AP-BAL Crash Report Link: Pakistan CAA - Safety Investigation Board
Broken dorsal fin of AP-BAL with letters 'BAL' visible.
Poor maintenance work and poor handling of the emergency situation by cockpit crew are blamed for the accident in report on CAA website.
All 45 people aboard the aircraft including 4 crew members died in this accident. A person on the ground also died.
Excerpts from the report.
Abbas6.6 Operations Analysis
188.8.131.52 PIA Flight PK-688 was scheduled to operate from Multan to Lahore / Islamabad, with departure time of 1200 hrs from Multan on 10th July 2006, with 45 souls (41 passengers and 4 crew members) on board.
184.108.40.206 Capt. Hamid Qureshi and 1st Officer Abrar Azhar Chughtai were detailed as the Captain and the Co-pilot of the aircraft respectively. Miss Tabana Jamil and Miss Amerah Sikander Azeem were detailed as the cabin crew.
220.127.116.11 All the aircrew and cabin crew possessed the requisite clearances and qualifications to operate the flight, however, cockpit crew were low experienced on F-27 aircraft.
18.104.22.168 Weather was fit to undertake this flight.
22.214.171.124 The aircrew and cabin crew were medically fit and had rested as per ANO 91.0012 dated 25.05.2006.
126.96.36.199 Aircraft weighed within the prescribe weight limitations.
6.6.2 Sequence till onset of emergency
188.8.131.52 The startup, taxi, line up and run-up checks, all remained uneventful.
184.108.40.206 During the roll for take off at about 60-70 Kts of speed, an unidentified pump was observed to be malfunctioning about which the aircrew showed their concern and the word pump was recorded in the CVR.
220.127.116.11 Subsequently the aircraft started to veer to the right side but the captain was able to straighten it to the runway direction in the right half of the runway.
18.104.22.168 At about 90 Kts of speed, the captain asked his co-pilot, if the right engine torque was less, to which he replied in affirmative.
22.214.171.124 After another 5 seconds, the co-pilot announced, ÃƒÂ¢Ã¢â€šÂ¬Ã…â€œV1 crossed. The speed at this point was calculated to be around 108-110 Kts.
126.96.36.199 The aircraft lifted off at 120 Kts of speed, which was above the scheduled Vr.
188.8.131.52 After about 44 seconds of the take off roll, the right engine flamed out (spooled down) and auto feathered.
184.108.40.206 Pieces of right engine turbine blades were found from 4000 feet to 6800 feet of runway.
6.6.3 Aircrew actions to handle the emergency
220.127.116.11 The sequence of events from Paras above, showed that the emergency had initiated when the aircraft was still rolling on the runway for takeoff and was at a speed much lower than V1 (a speed below which the take off is to be abandoned for any abnormality with the engine or aircraft) and the aircrew had very clear indications of the abnormal engine behavior during the takeoff role.
18.104.22.168 The aircrew decided to continue the take off contrary to the procedures.
22.214.171.124 Soon after the right engine failure the aircrew indulged in manual feathering and securing the right engine, which is forbidden unless a height of 400 feet AGL has been attained.
126.96.36.199 After take off the aircrew did not raise the gears contrary to the procedures.
188.8.131.52 Because the gears were not raised and the aircraft was not wings level rather was in a varying bank, the speed started to deplete.
184.108.40.206 Consequently the aircraft stopped climbing and attained maximum of 150-160 feet AGL height.
220.127.116.11 After 40 seconds from the take off, the speed reduced to a value at which the aircraft stalled.
6.6.4 Aircrew omissions
18.104.22.168 Right from the onset of emergency, all the way to the stalling of aircraft, the aircrew took the following actions contrary to the SOPs:-
22.214.171.124.1 Did not abort on the runway despite having very clear indications for an engine/aircraft abnormality.
126.96.36.199.2 Did not announce the emergency throughout.
188.8.131.52.3 Did not raise the gears.
184.108.40.206.4 Started the engine feathering drill before 400 feet AGL, instead of taking positive control of the aircraft.
220.127.116.11.5 Did not maintain runway direction. The constant turn consequently accentuated the speed reduction phenomenon.
18.104.22.168.6 The actions of aircrew lacked professionalism, a poor display of airmanship and an extremely poor emergency handling.
22.214.171.124 The aircraft stalled / crashed at 1.2 nautical miles North East of the break ground point.
126.96.36.199 All 45 souls on board sustained fatal injuries due to concussions and extensive burns.
188.8.131.52 MA was completely destroyed.
184.108.40.206 The response of the crash and rescue teams was prompt and within the minimum possible time.
220.127.116.11 The valuables/ belongings of the passengers recovered from the debris were handed over to the successors by the Multan Airport Management.
18.104.22.168 The members from the AAIB (UK) France, Germany, USA, and Holland contributed immensely towards unfolding all events.
22.214.171.124 The poor emergency handling by the aircrew showed inadequacies in training/assessment system.
126.96.36.199 Scheduling of both low experienced pilots (Capt and Co-pilot) for the flight, contributed to the improper emergency handling, resulting in the loss of precious lives and an aircraft.
7.1 Human Factor ÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬Å“ Air Crew ÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬Å“ Poor Emergency Handling Avoidable
7.2 Human Factor ÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬Å“ Maintenance Crew ÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬Å“ Poor Maintenance Improper Assembly of Right Engine Main Bearing Avoidable
8.1 The working efficiency of quality control at PIAC Maintenance and Engineering be improved to minimize poor maintenance and maintenance malpractices.
8.2 The airworthiness directorate at CAA should enhance surveillance of Engine Overhaul Shop at PIAC Engineering.
8.3 The Spectrometric Oil Analysis Programme (SOAP) be utilized for all engines.
8.4 A study be carried out with a view to determine the inadequacies in flying training/assessment system.
8.5 CRM training be made meaningful with participation from cockpit crew and qualified facilitators be deployed.
8.6 While scheduling, the pairing be done in a manner that at least one of the two aircrew should posses substantial experience on the type in their capacity as Captain or Co-Pilot.
8.7 PIA should institutionalize their system to study the human behaviour of aircrew with a view to pre-empt their behaviour under emergencies.
8.8 Figure of 72 Kgs of weight per person used for the calculation of all up weight in the Trim sheet be reviewed.
8.9 SIB be tasked to carry out a study to remove the inadequacies in the issuance and renewal of Certificate of Airworthiness.
8.10 Safety Division of PIAC be made more potent and effective by appointing Flight Specialists with substantial experience in Safety Program Management.
8.11 Those who failed to perform during overhaul of the engine and carrying out quality inspection and issued Certificate of Airworthiness, should be proceeded against under the existing Rules.