The Cost of Inaction: The crash of Air India Express flight 1344

The wreckage of Air India Express flight 1344 lay strewn across the airport perimeter road after the crash. (FirstPost)

On the 7th of August 2020, an Air India Express Boeing 737 departed Dubai for a repatriation flight, carrying 184 Indian passengers stranded by the Covid-19 pandemic. But as the plane approached the narrow tabletop runway in the city of Kozhikode, the flight took a turn for the worse. Storms swept the runway and rain poured out of the darkness. The plane’s windshield wipers weren’t working. The first approach had to be abandoned, forcing the pilots to try again. A tailwind rose up behind them and the runway became slick with water. Desperate to land, the captain put the plane on the ground — not realizing that there wasn’t enough room to come to a stop, despite his copilot’s desperate exhortation to go around. As passengers held on for dear life, the 737 skidded off the end of the runway, fell 30 meters down an embankment, and broke into three pieces, killing 21 of the 190 people on board.

The dramatic end to a flight that should have brought relief and joy shocked the country — not necessarily because of the deaths themselves, but because the crash brought back still-vivid memories of a very similar disaster 10 years earlier, involving the same airline, the same type of plane, and a similar airport. Aviation safety experts rightfully had to ask: after Air India Express flight 812 skidded off the end of a runway in 2010, killing 158, was anything learned? An exhaustive investigation of this latest accident by India’s AAIB would discover that safety at Air India Express had not improved in the wake of the 2010 disaster — if anything, it had gotten worse.

A poster extols the triumph of the Vande Bharat Mission. (MEA India)

In the spring of 2020, as the Covid-19 pandemic swept the globe, the government of India launched an ambitious operation to bring back millions of Indians left stranded abroad due to the cessation of international flights. Beginning on May 7th, the so-called Vande Bharat mission employed dozens of planes from flag carrier Air India and its low cost subsidiary Air India Express to bring home hundreds of thousands of people, mainly from the Middle East. By August 6th, the Vande Bharat mission had resulted in the repatriation of at least 950,000 people, and multiple relief flights full of stranded passengers were landing each day at every major airport in India.

VT-AXH, the aircraft involved in the accident. (Konstantin von Wedelstaedt)

One of these flights was Air India Express flight 1344, a repatriation flight on the 7th of August which was scheduled to bring a full load of passengers from Dubai back to the city of Kozhikode, a metropolis of about 2 million people on the coast of Kerala state in southern India. Kozhikode (pronounced like CO-rhi-CODE) is located on a coastal strip without much flat land; consequently the city’s main port of entry, the single-runway Calicut Airport, is a “tabletop airport,” an artificially leveled airstrip built atop a hill with steep drops on all sides. Like many similar airports in southern India, it could be treacherous at night and in bad weather, especially during the monsoon season.

Fortunately, 59-year-old Captain Deepak Sathe, the pilot in command of flight 1344, was no stranger to tabletop airports. Many of his 10,000 flying hours had been accumulated while he was based in Kozhikode, and he had landed there 36 times in the past year alone. His First Officer, 32-year-old Akhilesh Kumar, had started his career at Air India Express less than three years earlier and had so far racked up about 2,000 hours, mostly on the Boeing 737. With 184 passengers and four flight attendants in addition to the pilots, the Boeing 737–800 that they would be flying that day was filled nearly to capacity.

The route of Air India Express flight 1344. (Google + own work)

On the morning of August 7th, shortly before departing Kozhikode to pick up the passengers in Dubai, Captain Sathe received some unwelcome news: Air India Express had decided to change his schedule at the last minute. At the behest of the government, the airline wanted to add a third flight out of Kozhikode on the morning of the 8th, and Sathe would be called up from standby to complete it. There was no one else who could do it: out of 27 pilots based in Kozhikode, Sathe was the only qualified captain. Two more captains were being ferried in for the other two flights, but Sathe was the only person available to operate the third one, which was scheduled to depart at 8:30 a.m. Sathe was quick to note that if flight 1344 returned home on schedule at 19:40, crew rest limits meant he couldn’t fly again until at least 9:55 a.m. the next day. Accordingly, the airline rescheduled the flight to 10:00 a.m. — meaning that if flight 1344 arrived more than five minutes late, the flight the next day would also have to be delayed.

Left: Captain Deepak Sathe; Right: First Officer Akhilesh Kumar. (IndiaTV News)

With this in mind, the pilots flew to Dubai, picked up the passengers, and headed back to India — but not without a 30-minute delay at the gate, forcing Captain Sathe to try to make up for lost time en route.

The 7th of August in Kerala state fell within the height of the monsoon season, when powerful thunderstorms and heavy rain batter the region almost every day. During this time, pilots at Air India Express had to undergo monsoon training and follow special “monsoon procedures,” but Captain Sathe would not have been nervous; he had undergone the training and flew through the monsoon season countless times before.

Given the weather reports, which noted a sustained wind out of the west, the pilots decided to circle around to the east side of the airport and land on runway 28, which would give them a headwind on landing. Dusk had fallen by the time they neared the airport, and heavy rain had reduced visibility to near minimums, but that was normal for Kozhikode at this time of year. Nevertheless, the special monsoon procedures were probably in the back of Captain Sathe’s mind: during the monsoon season, it was forbidden to make more than two landing attempts; after a second failed approach, it was mandatory to divert, regardless of fuel remaining. And if they diverted, the flight the next morning would surely have to be cancelled.

An excerpt from the cockpit voice recorder transcript. (AAIB)

It was also apparent that Sathe and Kumar had been told of a problem with the plane’s windshield wipers, an issue which was not recorded in the technical log. As flight 1344 descended into the clouds that blanketed Kozhikode, Captain Sathe, referring to the windshield wipers, said to First Officer Kumar, “You just check that this works.”

“Yeah,” said Kumar.

“Remember, put it to high,” Sathe added.

“High,” Kumar repeated.

“High, yeah, high speed,” said Sathe.

Without any great difficulty, the pilots lined up with the localizer and glide slope, locking on to the two guiding signals from the instrument landing system. They extended the flaps and caught sight of the runway; the approach seemed to be going according to plan. But when First Officer Kumar turned on the windshield wipers at 19:21, the wiper on the captain’s side didn’t come on. “What has happened to it?” Sathe exclaimed. “Oh shit! Wiper is gone!”

“Shit,” First Officer Kumar interjected.

Laughing it off, Captain Sathe said, “What a day for the wiper to go!” Kumar chuckled along with him in solidarity. Nobody mentioned the fact that the windshield wipers were a mandatory item under the special monsoon procedures, and that they were obligated to divert to an airport without rain if the wipers weren’t working.

Moments later, just after completing the landing checklist, Captain Sathe ordered First Officer Kumar to put “all the lights on.” Apparently by this point the runway was no longer visible through the swirling clouds and heavy rain.

“APPROACHING MINIMUMS,” said the automated voice of the enhanced ground proximity warning system (EGPWS).

“Looking out,” said Captain Sathe, searching for the runway.

“FIVE HUNDRED,” said the EGPWS, announcing their height above the field.

“Check,” said First Officer Kumar.

“MINIMUMS,” said the EGPWS.

Flight 1344 had reached the minimum altitude; they could not fly lower without seeing the runway. But it was obvious to Captain Sathe that the runway was not there to be seen. “Let’s go around,” he announced, disconnecting the autopilot and putting the plane into a climb.

As the plane climbed away, the pilots retracted the landing gear and flaps, then informed air traffic control that they were making a missed approach. Their assumption was that they would circle around and try again to land on runway 28 — they had no way of knowing that this was not the scenario which awaited them.

A 3-D map of the path of flight 1344, including both approaches. (AAIB)

While flight 1344 was going around, an Air India plane announced its intention to take off on runway 10, the same runway from the opposite direction, despite the fact that this would put the wind at its back. If flight 1344 tried to land on runway 28, the two planes would be flying directly at each other. To rectify the situation, the controller asked the crew if they were okay with landing on runway 10, allowing them to come in behind the departing aircraft.

Captain Sathe decided to handle this question himself. “Don’t do anything, pay attention,” he said to Kumar. Keying his own mic, he said to ATC, “How’s the visibility for runway one zero?”

“Both runways two thousand meters with light rain… surface wind two six zero degrees at five knots,” said the controller.

The wind would be almost directly behind them, but at only five knots, it was well below what could be considered dangerous on its own. Captain Sathe decided to go for it. “Okay, set up for one zero,” he said to First Officer Kumar.

The problem with landing in a tailwind is that it increases the speed of the airplane relative to the ground. It is not possible to compensate for this because the lift generated by the wings is a function of airspeed, the speed of the plane relative to the air, which includes the tailwind; so if a pilot slows down to land at the normal ground speed, their airspeed will drop too low and the plane could stall. For this reason a tailwind always means a higher landing speed and a longer landing run. Even with a tailwind of only five knots, the pilots should have second guessed the decision to land with the wind at their backs on a wet runway with relatively tight margins and steep drops on all sides. But nobody said a word about the risk they were about to take.

(AAIB)

If the tailwind had in fact been only five knots, the story of flight 1344 would have ended very differently. The problem was that the real wind across the ground was at least 15 knots, gusting much higher at intermediate altitudes. The airport’s lone anemometer was located too close to the ground and in a depression between the runway embankment and an airport building, a position which investigators would later call “anomalous.” In this sheltered location, it produced readings which often bore little resemblance to the real wind speed over the runway, and on top of that it was mechanically unsound and failed frequently. Nevertheless, the controller faithfully relayed to the pilots whatever figures it gave him. Local weather authorities had issued two aerodrome weather warnings for Kozhikode at around the time of flight 1344’s approach, indicating the presence of thunderstorms and a 17-knot wind, but the airport meteorologist whose job it was to interpret these messages and tell the controller had left the tower against protocol and never informed him.

As flight 1344 made its second approach to Calicut Airport, turbulence battered the plane as it struggled against a 38-knot tailwind at a height of 3,300 feet. Once again the pilots intercepted the localizer and glide slope, aligning with the runway. Just above 2,500 feet, Captain Sathe ordered First Officer Kumar to turn the windshield wipers back on again. “You put it on properly in there,” he said. “I’ll tell you when to put it on. I hope it works.”

“Check,” said Kumar.

Sathe laughed out loud. “Checked.”

Kumar switched on the wipers, and this time the captain’s side wiper did come on, but only sort of. “What is this?” Sathe jokingly exclaimed. “Speed will be this much only?” Despite setting the wipers to “high,” they weren’t moving anywhere near fast enough to keep the windscreen clear of water. But again, they continued the approach.

Contacting the controller, Kumar said, “Calicut tower, Express India one three four four, on ILS one zero.”

“Express India one three four four,” said the controller, “Light rain over the field, runway surface wet. Wind two five zero degrees, zero eight knots. Runway one zero, cleared to land.”

“Runway one zero, cleared to land,” Kumar repeated.

The actual wind speed at this altitude was 26 knots, including a 22-knot tailwind component and a 13-knot crosswind component which forced the plane to crab sharply to the right as it descended. The winds were way beyond what was allowed for landing, but the pilots had no idea, and they continued their blithe descent into the storm.

(AAIB)

This time, however, the clouds cooperated. As the EGPWS again announced “FIVE HUNDRED” and “MINIMUMS,” Captain Sathe caught sight of the runway and announced, “Visual. Landing.” Disconnecting the autopilot, he took control for a manual touchdown.
At this moment he was immediately afflicted by a number of visual illusions. With little visible aside from the runway lights, he would have been subject to the “black hole effect,” in which the absence of outside references causes the runway to look closer than it actually is. Trying to look at the runway lights through a windshield covered in water due to the malfunctioning wiper would have produced the same effect. Because of one or both of these illusions, Captain Sathe apparently believed he was higher than he really was, and he immediately started pushing the plane below the glide slope at an abnormally high rate of descent.

“Rate of descent,” First Officer Kumar called out, attempting to warn him.

“Check,” said Captain Sathe, but he kept descending at 1,500 feet per minute.

“Rate of descent, Captain,” Kumar said again.

“Yeah, yeah, correcting, correcting, correcting,” said Captain Sathe.

“GLIDESLOPE,” announced the EGPWS. “GLIDESLOPE.” The automated system was trying to warn them that they were too low. In response to the warnings, Captain Sathe accelerated the engines to 60% power, pushing the plane back up through the glide slope. Now they really were too high. The approach was becoming dangerously unstable and should have been abandoned, but Sathe had the runway in his crosshairs and he wasn’t going to give up on it now. Seconds later, the plane crossed the threshold of runway 10 at a height of 92 feet (28 meters) and a ground speed of 169 knots, both higher and faster than normal, thanks to the 15-knot tailwind. Indeed, the landing was already set to be long, but Captain Sathe was about to make it much worse.

(AAIB)

As flight 1344 neared the ground, Captain Sathe pulled up to flare the plane for touchdown, raising the nose to plant the main gear on the runway. However, he did this too soon, with engine power set too high. Flaring the plane should drop it smoothly onto the runway, but with engine power at 60% and increasing, this maneuver increased lift and caused the plane to level off entirely at a height of about 16 to 20 feet (5–6 meters). The plane’s sink rate bottomed out at about two feet per second as it floated down the runway, rapidly eating up the designated touchdown zone.

“Just check it,” said First Officer Kumar, perhaps pointing to the rapidly approaching lights which marked the end of the touchdown area. But Captain Sathe didn’t reply. The end of the touchdown zoned zipped right by and disappeared behind them. “Captain?” Kumar said, starting to sound agitated.

The EGPWS announced that they were ten feet above the ground. Sathe finally seemed to realize that he had floated the landing and moved to plant the plane on the runway. As Sathe lowered the nose and reduced thrust, First Officer Kumar could tell that it was too late. “Go around,” he said, but his feeble exhortation fell on deaf ears, as Captain Sathe ignored him and slammed the plane down almost exactly half way along the 2,700-meter runway.

From the moment the wheels touched the runway, flight 1344 was all but doomed. The runway was wet, the wind was at their backs, they only had 1,400 meters to stop, and the runway was angled slightly downhill. There simply wasn’t enough room. Captain Sathe immediately deployed the thrust reversers and applied maximum braking power, but within seconds it became apparent to him that they were headed straight for the end of the runway. “Oh shit!” he exclaimed. He stowed the thrust reversers and lifted off the brakes, perhaps thinking he could get the plane back off the ground, but it was too late to do that either. “Shit!” he yelled again. Panicking now, he reapplied the brakes and redeployed the thrust reversers, pushing the engines to max reverse power. In the tower, the controller caught sight of flight 1344 and concluded that it wasn’t going to make it.

Still in possession of considerable momentum, the plane hurtled past the end of the runway. Panicking now, Captain Sathe stowed the thrust reversers, briefly causing the engines to generate forward thrust. For a second the plane actually accelerated, then he snapped the throttles back to idle. The 737 ran off the pavement and into the dirt overrun area, smashed into the ILS array, and careened off a 30-meter tall embankment at a speed of 50 knots. “Shit!!” First Officer Kumar screamed. His was the last word captured on the cockpit voice recorder. A couple seconds later, the plane slammed into the ground next to the airport perimeter road with a deafening crash.

A diagram of how the wreckage of flight 1344 came to rest. (AAIB)

Upon impact, the fuselage split open in the vicinity of first class, catapulting the cockpit across the road and into a brick wall, which collapsed. Several rows of seats with passengers in them tumbled into a pile of twisted debris in the middle of the road. Farther back, the main fuselage section stopped dead, while the tail continued downward into a ditch, causing it to separate a few rows in front of the aft galley. Within a split second, the shattered debris came to a stop, and for a moment, there was silence.

The cockpit slammed through a brick wall, taking heavy damage. (IndiaTV News)

Inside the cabin, a large majority of the passengers had managed to survive the brutal impact. Some found themselves stunned but unhurt, and in shock they wandered out through breaks in the fuselage and onto the road. Others were in much more dire straits. Both pilots had been killed instantly, along with 16 passengers, and many others were trapped. In the area where the tail broke off, the floor had turned nearly vertical, causing seats near the break to jam against each other; several passengers here became trapped within an inextricable tangle of cabin furnishings. Both of the forward flight attendants were severely injured and unable to help, leaving the two rear flight attendants to deal with the evacuation of over 150 people. Outside the plane, chaos reigned as bystanders rushed to help, swarming over the aircraft alongside the airport firefighters, who had hurried around to the perimeter road after discovering that the plane was not on the runway. Amid the mayhem it was unclear who was in charge. Nobody informed the airport doctor, no triage was conducted, and numerous victims were rushed to hospital in private taxis instead of ambulances. Attempts to free trapped passengers with a gas-powered saw inadvertently led to the cabin filling with noxious exhaust fumes. And by the time someone finally told the designated doctor about the crash, the road was so choked with traffic that he was forced to make his way to the scene on foot.

The area of the cabin forward of the wings was totally destroyed. (Hindustan Times)

All told, eighteen people died on the scene, and three more died later in hospital, bringing the total to 21 victims and 169 survivors, of whom 76 suffered serious injuries due to the extreme force of the impact and the collapse of numerous seat rows.

Although the outcome was less catastrophic, the crash of flight 1344 immediately drew comparisons to another runway overrun accident that occurred ten years earlier. In May 2010, Air India Express flight 812, another Boeing 737, landed long on a tabletop runway in the city of Mangalore in neighboring Karnataka state, causing the plane to fly off a high embankment and into a forest, whereupon it burst into flames. Of the 166 people on board, 158 were killed. In the intervening decade, Indian airlines had not suffered any major accidents — until the 7th of August 2020. What had gone wrong? How could Air India Express have lost another plane under near identical circumstances? Had the lessons of the Mangalore tragedy not been learned?

The aftermath of the 2010 crash of Air India Express flight 812. (The Guardian)

Answering those questions was the duty of the Aircraft Accident Investigation Bureau of India, or AAIB, an agency created in the wake of the 2010 Mangalore crash in order to ensure investigations’ independence from the Directorate General of Civil Aviation. Flight 1344 would be the first time it investigated a major accident.

A preliminary analysis of the data revealed the basic sequence of events. Already coming in hot due to a severe tailwind, the captain flared the plane too early and too aggressively, causing the plane to float down the runway; by the time it touched down, it was already much too far along. A study of possible scenarios showed that even if Captain Sathe had used the brakes and thrust reversers to their full potential within two seconds of touchdown, the plane still wouldn’t have stopped within the designated length of the runway; however, it would have stayed on the pavement and no one would have been hurt. The plane also would have stopped within the gravel overrun area if the captain had used the thrust reversers correctly but still briefly let off the brakes, as he did during the actual landing. All other scenarios resulted in the plane falling off the embankment. Furthermore, if Captain Sathe had actually tried to balk the landing when he considered doing so, the plane would not have reached liftoff speed before the end of the runway, leading to an even worse accident. Indeed, although the consequences would have been much more benign if Sathe had properly committed to stopping, the study showed that the most serious mistake was touching down in the first place.

A news station breaks news of the crash of flight 1344. (News Nation)

Upon listening to the cockpit voice recording, investigators were stunned to find that First Officer Kumar had actually called for a go-around about one second before touchdown — admittedly rather late given the conditions — and Captain Sathe ignored him. This was a violation of every principle of crew resource management (CRM), the set of strategies which govern crew interaction in order to ensure that all pilots make use of each other’s skills, knowledge, and judgment. To ignore another pilot when he calls “go around” is the height of recklessness and arrogance. In fact, when any pilot calls “go around,” the flying pilot is immediately required to comply. Conversely, when the captain did not respond to his “go around” call, First Officer Kumar was obligated to take control of the airplane and execute a go-around himself. However, like a mirror image of Captain Sathe’s arrogance and pride, Kumar’s submissiveness and uncertainty prevented him from taking action against a very senior captain who was nearly twice his age and had five times his experience.

Witnesses and rescuers alike swarmed the wreckage to extract the survivors. (NDTV)

Such a move would be difficult for any first officer to make, but rigorous CRM training can help level the playing field, making captains more receptive and first officers more assertive. The level of relative authority between the two pilots is referred to as the authority gradient: too shallow and it’s not clear who is in charge; too steep and the first officer can be shut out of the decision-making process. In the case of flight 1344, not only did the captain ignore the first officer’s belated go-around call, the CVR made it clear that the first officer’s role in the cockpit was limited to calling out parameters and flipping switches, as there was no discussion between the pilots about courses of action and the captain made all major decisions unilaterally. Evidently Air India Express had not adequately trained its pilots in basic tenets of CRM, which should have helped create an appropriate authority gradient. In fact, almost exactly the same thing happened in the Mangalore crash: in that accident too, the first officer urged the captain to go around, the captain refused, and the first officer failed to take control. In this respect, nothing had changed.

Police and members of the press at the crash site. (IANS)

Calculations showed that if the touchdown had occurred at the normal location, the landing would have been unremarkable. The brakes were all working properly and the aircraft did not hydroplane, despite the wet runway. The long flare which led to the late touchdown had no obvious explanation, but investigators theorized that due to the excess speed of the airplane on landing, the runway looked closer than it was. One of the ways we judge distance while in motion is through the relative movement of objects: things that are nearby move through the field of view faster, while things that are far away pass by more slowly. If the runway lights were moving past his window faster than he expected, it could have caused the captain to believe the runway was closer than it actually was. Expecting to hit the runway within the next couple of seconds, he pulled back to flare for touchdown, but ended up floating the plane down the runway instead. A look at Captain Sathe’s training history showed that he repeatedly struggled with this exact issue: multiple instructors had noted that he used a “prolonged flare” and had a “tendency to float during landing.” On top of that, instructors noted that he sometimes lost concentration while under stress. In fact, he had failed to upgrade from the 737 to the larger 777 because of these issues, all of which fatally manifested on board flight 1344.

Rescuers enter the tail section to free trapped passengers. (India Today)

Another possible reason for the botched touchdown was found not in the black boxes, but in Captain Sathe’s flight bag, which was found to contain four different diabetes medications and a bottle of ayurvedic (traditional Hindu) anti-diabetic medicine. Several tablets from each medication had indeed been consumed. Records revealed that the captain had been diagnosed with diabetes and prescribed Metformin, a drug which is approved for pilots, but he had acquired all the other drugs (some of which should have barred him from flying) on his own without consulting a specialist in aviation medicine. Blood tests revealed that at least two of the drugs were in his system at the time of the crash.

Most diabetes medications, including some that Sathe had in his system, are prohibited for pilots because they can cause hypoglycemia, a condition whose effects include confusion, lightheadedness, fatigue, impaired decision-making skills, and delayed reaction times, among other symptoms. Given his recent consumption of several of the medications, it was possible that Captain Sathe was suffering from hypoglycemia during the ill-fated flight, compromising his ability to handle the airplane, and causing him to make questionable decisions. Unfortunately, Captain Sathe might not have known that these drugs were dangerous for pilots because neither Air India Express nor Air India had employed an aviation medicine specialist since at least 2015, meaning that he was forced to go to regular doctors who didn’t necessarily know the special rules for pilots.

Many of the fatalities occurred in this area of the plane which disintegrated on impact. (FirstPost)

Despite the captain’s disastrous landing flare, the seeds of tragedy were clearly planted well before the plane touched down. Investigators heavily criticized the decision to land on runway 10 in the first place, noting that no pilot should willingly put themselves into a situation where they would have to land on a short tabletop runway at night in the rain with a tailwind. The risks are far too great. And yet the pilots accepted the controller’s suggestion without critically examining whether it was a good idea. The AAIB rattled off a litany of further mistakes that proved the pilots didn’t properly plan the approach: they didn’t choose the optimal flap setting; they delayed flap deployment (which was inappropriate in a tailwind, since flaps help the plane slow down earlier); they did not select the maximum autobrake setting; they chose an approach speed which was six knots above the normal speed for no obvious reason; and worst of all, they didn’t do the most basic step required of them: calculating the landing distance. Had the pilots calculated the legally required landing distance under the conditions and with the aircraft configuration that they had chosen, they would have found that their margin for error was unacceptably low, and they might have reconsidered their decision to land on runway 10.

Several seat rows came to rest outside the plane near the cockpit. (AP)

Failing to calculate the landing distance is undoubtedly a major violation of standard procedures. But investigators found that the practice was widespread throughout Air India Express. As it turned out, large numbers of Air India Express pilots were quite simply incapable of making the required calculations, even in a classroom setting, let alone in flight. Furthermore, the tables they had available to guesstimate the distances were not accurate enough to produce any useful information, and Boeing’s Operational Performance Tool, an iPad app which could have made these calculations for them, had not been installed on any Air India Express Aircraft. And finally, many pilots also believed that calculating the landing distance was a waste of time if they were familiar with the airport, as Captain Sathe was with Kozhikode.

When they observed the airline’s training program to understand why it was producing pilots who couldn’t do basic math, investigators discovered that nearly all the student pilots were given uniformly high marks regardless of their actual ability, which was in some cases appallingly bad. This was a major scandal all on its own, but in the midst of everything else, it only received a couple of paragraphs in the AAIB’s final report.

The offset between the tail and center sections was so great that one section of the floor became vertical. (AAIB)

Still more contributing factors became apparent when investigators examined some of the concerns which compelled the pilots to accept the proposal to land on runway 10. Looming large was the fact that the next morning’s flight would be delayed if they were late landing in Kozhikode, a situation which Captain Sathe clearly wanted to avoid. He also had to worry about the two-attempt limit on approaches in monsoon conditions, which could force a costly diversion if the second approach failed. The pressure on Sathe was particularly acute because he was the only captain based in Kozhikode, alongside 26 first officers, an egregiously imbalanced roster that rendered Sathe functionally irreplaceable. More so than any other pilot at Air India Express, the flight schedule relied on Deepak Sathe being available and punctual. In terms of the airline’s crew rostering system, Sathe was practically a single point of failure who could at any time cause escalating delays across the entire network. The reason for this egregiously bad pilot distribution? Air India Express had assigned its pilots to home airports based on where they currently lived, not where pilots were actually needed. In fact, there were 42 captains based in Delhi despite the fact that Air India Express operated few flights there, while Kozhikode, its busiest hub, had only one captain.

The cockpit traveled a considerable distance after the rest of the plane came to a stop. (NDTV)

Air India Express was an organizational disaster in other ways as well. For example, the head of training was based in Delhi but training took place in Mumbai; the Chief of Operations was based in Chennai but the Operations Department headquarters was also in Mumbai (and the aforementioned Chief of Operations was simultaneously a Boeing 747 pilot for Air India); the corporate headquarters was in Cochin; and the maintenance headquarters was in Thiruvananthapuram. The management hierarchy was mixed in with that of Air India, and it was unclear who reported to whom, and where.

Seats were strewn everywhere after the forward fuselage disintegrated. (Tribune India)

The Directorate General of Civil Aviation also came under the scrutiny of the AAIB for failing to implement recommendations that were made after the 2010 crash in Mangalore. In fact, the AAIB’s final report took the unusual step of including an entire chapter listing all the unfulfilled recommendations from that crash which were relevant to the crash of flight 1344. Despite recommendations that were made to address these problems, Air India Express was still dependent on Air India, there was still a steep cockpit authority gradient, the airline’s simulator was still in poor mechanical condition, crew scheduling was still inadequate, there was still no Aviation Medicine Specialist, runway end safety areas were still poorly maintained, tabletop runways still didn’t have overrun protection systems, airport firefighters were still poorly trained, and airlines still weren’t required to keep track of long landings.

Investigators get to work at the scene of the accident. (IndiaTV News)

Regarding the airport itself, the AAIB noted a number of failings. The airport firefighters had not been trained on the features of specific aircraft types, even though paperwork filed with the DGCA said they were; the anemometer was close to useless; the tower meteorologist was not in the tower during a severe storm; and the airport doctor lied to investigators about the coordination of rescue activities.

But most of all, the AAIB was visibly annoyed that nothing had been done to reduce the danger of runway overruns at tabletop airports after the disaster in Mangalore. The most effective means of improving runway end safety would have been the installation of Engineered Materials Arrestor Systems, or EMAS, which work like runaway truck ramps for planes, bringing a speeding aircraft to a halt in a short distance using specially designed gravel. Following a DGCA order to improve runway end safety areas, Calicut Airport considered installing EMAS, but ultimately went for something much cheaper: fiddling with the numbers to re-designate some of the runway as part of the runway end safety area instead. This involved no actual changes to the runway or the safety area; the only difference was that the published runway length became lower, potentially limiting the types of planes which could land on it, though in practice there was no real impact to operations.

Police officers stand in front of the shattered wreckage. (DNA India)

To justify this decision, the airport authority came up with a list of specious reasons why they couldn’t install EMAS, most of which were logical fallacies or were clearly less serious than the consequences of a runway overrun. The only significant issue was that unless the embankment were extended (a very considerable expense), the EMAS installation would overlap with the runway, also a considerable expense. But an EMAS would have prevented the crash of flight 1344, so the question must necessarily be asked — was the money saved really worth more than 21 lives?

At the end of the day 169 people managed to walk away from this broken plane. The toll could probably have been far worse. (BBC)

In its final report into the crash of Air India Express flight 1344, the AAIB issued no less than 43 safety recommendations intended to ensure that such a tragedy never happens again. But much the same thing happened after the previous crash, and very little actually changed. If anything, safety at Air India Express became worse. What is one to do in a country where the recommendations of safety experts are given so little weight? Can a clearly preventable crash, caused directly by the failure of authorities to act, finally change the industry’s values and practices? Or will another Air India Express 737 run off a runway in 2030, again taking the lives of dozens of innocent people? The answer is up to those in India with the power to effect genuine change. Today, one year after the tragedy in Kozhikode, it remains unclear whether another shattered plane, another 21 bereaved families, will be sufficient to stir them from their complacency.

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Analyzer of plane crashes and author of upcoming book (soon™). Contact me via @Admiral_Cloudberg on Reddit or by email at kylanddempsey@gmail.com.