Investigators have detailed how pilot error, poor communication, and work culture were all factors in the crash of an Air India Express Boeing 737-800 at Kozhikode airport (CCJ) on August 7, 2020.

The accident, which killed 19 passengers and two pilots after the plane ran off the tabletop runway, was caused by the pilots landing too far down the wet runway with a tailwind.

Indian investigators from the Aircraft Accident Investigation Bureau (AAIB) released their final report into the crash on September 12, 2021.

The AAIB said the probable cause was the captain, who was pilot flying (PF), failing to follow standard operating procedures (SOP) when he “continued an unstabilized approach and landed beyond the touchdown zone, half way down the runway.” This was in spite of a go-around call by the first officer (FO), the investigators said, also citing the FO’s failure to take over the controls and execute a go-around himself.

The investigators added that poor crew resource management (CRM), referring to communication and teamwork among the crew, was a major contributory factor in this crash, highlighting the airline’s work culture. 

“The work culture and the prevailing cockpit gradient in Air India Express leading to poor Crew Resource Management was a significant factor that contributed to the crash of AXB 1344 by preventing the FO from being assertive enough to take charge in the cockpit (when required to do so),” they wrote in the report.  

The Air India Express Boeing 737-800 aircraft, registration VT-AXH, was operating a return flight to Dubai (DXB) and back to repatriate passengers stranded due to the COVID-19 pandemic. The aircraft departed DXB at 10:00 UTC as AXB 1344, carrying 184 passengers and six crew. 

On the first approach to Runway 28 at CCJ, the windscreen wiper on the captain’s side briefly stopped working. A first attempt at landing resulted in a go-around, with the crew citing weather as the reason for not having the runway in sight at the required time.

At this point, another aircraft asked the tower if they could take off from the opposite runway, Runway 10. The tower agreed and asked AXB 1344 if they would take an approach for Runway 10. 

The crew of AXB 1344 agreed. However, the tailwind component was much stronger than that reported by the tower.

On the second approach, which became unstable after the captain flew below the glideslope and then overcorrected, the aircraft landed in light rain with a tailwind component of 15 knots, exceeding the company maximum of 10 knots. The aircraft landed long after what the report deemed an “alarming extended float period”, touching down at approximately 4,438 ft, half way down a wet runway that was 8,858 ft long and more than 1,000 ft beyond the touchdown zone. In addition, thrust reversers were not fully deployed.

The investigators said calculations and modeling showed the plane could not have stopped on the runway at the point where it landed in the weather conditions that day. 

VIOLATION

The investigators said the crew of AXB 1344 agreed to the runway change too hastily and failed to brief it properly. They noted the crew had sufficient fuel to take up a hold in order to discuss the implications of the runway change and how it would have changed critical factors such as landing distance, brake setting, and tailwind on a tricky runway like that found at CCJ. 

The crew also did not discuss an alternate airfield, which was required in the event of a second missed approach and due to the unserviceability of the windshield wiper on the captain’s side, investigators highlighted. 

“This was a violation of the SOP, and the error magnified on this approach as the landing was made in strong tailwind condition on a wet tabletop runway in active rain,” the final report states.  

While the first officer recognized that the approach was unstabilized and correctly anticipated the long landing, he did not speak up clearly enough, the investigators said. 

“The stiff and closed work environment, where hierarchy and seniority work to the detriment of the airline, contributed towards a breakdown of communication in the cockpit of flight AXB 1344,” they stated. 

“During the critical phase of planning after the missed approach, preparation of the second approach for runway 10, and at the final phase of landing on runway 10 (onset on deviations towards an destabilized approach and long float) the FO did not offer the required corrective inputs and displayed a meek and unassertive demeanour in the presence of the senior pilot.”

The investigators recommended improved simulator training for Air India Express pilots, including a scenario where the FO is required to step in and perform a go-around if the captain does not respond. They also said trainers at the airline should carry out random observation flights to check on CRM principles in practice.

The report also recommends that the Airports Authority of India ensures that initial and recurrent training for controllers emphasizes the impact of tailwinds and precautions to be taken when changing a runway in adverse weather.