Original subtitles

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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