PIA Fokker F-27 Multan Crash Report on CAA Website

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Abbas Ali
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PIA Fokker F-27 Multan Crash Report on CAA Website

Post by Abbas Ali »

Investigation report of PIA Fokker F-27 Friendship (AP-BAL) that crashed within minutes after takeoff from Multan Airport on July 10, 2006, is now available for reading/download on official website of Pakistan Civil Aviation Authority (CAA) on following link:

AP-BAL Crash Report Link: Pakistan CAA - Safety Investigation Board

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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.
6.6 Operations Analysis

6.6.1 Authorizations


6.6.1.1 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.

6.6.1.2 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.

6.6.1.3 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.

6.6.1.4 Weather was fit to undertake this flight.

6.6.1.5 The aircrew and cabin crew were medically fit and had rested as per ANO 91.0012 dated 25.05.2006.

6.6.1.6 Aircraft weighed within the prescribe weight limitations.

6.6.2 Sequence till onset of emergency

6.6.2.1 The startup, taxi, line up and run-up checks, all remained uneventful.

6.6.2.2 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.

6.6.2.3 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.

6.6.2.4 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.

6.6.2.5 After another 5 seconds, the co-pilot announced, “V1 crossed. The speed at this point was calculated to be around 108-110 Kts.

6.6.2.6 The aircraft lifted off at 120 Kts of speed, which was above the scheduled Vr.

6.6.2.7 After about 44 seconds of the take off roll, the right engine flamed out (spooled down) and auto feathered.

6.6.2.8 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

6.6.3.1 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.

6.6.3.2 The aircrew decided to continue the take off contrary to the procedures.

6.6.3.3 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.

6.6.3.4 After take off the aircrew did not raise the gears contrary to the procedures.

6.6.3.5 Because the gears were not raised and the aircraft was not wings level rather was in a varying bank, the speed started to deplete.

6.6.3.6 Consequently the aircraft stopped climbing and attained maximum of 150-160 feet AGL height.

6.6.3.7 After 40 seconds from the take off, the speed reduced to a value at which the aircraft stalled.

6.6.4 Aircrew omissions

6.6.4.1 Right from the onset of emergency, all the way to the stalling of aircraft, the aircrew took the following actions contrary to the SOPs:-

6.4.4.1.1 Did not abort on the runway despite having very clear indications for an engine/aircraft abnormality.

6.4.4.1.2 Did not announce the emergency throughout.

6.4.4.1.3 Did not raise the gears.

6.4.4.1.4 Started the engine feathering drill before 400 feet AGL, instead of taking positive control of the aircraft.

6.4.4.1.5 Did not maintain runway direction. The constant turn consequently accentuated the speed reduction phenomenon.

6.4.4.1.6 The actions of aircrew lacked professionalism, a poor display of airmanship and an extremely poor emergency handling.

6.6.5 Miscellaneous

6.6.5.1 The aircraft stalled / crashed at 1.2 nautical miles North East of the break ground point.

6.6.5.2 All 45 souls on board sustained fatal injuries due to concussions and extensive burns.

6.6.5.3 MA was completely destroyed.

6.6.5.4 The response of the crash and rescue teams was prompt and within the minimum possible time.

6.6.5.5 The valuables/ belongings of the passengers recovered from the debris were handed over to the successors by the Multan Airport Management.

6.6.5.6 The members from the AAIB (UK) France, Germany, USA, and Holland contributed immensely towards unfolding all events.

6.6.5.7 The poor emergency handling by the aircrew showed inadequacies in training/assessment system.

6.6.5.8 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. Finalization

7.1 Human Factor – Air Crew – Poor Emergency Handling Avoidable

7.2 Human Factor – Maintenance Crew – Poor Maintenance Improper Assembly of Right Engine Main Bearing Avoidable

8. Recommendations

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.
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Abbas Ali
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Re: PIA Fokker F-27 Multan Crash Report on CAA Website

Post by Abbas Ali »

6.6.2.7 After about 44 seconds of the take off roll, the right engine flamed out (spooled down) and auto feathered.
Calling it right engine, I think the report means engine# 2 (starboard side engine) was auto feathered.

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Engine of AP-BAL with feathered propeller blades. Engine# 2 ? i.e. starboard side engine ?

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The other engine had badly damaged/twisted propeller blades, an indication that they were rotating at the time of impact. Engine# 1 ? i.e. port side engine ?

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offspring
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Re: PIA Fokker F-27 Multan Crash Report on CAA Website

Post by offspring »

This report was a lot more detailed and through than the Airblue one. Comments from members related to aviation would be appreciated.

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Re: PIA Fokker F-27 Multan Crash Report on CAA Website

Post by faisal-777 »

We have a constant scapegoat for all aviation accidents in Pakistan - The Pilot.

I am not expert enough to comment on this case specifically that who is at fault. However, it's not surprising to see crew being blamed for this accident as well.
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Re: PIA Fokker F-27 Multan Crash Report on CAA Website

Post by Abbas Ali »

It's an established fact that a big percentage of world aviation accidents (fatal and non-fatal) happen due to pilot error.

However, in many parts of the world, many people see pilot as a demigod who cannot make a mistake. Also in those accidents where cockpit crew also dies, many members of general public maybe for sympathy reasons refuse to accept pilot error as the cause of accident.

Pilots are also human beings and humans are bound to make mistakes from time to time.

The Multan Fokker crash happened due to combination of factors including bad engine maintenance work, incomplete rest given to flight's captain, incorrect pairing of Captain and First Officer with low experience on F-27 and bad handling of emergency situation by the cockpit crew as mentioned in the report.

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Re: PIA Fokker F-27 Multan Crash Report on CAA Website

Post by Airborne »

I couldn't agree more here with you Abbas, after being an airline for almost 5 years as a first officer, I have come to realise how many redundancies are in every aircraft's systems, in simple words back up of the back up. I also agree that to err is human, and most of the crashes do occur due to a pilot error. However, human error can be reduced if incompetencies are dealt seriously and strongly. You'll be shocked to know how few pilots and especially female ones are often given leniency towards their evaluation as captains or first officers without realising ultimate consequencies of it regrettably.

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Re: PIA Fokker F-27 Multan Crash Report on CAA Website

Post by saadm80 »

I am Amazed because there is NO mention about WATER METHANOL at all. After Crash Engineer Found the Water METHANOL Switch on Port Side Engine 1 ON & Starboard Engine 2 Switch was OFF.
Last edited by saadm80 on Fri May 25, 2012 7:57 pm, edited 1 time in total.
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Re: PIA Fokker F-27 Multan Crash Report on CAA Website

Post by TAILWIND »

offspring wrote:This report was a lot more detailed and through than the Airblue one. Comments from members related to aviation would be appreciated.
IMO a substandard report. Did not include the required section of an aviation accident investigation report. THe analysis part is missing. Does not elaborate why did the pilots act or not act. What could be the possible human factor causes, both physiologically and psychologically. Unnecessarily blamed the 'lack of experience'. Drawn misleading conclusions with supporting facts.
Spaculative at places.

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Re: PIA Fokker F-27 Multan Crash Report on CAA Website

Post by raihans »

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Re: PIA Fokker F-27 Multan Crash Report on CAA Website

Post by Abbas Ali »

The good thing is that Pakistan CAA has begun placing accident investigation reports on its website for public viewing and I think this initiative taken by CAA deserves appreciation.

I hope reports of all future and recent accidents including Hybrid Aviation Cessna 150 and Bhoja Air Boeing 737 also get placed on CAA website when these reports get completed.

Ideally all major and minor accident/incident reports since the birth of Pakistan should be declassified and placed on CAA website for public viewing.

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Re: PIA Fokker F-27 Multan Crash Report on CAA Website

Post by TAILWIND »

Abbass or any other member may like to shed on some light on what happened to AP-BHO (ATR-42) which suffered a rwy excursion at LHE. Any report or some knowldge as to what went wrong.

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Re: PIA Fokker F-27 Multan Crash Report on CAA Website

Post by Abbas Ali »

^ AP-BHO was repaired and returned to service but investigation report was not released to news media/general public as far as I know.

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