Accident Boeing 737-8HG (WL) VT-AXH, Friday 7 August 2020
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Date:Friday 7 August 2020
Time:19:41
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different    
Boeing 737-8HG (WL)
Owner/operator:Air India Express
Registration: VT-AXH
MSN: 36323/2108
Year of manufacture:2006
Total airframe hrs:43691 hours
Cycles:15309 flights
Engine model:CFMI CFM56-7B27
Fatalities:Fatalities: 21 / Occupants: 190
Other fatalities:0
Aircraft damage: Destroyed, written off
Category:Accident
Location:Kozhikode-Calicut Airport (CCJ) -   India
Phase: Landing
Nature:Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:Dubai Airport (DXB/OMDB)
Destination airport:Kozhikode-Calicut Airport (CCJ/VOCL)
Investigating agency: AAIB India
Confidence Rating: Accident investigation report completed and information captured
Narrative:
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
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

METAR:

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

Accident investigation:
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Investigating agency: AAIB India
Report number: Final report
Status: Investigation completed
Duration: 1 year 1 month
Download report: Final report

Sources:

ndtv.com
indiatvnews.com
news18.com

Statistics

  • 4th worst accident in 2020
  • 8th worst accident of this aircraft type
  • 7th worst accident of this aircraft type at the time

Location

Images:


photo (c) Flightradar24; Kozhikode-Calicut Airport (CCJ/VOCL); 07 August 2020


photo (c) Google Earth; Kozhikode-Calicut Airport (CCJ/VOCL); 07 August 2020


photo (c) Konstantin von Wedelstaedt; Dubai Airport (DXB/OMDB); 21 December 2006

Revision history:

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