2. OUR TEAM
Abdullah Amjad 151
Laiha Nawaz 169
Hamza Mohammad 126
Hafiza Esha 156
Waleed Imtiaz 139
Arslan Jameel 165
Komal Arif 171
3. Background:
On the 7th of August 2020, a Boeing 737 was making its way from Dubai to Calicut with 190 people on
board as the 737-800 approached Calicut the monsoon was in full swing across the entire area the pilots
got their list of diversion airports through ACRAS.
At 1.19 pm UTC Chennai upper area control got in contact with flight 1344 letting them know of the
conditions at Calicut the runway in use was runway 28 and the visibility was at 1500 meters
As the flight descended it was handed over to the coach and lowered area control. Finally, by the time it
was at 12,000 feet it was contact with Calicut ATC.
At this point flight 1344 was 52 nautical miles away and the airport was experiencing some mild Rain. At
the airport had two active warning at that time which is thunder storm and rain
4. 1
st Attempt ;
Wind was 17 knots at the airport this meant the crash fire tenders were already at their predetermined
position just in case of an emergency as flight 1344 approached the airport it was clear to descent to
3600 ft as the plan lined up with the runway.
The weather seemed to ease up the visibility was at 2000 meters and the winds had come down to 5
knots. Butt they were having trouble with windshield wipers on the captain’s side the wiper would work
for a bit and then it would stop.
The captain remarked: “wiper gone what a day for the day for the wiper to go”. But they carried
on with the landing attempt on runway 28, The plane descended but they couldn’t see the runway,
eventually they hit their minimum descent altitude.
Without the runway in sight, they decided to go around.
5. 2nd Attempt :
At 1:59 pm and 42 seconds UTC, flight 1344 was cleared to descend from 7000 feet, they were cleared
for the ILS Zulu approach to runway 10.
The 737 was just 500 feet above the ground, the captain disengaged the autopilot and took manual
control of the plane.
The first officer cautioned the captain about the high rate of descent which momentarily reached 1500
feet per minute the approach was beginning to unravel they were 1.7 dots below the glide slope
signifying that the automated glide slope warning filled the cockpit
Captain arrested their descent at least for a bit he pulled back reducing the rate of descent to 300 feet
per minute but soon the rate of descent was back at 1000 feet per minute flight 1344 passed the
threshold of runway 1-0 at 92 feet as the 737 flew over the runway
Captain added a bit more power to slow the plane's descent they had gone through 1300 feet of runway
and the plane was still 20 feet off the ground when the plane was three thousand feet down the
runway it still hadn't touched down the first officer expressed some concern saying just check it.
6. 2nd Attempt Continued :
The plane was still not down the plane was eating a valuable runway as it floated along the first officer
said captain in an uneasy tone at this point the plane was 3 600 feet from the threshold of runway 10.
It still had not touched down the first officer was very concerned and First Officer called for a go
around but the captain did not acknowledge the call for the go around 4,400 feet down the
8,800-foot-long runway the plane finally touched down the captain immediately overrode.
The systems and commanded maximum braking within seconds the plane was nearing the end of the
runway the end of the paved runway end safety area loomed in front of them the airplane soon left the
paved runway
Aircraft dug itself into soft mud which slowed it down a bit but it wasn't enough flight 1344 overshot the
runway at 84 knots and fell 110 feet 21 people did not make it
7. Instrumental Error:
• The CVR transcript revealed that the wiper on the captain side did not work during the approach to
land on runway 28. However, during the approach for runway 10, the CVR transcript revealed that
the wiper on the captain side worked, albeit at a speed lower than the one selected.
• Subsequent to the accident, the wiper motor converter, wiper selector switch and the wiper blade
assembly were tested as per CMM for all speed conditions and found to be operating satisfactorily.
The aircraft wiring check was also carried out as per FIM and WDM and did not reveal any insulation
failure, abnormality or breakage.
• it is concluded here that the wiper on the captain side stopped working after operating for about 27
seconds during the approach to land on runway 28 and, although during the approach for runway 10,
it worked, albeit at a speed lower than the one selected.
8. Training Plan:
Description:
It is developed to build the understanding of CRM, in which include crew co-ordination skills,
assertiveness and seniority complex. This will help in operating the flight efficiently and enhance human
performance by minimizing human error.
Learning Outcomes:
Describe the methods that how to be assertive to maximize the efficiency of flightoperations
The art of saying ‘’no’’
Apply the concepts of crew co-ordination to maintain the cockpit environment
9. Objective:
Following are the objective that are given below:
·From this training, to take over the control in the cockpit the assertiveness will be enhance and follow
by the first officer in correct manner to prevent the accident whenever pilot in command failed to
respond.
·They will get more knowledge so that they will able to tackle the situation (tailwind on wet runway).
·As crew resource management plays an essential role in preventing the fatal accidents. From this
training the cockpit crew will be able to work as a team, they will also know the importance of
coordination between the crew. They will also able to exchange the authority between each other
without any seniority issue.
10. Need Assessment:
According to the NTSB Report, the Air India 1344 accident was caused By the Poor Crew Resource
Management. Before the touch down the first officer called the captain that the remain runway is not
enough for aircraft braking or stopping.
Captain was too over-confident due to his huge experience on this airport’s Runway. Before touch down
the first officer also advised to pilot in command that we have enough fuel to land on other Airport
which were near to them and have a pleasant weather for landing purpose
Butt captain did not respond the first officer advise and continue his 2nd landing Attempt on Kozhikode
airport.
The First officer did not give any input regarding this gross Standard operating procedure violation to
the Pilot in command, indicating a steep cockpit authority gradient resulting in poor Crew Recourse
Management.
11. Implementation:
By analysis the history of aircrafts Incidents and accidents in the world. We came to know that there
were 80% accidents were caused by Crew Mistakes. 80% percent of these accidents are too huge so we
want to prevent these accidents by training our crew with different tools and technique to secure our
human’s life and aircraft.
In this training section, we are going to introduce a tool and checklist for our crew training which are as
following
a. TDODARRule
b. Crew Checklist
13. Check List
ID Pilot Yes No
1.1 Have You completed your 8- hour sleep?
1.2 Do You have any kind of anxiety and Depression?
1.3 Did you receive your flight plan?
1.4 Is this flight is in your schedule?
1.5 Currently Are you using any kind of drugs and medicine?
1.6 Is there enough Lighting cockpit?
1.7 Have you done 360- procedure of your aircraft?
1.8 Did you attend your last Training session of CRM?
1.9 Have you ever been in this aircraft before as flight captain ?
1.10 Have you ever before collaborated with your current flight
officer?
1.11 Are you acknowledged by the weather information?
14. ID Flight Officer Yes No
2.1 Have You completed your 8- hour sleep?
2.2 Have you ever before collaborated with your current Captain?
2.3 Did you attend your last Training session of CRM?
2.4 Is this flight is in your schedule?
2.5 Currently Are you using any kind of drugs and medicine?
Check List
16. Safety Recommendation:
The safety recommendations have been divided under the following heads: -
Air India Express Ltd
Airports Authority of India
Indian Meteorological Department
Aircraft Accident Investigation Bureau
17. Investigator Conclusion:
• Unavailability Of Sufficient Number Of Captains At Kozhikode
• Experience Might Have Led To Over Confidence Leading To Complacency And A State Of Reduced
Conscious Attention
• 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.
• 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
18. Our Through & Conclusion
• After analysis whole accident we can to know that this accident happened due to lack of crew resource
management.
• These types of accident can be prevented by training session of Crew resource management
• The Pilot Monitoring did not make the mandatory announcement for the cabin crew to be seated on the
first approach for landing on runway 28 at Kozhikode. This is a very serious omission and
compromises cabin crew safety.
• The ATC reported visibility of 2000 m in light rain and winds 250/08 Kt while transmitting landing
clearance for AXB 1344. Prevailing surface winds were much stronger than the winds reported by
ATC. DFDR analysis confirms tail winds of 16 Kt when the aircraft was at 30 ft RA over runway 10.
19. Our Through & Conclusion
• The Duty Doctor at the Airport Terminal Clinic was not familiar with his role and responsibilities during
an aircraft accident as per the published AEP.
• The post-crash rescue efforts lacked effective command and control. There was no ‘Command Post’
established at the crash site. This was also an observation during the previous ‘Mock Drill’ held in
November 2019.
• The ARFF crew at Kozhikode were found lacking in aircraft familiarization training, which resulted in
delay in evacuating the pilots from the cockpit.
