Last updated: 6 December 2021
| Status: | Final |
| Date: | Friday 7 August 2020 |
| Time: | 19:41 |
| Type: |  Boeing 737-8HG (WL) |
| Operator: | Air India Express |
| Registration: | VT-AXH |
| MSN: | 36323/2108 |
| First flight: | 2006-11-15 (13 years 9 months) |
| Total airframe hrs: | 43691 |
| Cycles: | 15309 |
| Engines: | 2 CFMI CFM56-7B27 |
| Crew: | Fatalities: 2 / Occupants: 6 |
| Passengers: | Fatalities: 19 / Occupants: 184 |
| Total: | Fatalities: 21 / Occupants: 190 |
| Aircraft damage: | Destroyed |
| Aircraft fate: | Written off (damaged beyond repair) |
| Location: | Kozhikode-Calicut Airport (CCJ) ( India)
|
| Phase: | Landing (LDG) |
| Nature: | Int'l Non Scheduled Passenger |
| Departure airport: | Dubai Airport (DXB/OMDB), United Arab Emirates |
| Kozhikode-Calicut Airport (CCJ/VOCL), India | |
| Flightnumber: | IX1344 |
Air India Express flight 1344, a Boeing 737-800, suffered a runway excursion on landing at Kozhikode-Calicut Airport, India and broke in two. Both pilots and nineteen passengers died in the accident.
The flight departed Dubai Airport, United Arab Emirates at 10:15 UTC on a passenger service to Kozhikode-Calicut Airport.
The aircraft arrived from the west, overflying the airport at 13:42 UTC. It then performed a teardrop approach to runway 28. This approach was discontinued and the aircraft subsequently flew a teardrop approach to runway 10. According to a DGCA official the aircraft touched down about 900 meters down the 2850 m long runway at 14:10 UTC (19:40 local time). The aircraft failed to stop on the remaining runway and overran. It went down a 34 m dropoff and broke in two.
Weather
Weather at the time of the approaches and landing was poor. At 14:00 UTC scattered clouds were reported at 300 and 1200 feet with a few Cumulonimbus clouds at 2500 feet and overcast clouds at 8000 feet. The wind was from 260 degrees at 12 knots. Visibility was 2000 m in rain.
Airport and runway
The airport has a single runway (10/28) which is located on a flattened hill. The Landing Distance Available (LDA) for both directions is 2850 m. The runway strip extended to 60 m beyond the threshold. After the paved surface, there is a runway end
safety area (RESA), measuring 93 m x 90 m. The ICAO required RESA length is 90 m, whereas the recommended length is 240 m.
Past the RESA there is a 35 m drop off.
Probable Cause:
PROBABLE CAUSE
The probable cause of the accident was the non adherence to SOP by the PF, wherein, he continued an unstabilized approach and landed beyond the touchdown zone, half way down the runway, in spite of ‘Go Around’ call by PM which warranted a mandatory ‘Go Around’ and the failure of the PM to take over controls and execute a ‘Go Around’.
CONTRIBUTORY FACTORS
The investigation team is of the opinion that the role of systemic failures as a contributory factor cannot be overlooked in this accident. A large number of similar accidents/incidents that have continued to take place, more so in AIXL, reinforce existing systemic failures within the aviation sector. These usually occur due to prevailing safety culture that give rise to errors, mistakes and violation of routine tasks performed by people operating within the system. Hence, the contributory factors enumerated below include both the immediate causes and the deeper or systemic causes.
(i) The actions and decisions of the PIC were steered by a misplaced motivation to land back at Kozhikode to operate next day morning flight AXB 1373. The unavailability of sufficient number of Captains at Kozhikode was the result of faulty AIXL HR policy which does not take into account operational requirement while assigning permanent base to its Captains. There was only 01 Captain against 26 First Officers on the posted strength at Kozhikode.
(ii) The PIC had vast experience of landing at Kozhikode under similar weather conditions. This experience might have led to over confidence leading to complacency and a state of reduced conscious attention that would have seriously affected his actions, decision making as well as CRM.
(iii) The PIC was taking multiple un-prescribed anti-diabetic drugs that could have probably caused subtle cognitive deficits due to mild hypoglycaemia which probably contributed to errors in complex decision making as well as susceptibility to perceptual errors.
(iv) The possibility of visual illusions causing errors in distance and depth perception (like black hole approach and up-sloping runway) cannot be ruled out due to degraded visual cues of orientation due to low visibility and suboptimal performance of the PIC’s windshield wiper in rain.
(v) Poor CRM was a major contributory factor in this crash. As a consequence of lack of assertiveness and the steep authority gradient in the cockpit, the First Officer did not take over the controls in spite of being well aware of the grave situation. The lack of effective CRM training of AIXL resulted in poor CRM and steep cockpit gradient.
(vi) AIXL policies of upper level management have led to a lack of supervision in training, operations and safety practices, resulting in deficiencies at various levels causing repeated human error accidents in AIXL
(vii) The AIXL pilot training program lacked effectiveness and did not impart the requisite skills for performance enhancement. One of the drawbacks in training was inadequate maintenance and lack of periodic system upgrades of the simulator. Frequently recurring major snags resulted in negative training. Further, pilots were often not checked for all the mandatory flying exercises during simulator check sessions by the Examiners.
(viii) The non availability of OPT made it very difficult for the pilots to quickly calculate accurate landing data in the adverse weather conditions. The quick and accurate calculations would have helped the pilots to foresee the extremely low margin for error, enabling them to opt for other safer alternative.
(ix) The scrutiny of Tech Logs and Maintenance Record showed evidence of nonstandard practice of reporting of certain snags through verbal briefing rather than in writing. There was no entry of windshield wiper snag in the Tech log of VT-AXH. Though it could not be verified, but a verbal briefing regarding this issue is highly probable.
(x) The DATCO changed the runway in use in a hurry to accommodate the departure of AIC 425 without understanding the repercussions on recovery of AXB 1344 in tail winds on a wet runway in rain. He did not caution AXB 1344 of prevailing strong tail winds and also did not convey the updated QNH settings.
(xi) Accuracy of reported surface winds for runway 10 was affected by installation of wind sensor in contravention to the laid down criteria in CAR. This was aggravated by frequent breakdown due to poor maintenance.
(xii) The Tower Met Officer (TMO) was not available in the ATC tower at the time of the accident. The airfield was under two concurrent weather warnings and it is mandatory for the TMO to be present to update and inform the fast changing weather variations to enhance air safety. During adverse weather conditions the presence of the TMO in the ATC tower was even more critical.
(xiii) The AAI has managed to fulfil ICAO and DGCA certification requirements at Kozhikode aerodrome for certain critical areas like RESA, runway lights and approach lights. Each of these, in isolation fulfils the safety criteria however, when considered in totality, this left the aircrew of AXB 1344 with little or no margin for error. Although not directly contributory to the accident causation, availability of runway centreline lights would have certainly enhanced the spatial orientation of the PIC.
(xiv) The absence of a detailed proactive policy and clear cut guidelines by the Regulator on monitoring of Long Landings at the time of the accident was another contributory factor in such runway overrun accidents. Long Landing has 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.
(xv) DGCA did not comprehensively revise 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 of 2010 AIXL Managlore Crash regarding the exceedance limits, resulting in the persisting ambiguities in this matter.
(xvi) DFDR data monitoring for prevention of accidents/incidents is done by AIXL. However 100% DFDR monitoring is not being done, in spite of the provisions laid down in the relevant CAR and repeated audit observations by DGCA. DFDR data monitoring is the most effective tool to identify exceedance and provide suitable corrective training in order to prevent runway accidents like the crash of AXB 1344. However, ATR submitted by AIXL on the said findings were accepted by DGCA year after year without ascertaining its implementation or giving due importance to its adverse implications.
Accident investigation:
 |
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Classification:
Runway excursion
Sources:
» ndtv.com» indiatvnews.com
» news18.com
METAR Weather report:
13:00 UTC / 18:30 local time:VOCL 071300Z 20006KT 1500 -TSRA SCT003 SCT012 FEW025CB OVC080 24/24 Q1007 NOSIG
13:30 UTC / 19:00 local time:
VOCL 071330Z 27013KT 1500 -TSRA SCT003 SCT012 FEW025CB OVC080 24/23 Q1008 NOSIG
14:00 UTC / 19:30 local time:
VOCL 071400Z 26012KT 2000 -RA SCT003 SCT012 FEW025CB OVC080 24/23 Q1008 TEMPO 1500 -RA BR
14:30 UTC / 20:00 local time:
VOCL 071430Z 24011KT 2000 -RA SCT003 SCT012 FEW025CB OVC080 24/23 Q1009 TEMPO 1500 -RA BR
Photos
accident date: 07-08-2020
type: Boeing 737-8HG (WL)
registration: VT-AXH
Video, social media
Forwards..scary. Some people have also received spinal cord injuries, their life will be very tough ahead. Even a fracture pains when winter arrives (personal experience). pic.twitter.com/lWJWCs5DeO
— Tarun Shukla (@shukla_tarun) August 8, 2020
At the time of the tragic #AirIndiaExpress #IX1344 crash there was a large storm passing over #Karipur.
— Simon Proud (@simon_sat) August 7, 2020
This @eumetsat satellite data shows the storm (red) with the @flightradar24 flight path overlaid.
The flight made a go-around before crashing on the second landing attempt. pic.twitter.com/VMBsZC3kvY
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Dubai Airport to Kozhikode-Calicut Airport as the crow flies is 2659 km (1662 miles).
Accident location: Exact; deduced from official accident report.
Distance from Dubai Airport to Kozhikode-Calicut Airport as the crow flies is 2659 km (1662 miles).
Accident location: Exact; deduced from official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
