AirBlue jet down in Islamabad

[Shamim Shaikh]

I have the full report with me. It is a PDF file of over 12 MB. Can some one advise me advise me how to share it here?

Shamim Shaikh

[Abbas Ali]

^ Upload PDF file on any free hosting site and then post download link here or copy text from PDF file and paste it here.

Abbas

[Shamim Shaikh]

I have placed the report at
http://shamimshaikh.files.wordpress.com ... report.pdf

I am not a flyer so I do not understand the technicalities. However, to me it appears to be a truncated report with many important aspects missing. Will appreciate comments.

[TAILWIND]

One of the most pathetic, unprofessional and useless accident report I have ever seen. First 26 of 38 page report have been used to give the description of various on board systems. A professionally written written investigation report should give synopsis, then describe the events followed by a detailed analysis and finally recommendaions ( safety, technical and organaisational). Then there should be annexes including the CVR transcripts, figures, data, charts and functional description of relevent systems etc of required. Each and every conclusion and recommendation has a cross reference to events and incidents.
In this case its a rumble dumble (ommelete) sort of thing, and one cannot make out if you are reading the conclusions, analysis opinions or the events. Where is the supporting data and discussion which the investigation board used to make a conclusion or opinion (8.23 and 8.34 for example)
This report brought out nothing new, we all knew what happened but has exposed the pathetic professional standards of the CAA and its investigation board.

[offspring]

Not being from the aviation industry after reading the report I could not agree more with Tailwind. Yes the Captain was at fault, who was over confident and seemed to be in a hurry but there are numerous questions unanswered. The report, like always, has pinned all the blame on the Captain (not defending him).

For starters how about looking into Air Blue’s policy on delays and diversions? They cost money which any airline (let alone a small private one) can ill afford. From the report the Captain seems to be on some schedule and the report is silent on that aspect.

Furthermore what would be the consequence if a first officer took over controls from such an experienced and highly decorated officer? What is the procedure and outcome of such a scenario? What is Air Blue’s policy on this?

Lastly the role of a fully automated airplane like Airbus. The Air France airbus A 330 crash comes to mind.

Being an amateur, apologies in advance if I have said something not relevant or incorrect.

[Abbas Ali]

Airblue crash investigation: Captain’s son to challenge govt report

By Qaiser Zulfiqar

Published: December 28, 2011

ISLAMABAD: The government inquiry into last year’s Airblue plane crash put part of the blame on the captain of the flight Captain Pervez Iqbal Chaudhry. His son has now decided to contest the report to clear his father’s name.

“My father was an extraordinary pilot,” said Tahir Pervez Iqbal while talking to The Express Tribune on Tuesday. He said he would challenge it in Peshawar High Court (PHC) on the next date of hearing (January 19).

The government has released the investigation report, a copy of which is available with The Express Tribune.

“The captain’s behavior towards the first officer (FO) was harsh, snobbish and contrary to the established norms. This undesired activity of the captain curbed the initiative of the FO, created a tense and undesirable environment, and a very conspicuous communication barrier in the cockpit, portraying a classic crew resource management (CRM) failure. FO did not challenge the captain for his incorrect actions,” the report said.

The report is self-contradictory, said Iqbal, who is a Commercial Pilot License (CPL) holder but associated with the pharmaceutical industry in Lahore at present.

“If my father’s behaviour towards the first officer was snobbish, why did he ask him why the aircraft was not turning left?” said Tahir, adding the government was concealing the facts surrounding the incident to save air traffic control and the manufacturer of the aircraft.

Contrary to the claim in the investigation report that it was impossible to carry out a detailed autopsy or post-mortem examination on the captain’s body due to its severely charred condition, Iqbal said he had given his blood sample for DNA (deoxyribonucleic acid) testing for the identification of his father’s body but he never received the DNA report.

“My father no longer remains in this world to defend himself which is why he has been held responsible for this crash” said Iqbal.

Junaid Hamid, convener of the Airblue Crash Affectees Group (ACAG), and Col (retd) Shamim Sheikh who lost his son in the crash, appreciated Iqbal’s decision of challenging the report in court.

Reacting over the report, Col (retd) Shamim said, the government has simply said in its report that captain’s behavior was snobbish but has not revealed why he was snobbish towards the first officer. Shamim went on to add that the report did not conform to expected investigation standards, saying that 38 pages for a aircraft crash investigation report was unusually short and more like a summary of the incident submitted to appease the court due to delays on their part.

Hamid on the other hand said that ACAG’s legal team was carefully reading the investigation report which is full of loopholes and will certainly present their viewpoint to the court on the next date of hearing.

Source: tribune.com.pk

[raihans]

I am not an aviator but reading through the report; i can see that ATC had not shown proper reaction on time to prevent this tragic crash, why?

I dont know the ATC procedures but on a side note, PAF control all over Pakistan Airspace as well so why they did not reacted when the aircraft was approaching NFZ or they dont have any concern with such issues?

As far as Captain's behaviour is concerned, let the CAA release the CVR recording unless no one will accept this blame, neither do i.

[Shamim Shaikh]

Can some ex colleagues of the Captain comment whether this use to be his usual behaviour or it was some thing unusual. If it was an unusual behaviour, what could be plausible reasons.

Shamim Shaikh

[jameel.ashraf3]

Crash: AirBlue A321 near Islamabad on Jul 28th 2010, impacted mountaineous terrain near the airport

By Simon Hradecky, created Wednesday, Dec 28th 2011 18:54Z, last updated Wednesday, Dec 28th 2011 18:54Z
Pakistan's Civil Aviation Authority submitted their "confidential" final report to the Peshawar High Court. The report concludes the probable cause of the crash was:

Air blue crash has been finalized as a case of Controlled Flight into Terrain (CFIT), in which aircrew failed to display superior judgment and professional skills in a self created unsafe environment. In their pursuit to land in inclement weather, they committed serious violations of procedures and breaches of flying discipline, which put the aircraft in an unsafe condition over dangerous terrain at low altitude.

The report made following findings:

- ABQ-202, the mishap aircraft was airworthy to undertake the flight on 28 July 2010. Both the aircrew had valid medical and aircrew rating for the type of aircraft. Air Navigation and Aerodrome facilities were serviceable and as per AIP.

- Weather conditions indicated rain, poor visibility and low clouds in and around the airport. The information regarding prevalent weather and the required type of approach on arrival was in the knowledge of aircrew.

- Though aircrew Captain was fit to undertake the flight on the mishap day, yet his portrayed behavior and efficiency was observed to have deteriorated with the inclement weather at BBIAP Islamabad.

- The chain of events leading to the accident in fact started with the commencement of flight, where Captain was heard to be confusing BBIAP Islamabad with JIAP Karachi while planning FMS, and Khanpur Lake (Wah) with Kahuta area during holding pattern. This state continued when Captain of the mishap flight violated the prescribed Circling Approach procedure for RWY-12; by descending below MDA (i.e 2,300 ft instead of maintaining 2,510 ft), losing visual contact with the airfield and instead resorting to fly the non-standard self created PBD based approach, thus transgressing out of protected airspace of maximum of 4.3 NM into Margallas and finally collided with the hills.

- Aircrew Captain not only clearly violated the prescribed procedures for circling approach, but also did not at all adhere to FCOM procedures of displaying reaction / response to timely and continuous terrain and pull up warnings (21 times in 70 seconds) - despite these very loud, continuous and executive commands, the Captain failed to register the urgency of the situation and did not respond in kind (break off / pull off).

- FO simply remained a passive bystander in the cockpit and did not participate as an effective team member failing to supplement / compliment or to correct the errors of his captain assertively in line with the teachings of CRM due to Captain's behavior in the flight.

- At the crucial juncture both the ATC and the Radar controllers were preoccupied with bad weather and the traffic; the air traffic controller having lost visual contact with the aircraft got worried and sought Radar help on the land line (the ATC does not have a Radar scope); the radar controller having cleared aircraft to change frequency to ATC got busy with the following traffic. Having been alerted by the ATC, the Radar controller shifted focus to the mishap aircraft - seeing the aircraft very close to NFZ he asked the ATCO (on land line) to ask the aircraft to immediately turn left, which was transmitted. Sensing the gravity of the situation and on seeing the aircraft still heading towards the hills, the Radar controller asked the ATCO on land line "Confirm he has visual contact with the ground. If not, then ask him to immediately climb, and make him execute missed approach". The ATCO in quick succession asked the Captain if he had contact with the airfield - on receiving no reply from aircrew the ATCO on Radars prompting asked if he had contact with the ground; Aircrew announced visual contact with the ground which put ATS at ease.

- Ensuing discussion and mutual situational update (on land line) continued and, in fact, the ATC call "message from Radar immediately turn left" was though transmitted, but by the time the call got transmitted, the aircraft had crashed at the same time.

- The accident was primarily caused by the aircrew who violated all established procedures for a visual approach for RWY-12 and ignored several calls by ATS Controllers and EGPWS system warnings (21) related to approaching rising terrain and PULL UP.

The captain (61, ATPL, 25,497 hours total, 1,060 hours on type) was pilot flying, the first officer (34, CPL, 1,837 hours total, 286 hours on type) was pilot monitoring.

While on approach to Islamabad the crew received ATIS providing runway 12 being active. The crew briefed for a right hand downwind to runway 12, the captain requested the first officer to insert 4 waypoints, not approved for the procedures, into the flight management computer. The captain further briefed, that they would follow the downwind until about 3-5nm abeam the "Course to Fix Leg" (CF), which is automatically created by the Flight Management Guidance System on the extended runway center line 5nm before the runway threshold and then turn in for landing - this plan was in contradiction to established procedures for a visual circling at Islamabad.

During the descent towards Islamabad the captain requested a right hand downwind, radar however denied that request due to procedural limitations. The captain became worried about bad weather and low cloud at the left hand downwind.

Upon checking in with approach the first officer again requested a right hand downwind, the approach controller denied because of low cloud. The captain thus transmitted "We understand right downwind is not available, it will be ILS down to minima and then left downwind ok."

The cockpit voice recorder subsequently recorded a discussion between the crew about a waypoint PBD10 (place #10 defined by bearing and distance) northeast of the runway, that was to be placed on radial 026 at 5nm from the CF as well as another waypoint PBD11 on radial 026 from CF.

The aircraft was subsequently cleared for an ILS approach runway 30 followed by a circling approach to runway 12.

After extending the landing gear, while tracking the ILS, the crew again checked about the weather on the right downwind, the tower replied right downwind not available, only left downwind.

The captain subsequently wanted to descend to 2000 feet MSL but was reminded by the first officer of the Minimum Descent Altitude (MDA) of 2500 feet. The aircraft levelled at 2500 feet and was flown on autopilot to RN VOR (about 0.8nm before threshold runway 30 on extended runway center line). Due to becoming visual with the runway late the aircraft turned off the localizer to join the downwind with a delay, after overflying RN VOR the crew reported visual and turned to the right to join the left downwind. The altitude bug was set to 2300 feet and the aircraft descended to 2300 feet in violation of the MDA of 2510 feet.

Following the break off the localizer the captain commented upon the suggestion by ATC: "let him say whatever he wants to say" and continued his approach trajectory defined by PBD definitions unknown to ATC. Upon query by the first officer the captain responded he was visual.

When the aircraft was 1nm south of a no fly zone the tower controller instructed the aircraft to turn left, at that time the autopilot in NAV mode was steering the aircraft.

5nm north of the aerodrome a first EGPWS caution "TERRAIN AHEAD" sounded. The first officer told the captain "this Sir higher ground has reached, Sir there is a terrain ahead, Sir turn left."

The investigation commission commented at that point: "By now the Captain had become very jittery in his verbal communication and displayed frustration, confusion and anxiety resulting in further deterioration in his behaviour."

Tower inquired whether they were visual with the airfield, no reply from the captain, the first officer queried "what should I tell him?"

The tower controller queried whether they were visual with the ground. Both captain and first officer responded confirming they were visual with the ground. The first officer again pointed out: "Sir terrain ahead is coming", the captain responded "we are turning left". The heading bug was rotated left, however, the aircraft did NOT turn. Two "TERRAIN AHEAD" aural caution messages sounded.

In an attempt to turn the aircraft to the left the captain again rotated the heading bug, however, he did not pull the heading rotary knob so that the NAV mode did not disengage and the heading track mode did not activate. The heading bug reached a selected heading of 086 degrees.

12 seconds later, 40 seconds before impact, the autopilot mode finally changed from nav to selected heading mode, the aircraft was tracking 307 degrees at that point, the selected heading mode activated. As the shortest turn towards the selected heading 086 was to the right, the aircraft turned RIGHT towards the Margalla Hills.

From that point multiple "TERRAIN AHEAD PULL UP" EGPWS alerts sounded until impact.

The first officer begged twice in succession "Sir, turn left, pull up Sir! Sir, pull up!"

35 seconds before impact the throttle levers were brought into the MCT detent and the autothrust was disengaged, the selected altitude changed to 3700 feet, the aircraft still turned right. 6 seconds after the throttles were placed into the MCT detent they were moved to the CLB detent and autothrust was engaged in CLIMB mode, the selected altitude was reduced to 3100 feet.

The first officer begged another time "Sir, pull up, Sir!"

The autopilot was disengaged, the captain provided manual inputs to roll the aircraft from 25 degrees right bank angle into a left turn. 22 seconds before impact the aircraft climbed through 2770 feet MSL and engaged in a left turn.

The aircraft rolled to 52 degrees of left bank angle, the aircraft that had already reached 3090 feet began to descend again. Nose down control inputs increased the rate of descent, autothrust reduced the engine thrust due to increasing air speed. The captain again rotated the heading knob but again forgot to pull it to activate the new heading and exclaimed "why is it not turning left?"

16 seconds prior to impact the aircraft showed a 30 degrees bank angle to the left and 15 degrees nose up attitude, that was decreasing.

10 seconds before impact the aircraft peaked at 3110 feet and began to descend again until impact. The EGPWS alerted "TERRAIN TERRAIN"

6 seconds prior to impact the first officer exclaimed "TERRAIN, SIR", the aircraft showed a 4.6 degrees nose down attitude, the captain started to make nose up inputs. 3 seconds prior to impact the EGPWS alerted "PULL UP", the first officer exclaimed "Sir, we are going down! Sir, we are going down!"

The aircraft impacted terrain at N33.74433 E73.04347 at 2,858 feet of elevation.

[H Khan]

I must say that the these members of the investigation team posses almost zero skills in technical writing. Even a novice like me could write a better structured report.

There should have being several annexes along with the investigation report plus how in the world these air force pilots are in charge of civil aviation accidents????

Majorly screwed up systems!

[Shamim Shaikh]

Simon Hradecky has just quoted the excerpts from the the investigation report. What are his own opinion/ analysis? As mentioned earlier, the full UNSIGNED report submitted to Peshawar High Court is available at
http://shamimshaikh.files.wordpress.com ... report.pdf

Will appreciate honest views and analysis by experts.

Shamim Shaikh

[fawad]

Can some ex colleagues of the Captain comment whether this use to be his usual behaviour or it was some thing unusual. If it was an unusual behaviour, what could be plausible reasons.

Shamim Shaikh

There is also the question of whether or not he actually was awake (worshiping) the whole night before the doomed flight. This could have severely impacted his capabilities and sub-standard performance.

As far as the report is concerned, it would be nice to have the actual CVR clips. However, it would be safe to assume that this is the actual conversation that took place, since court can ask for actual recordings and it would be difficult to manipulate things at that time.

And this won't be the first time when such actions by a well trained and experienced pilot led to a crash. Aviation history is full of such things...AA pilots entering the wrong cordinates and getting totally confused an lost en-route to Cali, Pilots forgetting to extends the flaps during take-off, nobody flying the plane and everyone in the cockpit trying to fix a light bulb (of landing gear), etc, etc....in fact , the list goes on and on and on.

[Shamim Shaikh]

"There is also the question of whether or not he actually was awake (worshiping) the whole night before the doomed flight. This could have severely impacted his capabilities and sub-standard performance".

During an interview to Express Tribune, the Capt's son has denied about his keeping awake the whole night or fasting. And we have no reason not to believe him.
The question then remains as to why the Capt as well as the pilot behaved in a very unprofessional manner. After reading the report (now available on CAA Website: http://www.caapakistan.com.pk/downloads ... BQ-202.pdf) I get the impression as if they were on a suicide mission.

Shamim Shaikh

[raihans]

^ i think this is the first time CAA Pak has released the ED crash report online for public

[Abbas Ali]

^ Yes Raihan, it's the very first accident report made public on Pakistan CAA official website.

The link to AirBlue accident report has been added in 'Investigation' page of 'Safety Investigation Board' section of CAA website.

Link: Pakistan CAA - Investigation

Ideally, investigation reports of all major and minor Pakistani aviation accidents that happen in future or have happened, particularly on Pakistani soil, since country's birth in 1947 should be made public on Pakistan CAA website.

In my opinion, the credit for getting AirBlue crash report made public goes to:

1) Family members of AirBlue crash victims and people like Marvi Memon for pursuing this case in court.

2) Peshawar High Court and its judges for hearing this case and for ordering CAA to submit crash report.

They have set an example for others to follow. This will encourage family members of victims of other air accidents that happened in Pakistan particularly in recent years to go to courts and get reports of those air crashes declassified and made public.

Abbas