.

And the actions
on the part of the crew

to continue with
the approach really shocked us.

So if they were above
the glideslope,

that means when they crossed
the runway threshold,

they were 40 feet too high.

In a tail wind,
less than ideal.

If you fly off of the glide
slope this close to the runway,

it is unsafe
for you to continue,

yet this crew did
continue their landing.

Did the pilots believe
they could recover

from an un-stabilized approach
and land safely?

Auto-brake disarm.

Oh, crap!

Looks like the Captain
increases engine power

to stabilize the landing.

Investigators search
the FDR parameters to explain

how the pilots of Flight 13-44

dealt with their
un-stabilized approach.

In order to have
a smooth landing,

pilots typically add
a bit of thrust

just before touchdown...

which is probably what
the captain was trying to do.

He's pushing throttles
well beyond 80% percent.

30. 20.

The Captain adds so much power

the plane floats
down the runway.

The plane floats over the
runway for more than 3,000 feet.

Why wouldn't the Captain
just put the plane down?

His wiper was barely working.

It's night.
The weather is marginal.

What if he lost track of
where he was along the runway?

So when you approach
an airfield like Calicut,

there are no lights
surrounding the runway.

You just see the runway lights.

So in case you have light rain
but low cloud ceiling,

that is a very
unnerving feeling.

The Captain didn't know where
to put the plane down

because of his slow wiper

and the heavy rain
which reduced his vision.

They still could have
done a go-around.

The plane can
carry out a go-around

from any point of time,
even after touchdown

so long the thrust reversers
are not deployed.

So why didn't they?

Just check it.
Put the plane down.

Captain.

- 10.
- Go around.

The First Officer
called for a go-around.

And the Captain
ignored him.

Why would such an experienced
Captain not listen

to his First Officer
at such a critical moment?

That was fatal.

If the captain
would have gone around

the result could
have been different.

Okay.

I appreciate your assistance.

Thanks.

Investigators interview
other pilots

who flew with Captain Sathe

to determine how he worked
with others in the cockpit.

That was the last pilot
on the list.

And?

Here's some of the ways
they described him:

"cognitive rigidity",

"goal oriented",

"tendency towards
perfectionism".

Sounds more like an air force
pilot than a civilian one.

Which is what he was

for 21 years at the start
of his career.

The military aviators
are trained to be goal-oriented

because for them the success
of a mission

is the most important criteria.

There's another reason
the Captain may have been

determined to land in Calicut.

The crew were now making
a second approach into Calicut,

and if they had to go around
from this approach,

they would,
by the operating procedures,

be required to divert.

Did the Captain resist
a second go-around

so that he wouldn't be
forced to divert?

Here's something...

Investigators focus on
the Captain's flight schedule

before and after
the day of the accident.

Take a look.

Captain Sathe was scheduled
to be on stand-by

the day after the accident,
August 8th.

But the day before the accident,
there was a scheduling change

and Captain Sathe had to
pick up an additional flight.

He was the only captain
who could fly out of Calicut,

remember a tricky airport
and only captains can operate

flights in and out
of a tabletop airport.

So if he had diverted
to another airport

instead of landing,

the flight to Doha the next day
would have to be cancelled.

He was committed to land
because he knew that

there was no one else
to undertake the flight.

But even if the Captain
forced the landing,

the first officer could still
have taken over the controls

and diverted.
So why didn't he?

If the captain does not
carry out a go-around,

the co-pilot is expected
to take over.

In the safety of the flight,
that is a must.

Captain. Go around!

Investigators
examine the CVR transcripts

of Flight 13-44 to determine
why the first officer

failed to take control.

They discover
a pattern emerging...

Rate of descent, Captain.

...of a dismissive Captain...

Yeah, yeah. Correcting,
correcting, correcting.

... and a First Officer
who didn't assert himself.

Glide slope.
Glide slope.

Check.

Captain.

Go around!

The captain uses his authority
to dictate what he wants

and the co-pilot is
too submissive to call out

what he sees as unsafe.

Was this type of behaviour
common at the airline?

Investigators examine
Air India Express's

Operations Manual.

It would be very important
to understand how teamwork

is encouraged in the cockpit of
an Air India Express aircraft.

It says, "Captains need to
approve flight data

presented by First Officers."

That would certainly
promote a definite

hierarchy in the cockpit.

Maybe that's why
the First Officer

didn't feel empowered enough
to grab the controls

and do the go-around.

We realized that
the language used amounted

to the First Officer
is subservient to the Captain.

Despite the Captain's
rigidity, one simple procedure

could have saved
the passengers and crew.

I don't recall
them ever calculating

their landing distance.

Because they were now
coming in with a tailwind

onto runway 1-0, conditions
had changed entirely

from the headwind on runway 2-8,

and they needed to do a landing
distance calculation.

You're right.

He didn't do the calculation.

They missed critical decisions
on the tailwind, the wet runway,

and potential diversion options,

in addition to calculating
landing distance.

If they had done any of these,

it would have helped them
understand there was too little

margin of error
to conduct this approach.

Different airport,
different outcome.

The Captain would have been
able to pass controls

to the First Officer,

who had a fully working wiper,
to land the plane.

If they had just
diverted to another airport,

they'd all be alive today.

There were so many
opportunities the crew had

to conduct a missed approach
during this landing,

but the crew took none of them.

In their final report,

investigators recommend
expanding simulator training

for unstabilized approaches,

stressing that the
First Officer should

assertively assume control
and initiate a go-around

if the Pilot Flying fails
to respond.

Simulator training with
an emphasis on assertiveness

would go a long way
in allowing first officers

to take all appropriate actions
up to and including

taking control of the aircraft
when the pilot in command

does not respond appropriately.

This accident is avoidable.

We see the number of risks at
every stage the crew had taken,

which were unnecessary risks.

There was a human factor,
which came into play.

They do not see their
consequences of their actions.

That is a key point
in any accident.

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