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07.08.2020/
19:41 IST (14:11 UTC)
Kozhikode-Calicut Airport (CCJ), India
Final Report:
ACCIDENT INVOLVING M/S AIR INDIA EXPRESS B737-800 AIRCRAFT, VT-AXH, ON
07 AUGUST 2020 AT KOZHIKODE
 Air
India Express flight 1344, a Boeing 737-800 (VT-AXH), suffered a runway
excursion on landing at Kozhikode-Calicut Airport (CCJ), 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
The probable cause of the accident was the non adherence to SOP
(Standard Operating Procedure) by the PF (Pilot Flying), 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 (Pilot
Monitoring) 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 (Air India Express Ltd), 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 (Pilot In Command) 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 (Crew Resource Management).
(iii) The PIC was taking multiple un-prescribed anti-diabetic drugs that
could have probably caused subtle cognitive deficits due to mild
hypoglycemia 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 (Duty Air Traffic Control Officer) 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 (Barometric Pressure
at Sea Level) 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 (Civil Aviation Requirements). 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 (Tower Meteorological Officer)
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 (Airports Authority Of India) has managed to fulfill ICAO
and DGCA (Directorate General of Civil Aviation) certification
requirements at Kozhikode aerodrome for certain critical areas like RESA
(Runway End Safety Area), 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 centerline 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 (Digital Flight Data Recorder) 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 (Action Taken Report) 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.
The incident brought back memories of the May
22, 2010 crash of Air India Express flight IX 812 at Mangaluru
International Airport. In 2010, following landing errors by the pilots,
the aircraft fell off the cliff at the end of the runway and burst into
flames killing 158 of the 166 people on board.
Like Mangaluru, Kozhikode airport has a tabletop runway which was carved
out of a hillock. Runways at these airports, which are located on
hilltops, create the optical illusion of being at the same level as the
plains below when a pilot comes in for landing.
========================================================================================================
 Катастрофа
Boeing 737 в Кожикоде
07.08.2020/
19:41 IST (14:11 UTC)
Аэропорт Каликут (CCJ) близ города Кожикоде, Индия
Вечером 7 августа 2020 года авиалайнер
Boeing 737-8HG авиакомпании Air-India Express
выполнял плановый рейс IX1344 по маршруту Дубай
-Кожикоде, но после посадки в пункте назначения выкатился за пределы
взлётной полосы аэропорта Кожикоде, рухнул в ущелье и разрушился на две
части. Рейс Дубай-Кожикоде был вывозным в рамках программы Vande Bharat
Mission, помогающей гражданам, оказавшимся за границей в период пандемии
COVID-19. Из находившихся на его борту 190 человек (184 пассажиров и 6
членов экипажа) погиб 21.
Катастрофа рейса 1344 стала второй
авиакатастрофой в истории авиакомпании Air-India Express, произошедшей
через 10 лет после первой (катастрофа в Мангалуре, 158 погибших).
Самолёт
Boeing 737-8HG (регистрационный номер
VT-AXH, заводской 36323, серийный 2108) был выпущен в
2006 году (первый полёт совершил 15 ноября).
30 ноября того же года был передан
авиакомпании Air-India Express, в которой получил имя India Gate /
Gateway of India. Оснащён двумя турбовентиляторными двигателями CFM
International CFM56-7B27. На день катастрофы совершил 15 309 циклов
«взлёт-посадка» и налетал 43 691 час.
Экипаж
Самолётом управлял опытный экипаж,
его состав был таким:
• Командир воздушного судна (КВС) —
59-летний Дипак В. Сате (англ. Deepak V. Sathe).
Очень опытный пилот, проходил службу в ВВС Индии. В авиакомпании
Air-India Express проработал 10 лет и 8 месяцев (с 5 декабря 2009 года),
ранее работал в авиакомпании Air India (с 2004 по 2009 годы). Управлял
самолётами Cessna 152, Partenavia P.68, HS-748, Airbus A310 и Boeing
777-200/-300. В должности командира Boeing 737-800 — с 1 ноября 2014
года (до этого управлял им в качестве второго пилота). Налетал 10 848
часов, 4612 из них на Boeing 737-800.
• Второй пилот —
32-летний Ахилеш Кумар (англ. Akhilesh Kumar). Опытный пилот, в
авиакомпании Air-India Express проработал 3 года и 8 месяцев (с 1
декабря 2017 года). Управлял самолётами Diamond DA40 и Diamond DA42. В
должности второго пилота Boeing 737-800 — с 22 ноября 2017 года, ещё до
прихода в Air-India Express. Налетал 1989 часов, 1723 из них на Boeing
737-800.
В салоне самолёта работали четверо
бортпроводников:
• Шилпа Д. Катаре (англ. Shilpa D. Katare),
40 лет.
• Акшай П. Сингх (англ. Akshay P. Singh), 25
лет.
• Лалит Кумар (англ. Lalit Kumar), 27 лет.
• Абхик Бисвас (англ. Abhik Biswas), 24
года.
Хронология событий
Вылет из Дубая, заход на посадку, катастрофа
Известно, что самолёт дважды пытался зайти
на посадку, а также заходил на посадку с большой скоростью. Перед
приземлением самолёт сделал несколько кругов над аэропортом. Первый
заход на посадку осуществлялся на ВПП № 28, но из-за трудностей самолёт
дважды облетел аэропорт, пытаясь сесть, а потом вылетел с
противоположной стороны на ВПП № 10, где совершил аварийную посадку.
Фактическая скорость была выше посадочной, поэтому самолёт приземлился
дальше от точки приземления и не успел вовремя затормозить. Он выкатился
за пределы взлётной полосы и рухнул в расщелину,
развалившись на две части, при этом не спровоцировав пожара.
На борту находились 190 человек: 184
пассажира, 4 бортпроводника и 2 пилота.
Оба пилота и 19 пассажиров погибли и 136 получили ранения,
15 из них, находились в критическом состоянии.
Расследование
Расследование причин катастрофы рейса IX1344
проводил Государственный авиационный комитет Индии (DGCA) при участии
Управления аэропортов Индии (AAI).
Окончательный отчёт
(En) расследования был опубликован 17 августа 2021 года.
Одной из причин, приведших к трагедии,
являются погодные условия: сильный дождь.
========================================================================================================
 Пътнически
самолет са разби в Индия при приземяване, загинаха 21
 07.08.2020/
19:41 IST (14:11 UTC)
Летище Каликут (CCJ), Кожикод, Индия
Вечерта на 7 август 2020 года
Boeing 737-8HG (VT-AXH) на
авиакомпания Air-India Express
изпълнявал планов полет IX1344 по маршрут Дубай (OAE) - Кожикод
(Индия), но след кацане на летище Каликут до гр. Кожикод, напуснал пределите
на полосата за излитане и кацане (ПИК), сурнал се по прилежащия склон и
се разпаднал на две части. Полетът Дубай-Кожикод бил в рамките на програмата Vande Bharat
Mission, в помощ на гражданите, оказали се зад граница в периода на пандемията
от COVID-19. От намиращите се на борда 190 души (184 пасажери и 6
членове на екипажа) загиват 21.
Катастрофата на полет 1344 става втора
авиокатастрофа в историята на Air-India Express, случила се 10 години
след первата катастрофа в Мангалор със 158 загинали.
Двамата пилоти били доста опитни, с богат нальот
и добре познаващи особеностите на летище Каликут, което вероятно е
довело до подценяване и недостатъчна концентрация в действията им при
заварената неблагоприятна метеорологична обстановка сътояща се в ниска
разпръсната облачност с долна граница на 100 м и на места с комулумбоси
на 800 м, видимост при дъжд от 2000 м и скрост на вятъра малко над 6 м/с
в сумрак. Мокра ПИК.
Кацането им било при втори опит (на писта 10),
след като не успяват с първия на писта 28. Командирът на екипажа, който
и изпълнявал приземяването вземал множество лекарства за лечение на
диабет и комисията допуска, че зрението и способността му за вземане на
точните решения в ситуацията да са повлияни от това. След като
забелязва, че приземяват със завишена скорост от установената за кацане
и при това приблизително на 900 м от началото на полосата вторият пилот
казва убедено "Go around!" (Преминаване на втори кръг!). Късно! Двамата
пилоти са сред загиналите при катастрофата.
Окончателният
доклад (En) от разследването е публикуван през август 2021
г.
Комисията счита, че вероятна причина за
катастрофата е неспазване от страна на управляващия пилот на
стандартните процедури при кацане с нестабилизиран подход и
съприкосновенеие с полосата далеч зад пределите на зоната за това, както
и неглежирането на основателната препоръка от втория пилот за
преминаване на втори кръг.
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