PIA A320 Crash Karachi

[Sikpilot]

I'll start off with not a pilot, but a career IT person with much background in machine/user interaction. The same thought came to me also after hearing so many truly knowledgeable pilots say the same thing. I haven't read through all of the posts on this thread....too many to do so. But has anyone raised the thought of something akin to hypoxia or carbon monoxide poisoning? These were not two rookies, and yet their behavior is beyond anything any pilot could imagine taking place in a commercial airliner. Could some fault in the pressurization or environmental systems cause them to be disoriented or partially incapacitated? It just does not seem possible that they could have made so many bad decisions along the way without realizing they were getting deeper and deeper into trouble and taking some corrective action. The fact that, as ferry pilot stated, they made so many deliberate actions that were all wrong begs for a better explanation other than they thought they could get away with it.

Probably because they have been getting away with it all along. I would think the problem starts at the top at this airline and as a pilot, there is NO CHANCE you will be called in to the Chief pilots office because the plane told him you landed the aircraft and never stabilized the approach.

[KingAir1978]

Could some fault in the pressurization or environmental systems cause them to be disoriented or partially incapacitated?


Patrickal, Airbus has NOT given a technical recommendation. If there had been a problem with the airplane, they would have at least given a recommendation or comment. A possible line of inquiry would be the blood sugar levels of the pilots, as they may have been fasting, because of Ramadan.

[Rednerib]

By psychiatric test they mean psychological profiling. It is not fool proof. Moreover he has been in the business of aviation for 30 odd years and have logged 17000 hours. Psychological tests are very subjective and gives out very generalised opinions. Apart from Defence forces I doubt if it is being used anywhere else. The report (31 year old) is no reflection of pilots health as of today.

In my opinion it was a very rare occasion when small small issues aligned to gradually take the pilot into this mess. Ego, complacency, gap in flying, empty sky, over confidence and simply oversight made them high and hot. Thereafter they tried to catch up with it and in rush of things the two pilots went out of synchronisation. The number of parameters that they were juggling were simply beyond their cognitive abilities. Still seeing the runway straight ahead they thought they can salvage the approach.

Things would have worked out (in pilots opinion) but because of one aspect, gear, which he thought was down. I think the pilot all the time thought that the gear was down. Perhaps it could be on the back of his mind that in case they land too long he will go round. Moreover human is capable of doing something which escapes explanation. I feel sad for the Pilot monitoring who could not muster enough courage to challenge the pilot. I think it is an organisational issue.

[parkfell]

Probably because they have been getting away with it all along. I would think the problem starts at the top at this airline and as a pilot, there is NO CHANCE you will be called in to the Chief pilots office because the plane told him you landed the aircraft and never stabilized the approach.

To complete an overall picture for the Airbus fleet, apart from FDR / FDM which might have been available, ask ATC at the various national airports as to the ‘style’ of the approaches generally.
Any “Pony Express” mentality?

Had the radar recordings prior to this tragic avoidable event been analysed (preserved for 30+ days before used again?) then a clearer picture would have emerged as to the modus operandi of PIA.

As for the concept of failing the psychometric testing prior to employment, appealing to a Tribunal, who can then instruct the employer to enrol them....more questions than answers....wonder if his training records any unusual qualities...? Just who was he?

[ferry pilot]

Despite all the evidence available, all the time that has passed and all the expert opinion offered on this forum, there has been no solution to this mystery. We know what happened, but we do not know why. So we speculate.
Having ruled out almost everything else, it looks like the pilots broke all the rules and tried to fly the airplane so far outside its operating limits and their own, they crashed it. In the worst case, they were having a little fun, playing a dangerous and illegal game that got out of hand. Hard to believe, but if there is a more forgiving explanation on the cockpit voice recorder we should be hearing it sooner rather than later.
If not, and this awful conclusion turns out to be correct, this crash was not an accident. It was a systemic failure. We don’t speculate on that. Or at least I don't

[ETOPS]

there has been no solution to this mystery.

We need to "hear" the CVR in full.
By this I mean a properly translated record that captures the nuances of the language used in the technical environment. I would guess only a fellow native speaking Airbus rated pilot would be able to get the subtleties of the interraction between the crew and ATC.

Just the R/T side leaves too many questions.

[Uplinker]

.......... But has anyone raised the thought of something akin to hypoxia or carbon monoxide poisoning? These were not two rookies, and yet their behavior is beyond anything any pilot could imagine taking place in a commercial airliner. Could some fault in the pressurization or environmental systems cause them to be disoriented or partially incapacitated?

Yes, I suggested this a while back. Undetected fumes, e.g. CO, undetected food poisoning, undetected depressurisation.

My reasoning, like yours, is because the actions of these pilots were not just accidentally negligent - they were deliberately and therefore criminally negligent. Why would two pilots be criminally negligent unless they were mentally compromised in some way?

I don't buy the assertion that the pilots were discussing Covid19 for the last 30 mins either.

Maybe the Captain's son was in his seat driving Daddy's plane, and it got out of hand before the Captain could get back in his seat? I hope not.

[ATC Watcher]

We need to "hear" the CVR in full.
By this I mean a properly translated record that captures the nuances of the language used in the technical environment. I would guess only a fellow native speaking Airbus rated pilot would be able to get the subtleties of the interraction between the crew and ATC.
Just the R/T side leaves too many questions.
I will not be too hopeful the public will "hear" the CVR. The tendency nowadays in recent major reports to avoid media interpretation ( and probably ours here as well seeing some of the posts ) is to release only an edited transcript ..Some countries have even now prohibiting the publication of CVRs ,I do not know what the current law in Pakistan is .
As to the ATC R/T divulged on internet immediately after the accident , as I mentioned at the beginning here, for me it looks like there are transmissions missing ( not recorded) just like it was in the Kathmandu Dash 8 accident.

[clark y]

This sequence of events leading up to this accident is not unique.
For anyone interested read up on Garuda flight GA200 into Yogyakarta, Indonesia.

[WillowRun 6-3]

SLF (expanding into aviation law)
Isn't there a case in this exact kind of situation for the full CVR output to be made available to an authorized and official inquiry group to vet for some public disclosure? -- and for this to happen much quicker than the routine process of a full AAIB review and report?
Reason for advocating faster process in this situation has two parts. First is the fact that the globally widespread standing-down of civil aviation holds at least some prospect of decrease in overall performance attributes of returning pilots. Not all, and not necessarily serious where it does occur, but the situation is truly uncharted territory (isn't it?) and so a measure of urgency appears justified, despite the standard rule of waiting upon the final report. Second, whatever the truth turns out to be about why this accident occurred, the fact is that, today, it presents unknowns beyond the stock or catalog of occurrences with tragic results. I mean, probably dozens of very highly qualified aviators have weighed in on-thread about how the badly unstabilized approach, and how many if not mostly all of the two pilots' actions (or omissions of actions), just don't make any sense. (I'll rely on this second factor alone if the first one is too ill-informed.)
As for a vehicle within which to make this quite atypical disclosure, well Annex 13 isn't carved in stone (ask the Iranians . . . ) and so it "**should**" be possible and even feasible to create a subgroup, and to have the equivalent of what we do in courtrooms in the U.S. -- in camera review, where only the judge and his or her staff see the material, and then decide what -- if anything -- can be put on the record. I quite realize this process doesn't exist at present. But….some combination of 'necessity is the mother of invention' with 'hard cases with allegations of bribery in the background make uncomfortable law'.

[compressor stall]

Yes, I suggested this a while back. Undetected fumes, e.g. CO, undetected food poisoning, undetected depressurisation.

My reasoning, like yours, is because the actions of these pilots were not just accidentally negligent - they were deliberately and therefore criminally negligent. Why would two pilots be criminally negligent unless they were mentally compromised in some way?

Have you been fasting too?

I do not believe for a second that the crew decided to land wheels up.
Hard as it is for those of us who fly in another hemisphere and culture, this sort of cowboy flying is not uncommon. Stable approaches are for the weak.
I can't say that they weren't incapacitated of course - and that still may be the case - but don't feel pressured to make up scenarios just to excuse what you or I would call incompetence and recklessness that subsequently leads to an accident.
I don't buy the assertion that the pilots were discussing Covid19 for the last 30 mins either.
It was on the CVR?
Maybe the Captain's son was in his seat driving Daddy's plane, and it got out of hand before the Captain could get back in his seat? I hope not
Really?

[clark y]

I think the Daddy's plane comment is a reference to Aeroflot 593.

That accident occurred after the pilot let his son have a fly of an A300 Airbus.

[parkfell]

.....I would call incompetence and recklessness that subsequently leads to an accident......

Their mental state is central to this tragic crash. I would suggest that during the (late) descent the chemical and electrical pathways in the brain were such that an ‘abnormality of the mind’ occurred. The psychologists views on the CVR will be interesting.

As to why this occurred is at present subject to conjecture ~ fasting, dehydration might be two routes to explore? Toxicology report awaited.

As far as has been disclosed in 22 June report, no evidence of fumes in the cockpit / decompression.

The jigsaw is far from complete.

[compressor stall]

I think the Daddy's plane comment is a reference to Aeroflot 593.

That accident occurred after the pilot let his son have a fly of an A300 Airbus.
I got the reference, just wondering its relevance here?

[compressor stall]

Their mental state is central to this tragic crash. I would suggest that during the (late) descent the chemical and electrical pathways in the brain were such that an ‘abnormality of the mind’ occurred. The psychologists views on the CVR will be interesting.

As to why this occurred is at present subject to conjecture ~ fasting, dehydration might be two routes to explore? Toxicology report awaited.

As far as has been disclosed in 22 June report, no evidence of fumes in the cockpit / decompression.

The jigsaw is far from complete.
yes all the pieces of the puzzle need to be searched for. Some may be found. We don’t know how many pieces there are yet.

But as it stands we have:

a distracted crew from COVID,
not very current
missed the TOD from (1)
possible pride “real pilots don’t orbit or go around”
meek FO
gear out at 7k to help descent
gear up on GP intercept (meek FO moves the handle the only way it will go, maybe getting confused for a go around?)
Approach waaay to fast and no Dangling Dunlops that normally slow them down when they might have done this before.
real pilots don’t go around. That’s embarrassing.
oh crap the gear is up.

I don’t think this scenario “needs” a fumes event factor.

There may be one, I can’t say there is t just as you can’t say there is. But there’s enough in the list above not to need one.

I have sat at at the holding point in India on a 2000m runway. Pretty much half way along the runway. We were waiting for the arrival on an aircraft inbound so we could enter and backtrack. It was a bit over 10 years ago, actually right in the midst of the last fake pilot scandal.
We commented how high the aircraft was on final.... we sat waiting for the go around. It never came. The 320 was well past us before it touched down.

[parkfell]

....... Still seeing the runway straight ahead they thought they can salvage the approach........ I think it is an organisational issue.

Clearly they thought that. It was insane to think it could be ‘salvaged’, even if the gear had been down.

Perhaps the original psychometric testing had revealed an important characteristic?

[Euclideanplane]

As Rednerib also points out above, this Twitter post is way over the top. A psychometric test does not address "psychiatric issues". And the conclusions based on a test made more then 30 years ago have little or no validity that concerns the present day individual.

[Rednerib]

I am trying to see things from their point view. I agree that the approach had no chance of resulting in safe landing even with undercarriage down. But had undercarriage been down they would have been saved doomsday as after landing they could have sat on brakes and may be overshot the runway or in other case they would have gone round safely after touch down too. I do not fly this aircraft but I do feel the pilot did see some scope of forcing a landing. How that the gear was not down was the weakest link which was missed out. When I say this I do not by any stretch of imagination approve of such acts. The approach , sensibly should have been aborted. Thanks for your reply.

[vilas]

Compressor stall
Something is misfiring here. 2000m runway you are holding at halfway and an A320 flashes past you and touches down after that and stops in remaining say 800m? Some Airbus I must say.

[PPRuNeUser0171]

Parkfell :

Which lessons in this case ? Go around if not stabilized by 1000 or 500 ft ? already there. but to be cynical , it does not matter which recommendations comes out of any report , they all fade away . I was a bit involved in Teneriffe, lots of good recommendations came out at the time ,but it took a few years to implement the " line up and wait " phraseology , and even then our US friends did not like it and it took decades to convince them ... Learning from others mistakes and implementing changes is one of the most difficult things in aviation ...

From what I understand of this crew, such a recommendation would have been ignored because they weren't exactly following checklists or doing any CRM at all so you can change the checklists all you like. You can add more bells and whistles, you can add flashing lights but just because of human nature and the ability to be single task focused it will all be ignored.

[compressor stall]

vilas

I’d have to go back through emails to find the charts to give you the exact distance from back then as they were restricted distribution (military / civil) and the airport and runway has since been upgraded as I went to measure the distance on GE just now.
We were shouting and waiting for the crash. Obviously light and hard on the anchors.

[parkfell]

Euclideanplane

If the final report leaves no stone unturned, then his whole training history including the selection process, and latter development will shed light on those aspects of the jigsaw puzzle yet to be revealed.

If he had “psychiatric issues” or an abnormal personality, how was it possible to obtain an Initial Class One Medical?

[Uplinker]

Have you been fasting too?

I do not believe for a second that the crew decided to land wheels up.

No, you misunderstand me. By not sorting out the late hot-and-high descent when they had plenty of time and airspace to do so, and after ATC suggested this several times, including a direct instruction to turn away from the approach - that was the negligence by the pilots.

Continuing a landing attempt while not configured, not on speed, barely on profile, no landing checklist completed and not stable - that was negligence too.

Of course they did not intend to crash, but I have tried to think why a supposedly fully qualified and experienced crew would get so badly out of shape, yet still continue to a frankly suicidal landing attempt. I don't believe they intended to land gear up either. That got missed because they were at least 20nm behind the aircraft.


It was on the CVR?
Was it? Have you actually heard the CVR? Could the Covid comment by (I forget which official) be an attempt to distract us from extremely poor piloting? - not that it would be any excuse.

Really?
I don't know do I? hence I said 'maybe'. It has happened before. I am just trying to imagine why this crash happened. Why did the pilots not break off the descent and sort themselves out and make a proper approach? I am just trying to think what could possibly have happened on that flight deck that resulted in such a tragic and fatal crash.

[compressor stall]

Ok, now it’s a bit clearer.

have tried to think why a supposedly fully qualified and experienced crew ... still continue to a frankly suicidal landing attempt.
my feeling is that it starts with “cul” and ends with “ture”

[Rednerib]

I agree too many things bundled up together. About the incident in India which runway are you talking about? Just curiosity as I am from India. Rare but such things (total break down of human machine) do happen once in a blue moon and we land up with such accidents like PIA 8303. There are just too many cognitive biases we all are susceptible and not even aware of. While we as human would consider us as superman but the fact is that we are the weakest link in this human machine interface. Pilots swear by their ability to juggle multiple tasks while flying but the fact is that human as species just can not multitask. Most of the times we are not aware of of our inherent limitations. Juxtaposing this limitation with the scene in side PIA 8303 there is no doubt that the crew would have been mentally saturated by the number of events taking place.

[ferry pilot]

The truth is on the tapes. And in the minds of those who knew this crew. They were hired, trained and checked by professionals, some of whom may be shocked but not surprised by this event.
The disruption caused by the current pandemic has upset everything in the industry, including subtle but essential unspoken rules. Some pilots should never be scheduled to fly together

[Black Pudding]

I have to say I have flown several times with Pakistan Nationals and on all occasions found them to be very competent and professional. I would go as far as to say much better than most other nationalities I’ve flown with. Do not judge all by the unfortunate behaviour of a few. Do not judge a person simply because of their nationality.

I’ll also stick to my original post a few weeks ago. I simply think this accident occurred because of the maverick attitude of the Captain and the lack of confidence in the FO to speak up and intervene.

PIA need a good kick up the arse and need to get outside help to get their shop in order and I think it should start with MCC and CRM.

[homebuilt]

According to this tweet from an American expat in Pakistan (she famously claims to be a #MeToo victim of local politicians), the PK8303 captain had failed a psych test when he first applied to PIA as a Cadet Pilot. He appealed and a Sindh judge ordered him hired.

https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/2000x995/ritchie_2_e1a80ee0d724dcae64e4189c99975f492cb09aa6.jpg

The guy applied as a Cadet with PIA ?? I thought he was a former military pilot...

[Rednerib]

Interesting observation. Crew compatibility?

[Rednerib]

I agree. I have read many accidents from all over the world which are as bizarre and unthinkable.

[FlightDetent]

No, sir. Of all I could remember, the crews were trying to avoid hazard and save the aeroplane, even if those actions did on occasions seal their fate. Not this one.

This crew landed the aircraft inside the overspeed range, beyond the redline on the speed-meter, about 140 km/h faster than normally acceptable. Imagine yourself parking a car into a garage with a sideways-folding door that'd be unlocked yet closed. Right through them and doing 20 mph with gear engaged! That is the civil life equivalent of how they approached the touchdown zone. Dead serious, no joke.

Neither of the two, sad to say, was fit to act in the role of an Air Transport Pilot that day.

(Let's forget the gear, that is not beyond imaginable - double selection leading to a reversal of the assumed position, under mental overload.)

[Airbubba]

Whatever the excuses trotted out, covid etc, truly shocking levels of incompetence.

Yep, the excuses will become ever more convoluted with time. :ugh:

We must pretend that this could happen to any of us, low blood sugar, some warnings were inhibited, we must not judge from a Western cultural perspective etc.

And, I realize that the report must come up with some convenient fiction to explain away this idiotic Banzai Kamikaze flight profile. They did not know, the controller didn't tell them that they shouldn't cross the threshold at 210 knots gear up, the cabin crew didn't tell the captain that the engines scraped.

I realize that very few folks here are professional pilots so I hope my criticism doesn't sound insensitive or harsh. The PIA crew were good people who made poor choices and were trying to turn their lives around when the engines quit.

I remember flying in the Third World decades ago with a Pan Am captain named Doug. He was a grizzled old Marine, gruff and to the point. When I would be amazed at how screwed up things were in the air and on the ground he would comment, 'What you have to remember Airbubba is that these people are not from Chicago!'

[Euclideanplane]

And, I realize that the report must come up with some convenient fiction to explain away this idiotic Banzai Kamikaze flight profile. They did not know, the controller didn't tell them that they shouldn't cross the threshold at 210 knots gear up, the cabin crew didn't tell the captain that the engines scraped.'

Minister Khan seemed to have sorted all that out already. Only thing the rest of us are still unaware of is what omissions were made by the passengers.

[LookingForAJob]

Pilots swear by their ability to juggle multiple tasks while flying but the fact is that human as species just can not multitask. Most of the times we are not aware of of our inherent limitations. Juxtaposing this limitation with the scene in side PIA 8303 there is no doubt that the crew would have been mentally saturated by the number of events taking place.OK, if humans cannot multitask, we can call it time-slicing. The fact remains that on the face of it, this crew were unable to manage their aircraft in a situation where the vast majority of other crews would have been so able......and probably would not have got themselves into any one of the multitude of adverse situations that arose on the day of the flight.

[FlightDetent]

... very few folks here are professional pilots so I hope my criticism doesn't sound insensitive or harsh. And you have not even started. Here's one for you, they did narrowly missed a school. Pin at the crash location. (https://www.google.com/maps/place/24%C2%B054'42.6%22N+67%C2%B011'16.8%22E/@24.9116101,67.1877591,245m/data=!3m1!1e3!4m6!3m5!1s0x0:0x0!7e2!8m2!3d24.9118199!4d67.18 79909) Zoom out and then there's no need to tell each other which dots need connecting...

[Loose rivets]

I doubt anyone that was sounding like Joe Cool, would be suffering from hypoglycaemia. Their bold, erm, and spelling.


These are often called the “warning signs” of hypoglycemia. Lack of glucose to the brain can cause trouble concentrating, changes in vision, slurred speech, lack of coordination, headaches, dizziness, and drowsiness. Hypoglycemia can also cause changes in emotions and mood.

I've told so many tales of bewildering things happening that you might think I'm not fazed by this accident. But I am. Bewildered. I can usually come up with some bit of lateral thinking that would explain things, at least is someone's universe, but not for this. Given their speech wasn't slurred (ATC data) then there's not much left but a native incompetence that has been rescued time and again with automation. But I somehow I even doubt that.

[gums]

Excuse me if I do not unnerstan the ROE here.

I see countless posts about ethnic and political characteristics of various airline crews. I do not like that, but it is likely a fact of life that crews will tend to follow their background for many aspects of their professional performance. I also do not relish reading opinions about how incompetent a crew is until all the facts are known - wait until it's your eulogy at the funeral, huh? I'll meet you at that neat bar in the sky for a beer.

So an attempt to get all the crapola outta the way and talk about some technical and FCOM procedural things concerning gear up/down, go around, etc, was deleted over on the "tech log". Beats the hell outta me, and lots less ethnic and political discussion. Seems we could discover how the 'bus gear up/down criteria works and other stuff that may be a factor in the crash.

But what do I know? I just wanna have a happy feeling next time I fly in one of those jets.

[cavuman1]

Fife by, Gums!

[Lookleft]

Bewildered. I can usually come up with some bit of lateral thinking that would explain things, at least is someone's universe, but not for this. Given their speech wasn't slurred (ATC data) then there's not much left but a native incompetence that has been rescued time and again with automation. But I somehow I even doubt that.
Loose rivets is online now Report Post

The only thing I can come up with is that the crew panicked and were no longer capable of thinking logically. Was it fear of punishment if they went around? Was it stress from being stood down and thinking they would be out of work again? No-one will ever know. I don't agree that it was native incompetence but in my mind the only thing that can explain such irrational decision making is panic by the PIC which affected the F/O. How do you counter that? I don't think you can as it is an individual response and will only manifest itself in unusual circumstances.

[iceman50]

GUMS
Seems we could discover how the 'bus gear up/down criteria works and other stuff that may be a factor in the crash.

If it had been a factor Airbus would have issued a Technical Notification to all airlines. Unfortunately some "pilots" can screw up royally, probably did not set out to do it but did. Recognizing you have messed up and doing something about it is what makes a "professional" pilot, not "pressonitus".

[FlightDetent]

Excuse me if I do not unnerstan the ROE here. Fair call.

gums, any thoughts about the crashing technique?

Cactus 1549 was brought back down at full AoA limiter. PIA8303 seem to have stalled in. Approaching with a right circuit, topography suggests there were other choices available for a controlled crash-landing. The undershoot of 25R for instance.

Does your ilk receive any training in that apart from the ejector seat, which might be beneficial for the busdrivers among us?

[vilas]

The thinking process had stopped from the time they kept saying we are comfortable. There's a possibility that they never realized they landed on the Engines because why would they pull reverse? and they went around only because they had doubt about stopping. That's why they asked for another radar vector. Had they realized landing on Engines then they may not have gone around or if they did they would have asked for visual circuit and definitely made it to the runway.That's why perhaps they are involving the cabin crew about not informing them of landing without gear. Also their gear operations appear more like habit interference. First approach they raised it normally they would lower it. After GA they would raise it but lowered it and then realizing it put the lever up. More of mechanical actions that at this altitude gear status has to be changed. Lots of grey areas if they raised flaps it should go to 1+F. If Both engines failed then gear should have been lowered by gravity but there's no evidence of that.
And does ever a discussion take place after the full report is out because in the years that it takes the focus shifts to more recent ones. If report is going to take years it's useless because some more accidents could have taken place due to same causes.

[Goldenrivett]

I can usually come up with some bit of lateral thinking that would explain things, at least is someone's universe, but not for this. Since the crew had selected the gear down early and declined ATC help suggests to me that they were indeed comfortable with their position. I wonder if they had done similar types of approach before? If the gear had remained down at the 5 mile point then perhaps we wouldn't be having this discussion and PIA's lack of data monitoring would have gone unnoticed for a lot longer. (see post 12 of "PIA banned from Europe" which shows EASA reason for the ban).

I suspect the gear was raised in error at 5 miles because PF normally called for gear at that point (learned reflex) and the PNF normally moved the gear lever. When the aircraft ceased to decelerate as expected, then confusion overloaded their last brain cell.

I'll wait for the CVR and accident report with interest.

[olster]

Gums you of all people surely understand a robust debrief. I believe that in the military a no holds barred approach is used where opinions are direct. Mistakes are admitted. Shortcomings acknowledged. How to make it better next time. Ok off to the bar.
This used to be how it worked in civil aviation until (picking my words) a more ‘sensitive’, no hurt feelings etc style , was introduced for a whole set of well documented reasons. So, let us say you were assessing this accident in the simulator without the inconvenience of all the lives lost. What would you say to every rule broken? Stabilised approach criteria busted by a mile. Going around after selection of reverse thrust? Those are definitely fail items! So the ROE are analysing all that without upsetting anyone.

By the way I really do enjoy your posts, amusing and to the point.

Cheers

[ATC Watcher]

There's a possibility that they never realized they landed on the Engines
I doubt anyone here has ever landed an A320 without gear , except perhaps in a sim , but having had this unfortunate experience on a GA aircraft , I can tell you you cannot miss it ,the lower than normal position on touch down , lack of suspension makes the actual landing quite harder , the faster deceleration with vibrations and the noise...
I realize the main gear on an A320 is not that much higher than the cowlings, but still with a few hundreds landing under the belt on the type you should notice the difference, OK, a hard landing can be the same as on wheels and not sure if the eventual pressurization remaining would suppress all that noise, but the vibrations caused by the scraping should be felt and the deceleration quite abnormal..So I doubt they did not notice..

[vilas]

I doubt anyone here has ever landed an A320 without gear , except perhaps in a sim , but having had this unfortunate experience on a GA aircraft , I can tell you you cannot miss it
The way this approach was flown so many warnings, visual staring in the face, audio warnings driving them deaf were ignored, there's absolutely nothing that one can say you cannot this or cannot that. Everything is in the realm of possibility. All posters by now know what happened but they are desperately trying to find some method in the madness. That's all.

[Clandestino]

We must pretend that this could happen to any of us, low blood sugar, some warnings were inhibited, we must not judge from a Western cultural perspective etc.

Yeah! We need to throw away all the PCishness and ask ourselves the hard question: would the crew originally trained by the USAF ever be able to plonk their DC-9-32 N10556 onto the KIAH runway 27, gear up, at Vapp+61 kt and let it slide 6850 ft down the runway till it stops in the grass, 140 ft left of the runway centerline?

[vilas]

I'll wait for the CVR and accident report with interest
golden your patience will be tested for sure. Their last fatal was in 2016 report is not yet out. May be EASA ban will expedite matters in this case.

[farsouth]

Yeah! We need to throw away all the PCishness and ask ourselves the hard question: would the crew originally trained by the USAF ever be able to plonk their DC-9-32 N10556 onto the KIAH runway 27, gear up, at Vapp+61 kt and let it slide 6850 ft down the runway till it stops in the grass, 140 ft left of the runway centerline?

Here’s a link to the report on the accident referred to above. A lot of similarities, and certainly shows that the PIA accident cannot only be blamed on a non-“Western cultural” mindset.

For those who don’t wish to read the whole Houston DC9 report, the Co-pilot (PF) realised the flaps had not deployed, and that they were way too fast, (but not that the gear was not down)

Five seconds after the captain rejected his go-around request by stating “no you’re alright,” the first officer said “I can’t slow it down here now.” The captain again stated “you’re alright,” and the first officer replied “we’re just smokin’ in here.”

The Co pilot three times suggested going around before the captain took control, and landed, gear-up, at 40kts above the flaps up vref, and >60kts above the vref for the selected flap setting.

Both ex-USAF pilots.


https://reports.aviation-safety.net/1996/19960219-0_DC93_N10556.pdf

[Lonewolf_50]

Yeah! We need to throw away all the PCishness and ask ourselves the hard question: would the crew originally trained by the USAF ever be able to plonk their DC-9-32 N10556 onto the KIAH runway 27, gear up, at Vapp+61 kt and let it slide 6850 ft down the runway till it stops in the grass, 140 ft left of the runway centerline? Number of fatalities in that accident in 1996 was, let me check, oh, yes, here it is (https://aviation-safety.net/database/record.php?id=19960219-0): 0
"Any landing that you can walk away from ..." :E (But I'll go with 'sometimes, better lucky than good' on that one)
The Co pilot three times suggested going around before the captain took control, and landed, gear-up,
One would hope that in the last quarter of a century, CRM has improved a bit at Continental.

Is learning from someone else's mistake acceptable, or must one make one's own mistake to learn the same lesson and then decide "Yeah, that could happen to me too"?
Answers on a post card, if you please.

[WillowRun 6-3]

The strength of the international civil aviation system including the parts of it within the area of 'public international air law' derives in major part from the sovereign capacity of each country to work through official processes as it best sees fit - in this instance the Annex 13 official AAIB report of course. But a weakness of that same international civil aviation system derives from that sovereign and independent capacity - it's not actually too realistic to expect someone in a position of authority to pick up a phone to call somebody in Pakistan and put a boot in a backside to get the report done in a lot less time (and still done properly). As I have said earlier there really isn't much imagination required for the system (as described above) to lose its virginity and have a subgroup of the AAIB under Annex 13 plus a select few professional people (like, huh, hey about EASA, they're sort of interested already, no?) join in, and hear the entire CVR output. Not public dissemination, but whose important stake in civil aviation safety globally could possibly suffer if the preliminary report is supplemented with some significant additional information from that evidently critically important CVR output??

With the speed with which places like forum threads dig into accident facts as they emerge and yield up a great many insights even as just based on partial information, one would think the investigation process cannot stay in slow motion. I'm an SLF certainly but I've traveled by air since I was less than 2 years of age (that's a fact) and something like this accident which sends pro pilots scratching their heads in bewildered or at least quite puzzled concern is not the norm, not even close. So the post by vilas about not waiting, I'm on that bandwidth.

And as for Goldenrivetts postulating a wrong-directional push of the gear lever, based on a routine call-out having been made despite that call-out having been obviated by previous action (if I read that post right), if that is what turns out to have occurred, well it'll be a case of aviator daydreaming or sleepwalking. This is not a matter of cultural factors but it is a matter of whether you're playing in a realm where rigor counts or it does not.

(And Toulouse says nothing about an aircraft issue, that speaks volumes, does it not?)
WillowRun 6-3

[gums]

Thank you, Olster. And good stuff from vilas ( 95% of the time, LOL). And point taken Detent.

My goal was to get over to the tech log and talk about the profile and the gear logic. Someplace it was mentioned that you couldn't lower the gear above "xxx" knots, and I unnerstan that. But then what happens when it's down and you exceed "xxx" knots? Does HAL raise the gear?

Simple question, but instead the thread was deleted and over here with armchair aviation afficianodos and a few real pilots/crew we still keep harping on ethnic and cultural crapola. I know that those elements of the bidness can play a role in accidents and just as well as super airmanship. I would prefer the cultural stuff to stay here and get the technical stuff over on the technical forum.

As far as the military debriefs go, the first 737 crash would not have happened in any unit I ever flew with if we flew that type. Good friggin' grief. To fly a leg with the shaker going and turning off stuff to fly completely manual ( glad those folks could do it for the sake of the SLF riding behind them), and then not putting that into the maintenance log? BEAM ME UP!!! Whenever we had a strange thing happen we talked about it. We also spared no feelings when debriefing the sorry performance of any of us. No room for a thin skin or PC stuff, none.

@detent We indeed have a few "light" types that have ditching or dead stick procedures - very few. I only flew three with the dead stick procedure and did it for real one day. We also had procedures for landing with partial gear down. I would have had no qualms about setting down the Viper in the weeds, but a water ditch would be very problematic due to the intake position. The A-37 could easily be set down on most corn fields/ rivers and you could walk away. In any case, I appreciate the "heavy" folks that don't have the nylon letdown that I had for so many years.

[Lonewolf_50]

My goal was to get over to the tech log and talk about the profile and the gear logic. Someplace it was mentioned that you couldn't lower the gear above "xxx" knots, and I unnerstan that. But then what happens when it's down and you exceed "xxx" knots? Does HAL raise the gear? That was discussed in this thread a few dozen pages ago, and I think that the consensus was 'no' (and IIRC the rationale was 'it would damage the gear doors if the system did that at speeds in excess of the limits from the manual ...). Go back about a week or two in posts and I think you'll find the discussion on that. Starts at around page 28, something about a logic gate based on IAS of 260 knots.
Simple question, but instead the thread was deleted and over here with armchair aviation afficianodos and a few real pilots/crew we still keep harping on ethnic and cultural crapola. . I think that part of Clandestino's point was that an unhealthy cockpit gradient can happen anywhere.

[Airbubba]

The Co pilot three times suggested going around before the captain took control, and landed, gear-up, at 40kts above the flaps up vref, and >60kts above the vref for the selected flap setting.

Both ex-USAF pilots.

And the captain was a former FAA Air Safety Inspector. 'Watch this...'

[FlightDetent]

L/G won't come down above certain speed, due to hydraulic being de-powered.

If the wheels are out, and you dive above V(lo), the hydraulics will at best cut off again. No autoretract fitted, let alone a gravity one. 😊

[vilas]

Auto retraction simply not possible and even the concept is illogical. VLE is 280kt. retraction speed is 220kts. If it doesn't allow you to lower beyond 260kt. why will it retract?

[gums]

Good point(s), Vilas.

My concern was that HAL may have retracted the gear on the initial approach attempt with no pilot action. e.g. they had gear down but then speeded up above "xxx" knots. I don't know of any plane that lets HAL retract the gear without a pilot command, but there some that do not send the gear handle signals to the hydraulics without a signal from the WoW switch, huh? Sorry I have not seen all the plots of data from the FDR, and lost the FCOM I had downloaded back in 447 days.

I still would still like to see this discussion on the Tech Log and let the management and other stuff stay here.

[FlightDetent]

Vilas, we're saying the same thing.

gums, the A320 is a very conventional design, no HAL. Although the FBW has hard limits at the envelope's edges.

The raising of the gear and retraction of speed-brakes at 5 NM on the first approach, is consistent with crew wanting to put the gear down but not realizing it already was. So the handle was just moved the other way.
The G/A gear flick DN and UP identically so.

It has happened before (*). If it was not for the overspeed clacker, they would hear and see the ECAM warning. If it was not for the high speed, the GPWS would have told them as well.

[ferry pilot]

This was an approach like no other, but it must have been carried out that way for some reason. No matter how pointless it appears to have been, it was not pointless to the pilot. Or the first officer so it seems.
There has been much discussion on this forum about the gear, and what would happen in the case of overspeed and gear selection.
If you were not sure what the gear would do, you could try cycling it at high speed. With a long enough runway and a compliant copilot, why not try it and see what happens? Why not indeed.
This accident makes no sense whatsoever except for this. If an attempt was being made to settle an argument regarding gear selection and overspeed limits, it is not so strange at all.

[gums]

Sorry, Detent, but that dog won't hunt.

the A320 is a very conventional design, no HAL. Although the FBW has hard limits at the envelope's edges.

I am more familiar with the 330 due to the 447 discussions some years back, but your FBW has a lot more modes and submodes and "shaping" algorithms of control surface movement and rates than so-called "protection" at the edges of the envelope. e.g. bank angle and other limits vary according to which "alternate:" law you are in until "direct".

The raising of the gear and retraction of speed-brakes at 5 NM on the first approach, is consistent with crew wanting to put the gear down but not realizing it already was. So the handle was just moved the other way.The G/A gear flick DN and UP identically so.

My diagrams of the instrument panel seem to show a handle and adjacent indicator just above the center pedestal. Clearly marked "up" and "down". So your last minute checks don't involve touching or visually verifying the position and the lights?

If it was not for the high speed, the GPWS would have told them as well.

I thot HAL knew if gear was down for a landing and the FBW was switching into the "flare" mode at "x" altitude above the ground/runway. So can I perform CFIT by just getting above "x" speed with gear up? Somehow, I thot GPWS/HAL would have said something. "Dave? Sure you wanna try this?" I gotta admit they "greased it on", but maybe that was because they were not in "flare" mode, which seems to be almost pure "direct" law with "heavier" pitch command deflection.

Oh well, back to the Tech Log.....

[Euclideanplane]

There has been much discussion on this forum about the gear, and what would happen in the case of overspeed and gear selection.

From the report it seems they hit a maximum of 258kts IAS at 2000ft just before the indicated retraction of L/G. In which case the 260kts overspeed limit should not become an issue, so far as L/G is concerned.

That aside, I am curious about a small difference in the report concerning the landing gear controls.

The report at 7221ft determines that the FDR "indicated action of lowering of the landing gears".

At 1740ft the FDR "shows action of raising of the landing gears" and "the landing gears and speed brakes were retracted".

Does it mean that between 7221ft and 1740ft we cannot tell from the FDR evidence whether the L/G was actually extended, even if there is evidence to show that action was taken to lower it?

[tdracer]

Gums, if you go back 20 or 40 pages (:sad:) there is a discussion about the gear up warning. Apparently, above 210 knots, the warning changes from 'Too Low Gear' to the GPWS 'Too Low Terrain' (or words to that affect) based on the assumption that if your going over 210 knots, you're probably not trying to land. Assuming they got the 'Too Low Terrain' warning, it would be somewhat understandable if the pilots dismissed it as a nuisance since they thought they were landing.
I presume similar flight control logic would have come into play (or not come into play) since the gear was up and they were going to fast.

[gums]

Yeah, TD I finally found an A320 FCOM and am wading thru it. Definitely looks like the "Too Low Terrain" warning should have come on, and I agree that it could be judged a nuisance if you trying to land and already know you are faster than normal.
'
Trying to find the excruciating details for the "flare" mode, as I am thinking it was not in effect and normal gear up control laws helped them to grease it on. Might also explain why thrust reversers may not have actually deployed regardless of throttle position/selection/whatever when WoW shows airborne.

[YRP]

Here’s a link to the report on the accident referred to above. A lot of similarities, and certainly shows that the PIA accident cannot only be blamed on a non-“Western cultural” mindset.


Farsouth, it is quite possible that the PIA can in fact be blamed on a non-western mindset while at the same time the Houston accident can be blamed on an excessively western mindset (ie cowboy).

Your point that western aviation mindset isn’t infallible is of course correct.

[compressor stall]

Another factor I have not seen mentioned is the disconnection of the autopilot early in the approach @ about 9000’. .

A320 gets full speed brake without AP but only half with.

This is consistent with recognition that we are high and we’re going to get down as fast as we can. Further backed up by the 7000{‘ lowering of the gear.

[FlightDetent]

I am more familiar with the 330 due to the 447 discussions some years back, but your FBW has a lot more modes and submodes True, though rated pilots might find your re-phrasing a bit coarse around the edges. The gear v.s. HAL was what I was pointing at, meaning to say apart from the F/CTL FWB, the A320 is a totally conventional aircraft. Vilas pointed the rest.

For your Q about verifying lights and levers for the final checks: Yes we do, and other pilots too. Typically challenge-response read from a laminated check-list, confirmed by both pairs of eyes.

Unlike the doomed crew. Come to think of it, once they already raised the L/G thinking they were lowering it, touching the lever would not amount to much. The lights would be showing nothin, with gear up and closed. ... why no "3 greens check"??? Well, easy. Normally the ECAM upper screen displays abbreviated "LDG MEMO" with 5 action lines, that change as you finish the individual items (arm spoilers, LG/DN). Hence we verify (from the paper C/L) "ECAM MEMO? .... (displayed) LANDING: (showing) NO-BLUE" I.e. we look at the ECAM for LANDING memo, that is showing all green text with no blue action items left.

The memo comes up automatically whenever RA<2500 ft (large A/C passing below you in cruise, you will get it at 35k - like I said, no HAL apart from the F/CTL). The problem for the PIA flight is that the LDG MEMO occupies the same ECAM screen space on the upper display unit (called Engine/Warning Display) as any ABN warning will and those take precedence. Hence in overspeed it shows OVERSPEED in red letters and the applicable limiting speed, and no LDG memo.

There are 3 green triangles showing on the panel above the gear lever, but those we do not really check actively, it's done via the ECAM LDG MEMO. For normal landing, the lower DU shows ECAM "WHEEL page" with another 3+3 green triangles, ... the page automatically comes on with ... you guessed right: selecting the L/G down. Malakia.

Basically, if you attempt to land this aeroplane in flap overspeed and ignore the landing paper check-list (which even lists the 5 action lines in print, in case the screen went T.U.), it is perfectly possible to land gear up unnoticed, unless you notice.

[gums]

Thanks for the info, Detent.

Quite a bit different with electronic "help" for the procedures and such from what I endured for a few thousand hours.

[jolihokistix]

At which point does a person lose faith in the electronics, assume that all the various warning signals are false, and maybe remark that there must be technical problems?

[White Knight]

Trying to find the excruciating details for the "flare" mode, as I am thinking it was not in effect and normal gear up control laws helped them to grease it on

You can 'grease' it on with Flare Mode btw!!! HAL as you call it is not all doom and gloom...

[Check Airman]

There are 3 green triangles showing on the panel above the gear lever, but those we do not really check actively, it's done via the ECAM LDG MEMO. For normal landing, the lower DU shows ECAM "WHEEL page" with another 3+3 green triangles, ... the page automatically comes on with ... you guessed right: selecting the L/G down. Malakia.

I'd considered the lack of presentation of this page ought to have been another hint. Maybe the lower ECAM was otherwise occupied for some reason? Admittedly, this would've been a subtle hint, lost in th ocean of bells and whistles going off.

Good point on the LDG MEMO not showing while above Vmax. The more I think about it, the less sense it makes. They had the GPWS going off, airspeed above Vmax and no LDG MEMO on the ECAM. I hope the final report shows us what the screens looked like at 500ft.

Maybe they had no warnings. Maybe the combination of things warnings that had to be presented was way beyond what the engineers had envisioned, and the DMC's and FWC's just gave up and rebooted.

[Uplinker]

Certainly appears to be mental overload, for whatever reason.

We are not supposed to speculate but........a possible scenario is as follows:

Captain is a very autocratic Captain who had marginal ability and got into the LHS by other means.......and a meek or compliant F/O.

The Cap f****d up the descent, but did not want to lose face to his F/O, so instead of acknowledging his mistake and asking for extra track miles, the Cap kept saying he was comfortable, and barked orders to the F/O and then ignored instructions from ATC. I can imagine Cap saying "He [ATC] is a donkey, what does he know, we are on the ILS and visual....".

The A/P disconnect is consistent with wanting full speed brake to increase rate of descent. Selecting gear down is also consistent with this, although a bit desperate when all you need are some more track miles. But pride probably prevented Cap from asking or agreeing to longer vectors.

Cap almost got it sorted, but then, as he just about regained the profile, (but crazy fast), his "muscle memory" kicked in, and he barked "Gear", while stowing the speed brakes, as you would if you had just recovered a slightly high and a fast approach. Unfortunately, the Gear was already selected down but the F/O had stopped thinking for himself or was too cowed to say anything, so simply moved the lever in response to the shouted order, in this case to UP.

Cap, not realising the Gear reversal, now thought he had made it. He ignored all the warnings that must have been sounding and became focussed on the runway and the landing. He forgot speed, forgot stability and forgot landing checklist, one item of which is to check the gear is down. (As others have said ECAM memo might not have been displayed, nor the Wheels page on the SD. However there are secondary independent conventional gear indicator lights on Airbus FBW - 'three greens').

Cap flies down and flares, but because of ridiculous speed, the sink rate is much less than in a normal flare and he greases it on, lower and lower and..........oh sh*t !!...............TOGA!! They get airborne again but having fatally damaged the engines, the subsequent accident is now sadly inevitable. RIP

All possibly caused by ego, and a person not able to say, "Oooops, sorry, I made a mess of that! [descent]. Can you ask for some more track miles". RIP


I have a simple mantra I use at a few miles out from landing to double-check we can land safely: "Fly......By......Wire".

F = Flaps. Are they set for landing?
B = Brakes. Is there any residual pressure and has auto-brake been selected?
W = Wheels. Is the gear down?

As I say each item quietly to myself, I visually check the appropriate indicators in front of me :ok:

[parkfell]

Has it ever been made clear if any form of FDM operated prior to the crash?
If it did or didn’t, then hopefully it will be part of the AAIB investigation.

The EASA suspension letter gives some insight as to the short term relationship with PIA.

The LEVEL ONE item ~ SMS shortcomings. That speaks volumes.....

[AviatorAtHeart]

Quick question from a non-pilot. Any guesses as to what would or could have happened if the landing gear was down, all else being equal? Is it possible they performed similar unstabilized approaches before and got away with it? Thanks.

[FlightDetent]

Best educated guess is that the landing would be pretty much the same (they did manage it after all), only around 60 mph slower. Vacate the runway with hottish brakes (500 deg), engage the cooling fans and 15 minutes later a forensic examiner wound not find a single atom misplaced.

My personal opinion (based on nothing but gut feeling how pilot psyche works) is they were no strangers to wild approaches, but this one was still a league steeper than experienced occasionally before. The sensory overload and unexpected behaviour debilitated the crew, rendering them incapable to put 1+1 together (read the landing C/L and discover the true gear state) nor break the error chain by going around while it still made sense.

[ExSp33db1rd]

Best educated guess is that the landing would be pretty much the same (they did manage it after all), only around 60 mph slower. Vacate the runway with hottish brakes (500 deg), engage the cooling fans and 15 minutes later a forensic examiner wound not find a single atom misplaced

Possibly have run off the far end, which would have displaced a few atoms, but likely no deaths.

[Check Airman]

I guess it depends on where they put it down. Assuming they recognised it at 500ft (which is the last data point we have), from 220kt, I'm also in the camp that they'd wind up going off the far end of the runway.

[LandIT]

See - I told you we'd make it....

https://www.youtube.com/watch?v=V-NPkZRAS9Y

[FlightDetent]

Possibly have run off the far end, which would have displaced a few atoms, but likely no deaths. Let's not forget the brakes are oversize, designed to stop a rejected TKOF from somewhere well past the runway half-point.

Karachi landing distance available is 3400 m. Performance data show only 1950 m is required at approach speed + 50 knots (QRH numbers).

Assuming they recognised it at 500ft (which is the last data point we have), from 220kt, I'm also in the camp that they'd wind up going off the far end of the runway. Back of the fag packet: 220 IAS = (nearly) 220 G/S = 1100 fpm = (nearly) 30 seconds to touchdown from 500 ft. The deceleration rate with landing flap and L/G down is at least 20 kt / 10 sec (yellow speed-trend arrow), ie. reduction from 220 to 160 is possible.

Assuming the original Vapp at 140 kt, 160 is Vapp+20. QRH strikes again: for Vapp+25 LDA is 1500 m. No one would have known, they had double the length required. And the touchdown was well done distnace-wise, given the lack of gear-legs.

In your scenario, there would be a delay before the gear unfolds and comes down, which I conveniently omitted. Still some room to spare, AFAIK.
o my defence, AviatorAtHeart did ask about the effect of L/G down from where they flicked the lever, at 1700 ft / 5 NM.

Come to think of it, with 220 at 5NM and everything hanging down as it should, the approach might have been stable by 500. (Vapp+15 max). Somebody mentioned going 250 to the marker for skills development, didn't they? :E

AviatorAtHeart: Google for Normalization of deviance, someone mentioned already in the thread. It's a common organizational trait, everyone is susceptible. It is that natural and so dangerous, the industry mandated a computerized monitoring of flight parameters long time ago. Called FDM, it is the cornerstone of FOQA / SMS. Without SMS in place the legal requirements to run an airline, or even a small 2 aircraft operation are not satisfied. EASA just banned PIA from EU airspace, citing lack of SMS and their inability to rectify the situation for extended periods of time, in spite of the warnings the've been given.

[Check Airman]

Touché. Assuming I make it to my next recurrent sim session, I'll give it a shot (is there a way to silence the CRC in the sim?).

We did 250 to the marker with some regularity in the RJ. The most I've done in the 320 was 250 to 10nm, with a pretty good headwind, if I remember. We got the flaps to full at 1020 ft, and were stable at 550ft. If I'm doing that on the line, I'd prefer trying it a few times in the sim first.

[Check Airman]

See - I told you we'd make it....

https://www.youtube.com/watch?v=V-NPkZRAS9Y

Is all that smoke coming from the reversers or the brakes? :E

Our company procedure for TGU is a mandatory GA if we float past the first exit (I think...it's been a while). That being said, I think I know that guy :suspect:

[Uplinker]

(is there a way to silence the CRC in the sim?).
.

The EMER CANC key (red guarded switch in photo below), will silence some CRC, I don't know if it will silence all.

https://cimg7.ibsrv.net/gimg/pprune.org-vbulletin/2000x1504/84b4d0c9_6aa5_4a5b_98b9_6a130137d424_4eeb1ff81b81aaa956dd712 73c5925debf1575a9.jpeg

[MPN11]

See - I told you we'd make it....

https://www.youtube.com/watch?v=V-NPkZRAS9YTrying to correlate that video with Google Earth.It seems to finally touch down with c. 1,000 ft to go! Or am I misinterpreting ground images? Is it more like 3,000 FT?

[FlightDetent]

Most likely not. Given the inherent and regulatory margins, over-running the runway with a modern-day airliner requires substantial effort.

History suggests these usual suspects:
- runway is short (less than 2000 m)
- runway is slippery
- the braking effectiveness of the aircraft is significantly reduced
- touchdown is achieved well further than 2x the normal point (not to be confused with runway "touchdown zone")
- significant extra speed is carried for the landing, 20% or more.

Evidence shows satisfying 2 of the above is not enough to mowe the lawn. 3 will do, 50:50 and with 4 all you can do is wait for the final investigation report.

[MPN11]

Thanks. I've reviewed my guesstimate and edited my post. That aircraft was certainly reluctant to stop flying, though.

[CaptainMongo]

Touché. Assuming I make it to my next recurrent sim session, I'll give it a shot (is there a way to silence the CRC in the sim?).

.



“EMER CANC Button When pushed:

Warnings - Present aural warning is cancelled. MASTER WARN switches extinguish. ECAM message display is not affected.”

So yes, I would say it does cancel the CRC, however is there any reset built in to the system where the warning will be retriggered?


Landing with abnormal gear has one accomplish this: “GPWS SYS switch - Off” so if there is a retrigger, switching the GPWS off would prevent another CRC. Vilas?

[AviatorAtHeart]

Thanks for the replies. While I wasn't fully aware of the term 'Normalization of Deviance', holistically, one can see it when comparing what is generally acceptable in different parts of the world. That's concerning, especially when so many lives are at stake.

It'd be interesting to look back through PIA FR24 data to see how many times unstabilized approaches were attempted and completed without such dire consequences. I think someone suggested looking through available information earlier in the thread but I am not sure if anything ever came out of it.

[Flaremode]

“EMER CANC Button When pushed:
So yes, I would say it does cancel the CRC, however is there any reset built in to the system where the warning will be retriggered?


If you EMER CANCEL any warning/caution it will be silent this kind of warning/caution for the rest of the flight. You will get a white info-text in the EWD what kind of warnings/cautions are silent. If you press and hold the clear button for more then 5 seconds, all silent warnings are cleared and everything is "normal" again.

[vilas]

When high and fast first get the speed right that reduces closing in speed. At 10.7nm. 7000ft. 245kts had they leveled with speed brakes and gear configured to Vapp they would have had six miles to touchdown and 7000ft to loose. Easily done(since they were bent upon doing).

[vilas]

Landing with abnormal gear has one accomplish this: “GPWS SYS switch - Off” so if there is a retrigger, switching the GPWS off would prevent another CRC. Vilas?
It only says about Mode5 Descent below glideslope, pressing GPWS push button cancels the warning but this is temporary. The mode is automatically reactivated for a new envelope.

[Lost on the Tundra]

I have to wonder... if after another incident directly attributable to gross pilot error, and/or some impossible to reasonably foresee design "flaw" (NOT saying PIA 8303 is such, yet) inflamed public pressure (see now fully systemic media hysteria) on regulators/politicians leads to manufacturers/lessors being barred from supplying aircraft to ... erm, non-compliant airlines, and the ensuing somewhat justifiable cries of the r word when most of the world's airlines are forced to fly TU154b's!

Commercial transport, I would argue, has entered an entirely futile and moribund phase of existence where any and all incidents are just more nails in the coffin, unless some broadly acceptable new way forward is established.

How exactly does one reintroduce acceptable risk in our increasingly and relentlessly risk-averse society? My feeling is we have reached the apex of airliner design and automation and Artificial Incompetence is simply not a path forward for the foreseeable future.

Don't even ask me what that way forward is! I'm just a lowly PPL that becomes heavily task-saturated whilst walking and chewing gum at the same time. My speculation may be a tad hyperbolic, but some variant of the theme could/should prove an entirely reasonable subject to ponder.

[Old Boeing Driver]

I'm late to the party. I assume this has been posted. https://aviation-safety.net/database/record.php?id=20200522-0

[Check Airman]

CaptainMongo

Well don't I feel stupid? :ugh:

I imagine i should've known that. Being a 320 pilot and all...:\

[Teddy Robinson]

They had both Gens offline, no APU Gen and the RAT deployed, so the aircraft is now operating in emergency configuration ...
Question to those current: I would imagine this put us into direct law, but are any protections still active ?

[homebuilt]

On the 330 in such configuration (ELEC EMER) you get into alternate law. That means you have no more ‘‘hard’’ protection preventing you to escape from certified flight domain. You can physically stall, nothing will prevent you from this, except an aural warning ‘‘STALL STALL’’. I don’t know whether it’s different with the 320..

[vilas]

The aircraft goes in alternate law with reduced protections. Protections are there but can be overridden by pilot.

[PJ2]

Hi vilas - not current, but if I remember, in the Emer Electrical Config the a/c is in Alt.Law as stated, but all protections are lost and when the gear goes down the aircraft reverts to Direct Law?....

[vilas]

No!. It's the other way around. It goes in alternate law with reduced protection. When gear down direct law with no protection.

[Teddy Robinson]

They had both Gens offline, no APU Gen and the RAT deployed, so the aircraft is now operating in emergency configuration ...
Question to those current: I would imagine this put us into direct law, but are any protections still active ?

It was the gear down case that I was fishing for as I am no longer current on type.
So the final descent could not have been flown at alpha max, as there were zero protections if I read this correctly.

[FlightDetent]

No FDR post the dual engine failure suggests no APU. Then irrespective of any good residual hydraulic pressure from the wind milling engines (well, loss of oil...knock, knock) the configuration would be Emerg ELEC and that is DCT law after gear down, in the book.

[Escape Path]

Yes.

No FDR post the dual engine failure suggests no APU.

Seems like they: a) forgot to turn on the APU by instinct after recognition of the second engine failure; b) didn’t remember/have time to apply the “Emer Landing (all eng fail)” procedure; or c) they did start it, but there wasn’t enough time for the APU to spool up and get the generator online. The last one I hardly doubt it, because I remember seeing the APU intake flap closed in the first photos we saw of the aircraft, right before it crashed.

It would/will be very interesting to see how they managed the dual engine failure, after all the mess that happened right before...

[vilas]

The PM was confused with gear actions. On first approach at 1700ft mechanically did something to the gear lever. To his bad luck it was down he put it up. After go around again irrationally did something to the gear lever. This time it was up he put it down but realizing it was up he put the lever back. What they did with flaps is not known but must have retracted to zero and again lowered. When did they lower the gear is a mystery because it wasn't lowered by gravity extension.
It is too much to expect they would start APU or any checklist for dual flame out. It was of no use anyway.

[Joejosh999]

My question is 1) when did they realize they had dual engine failure and 2) had they already put the gear back down the final time? Or did they somehow know they had no engines YET put gear down anyway, not realizing it would kill their glide range?

[infrequentflyer789]

Is there not a third option for (2) along the lines of: did they actually think the gear was down for the landing(*) and then "raised" it (but actually lowered it - continuing previous apparent state of confusion on this) to extend the glide when they realized they had no engines.

(*) thinking it's maybe possible they went around having, belatedly, realized they were too fast and brakes / reversers weren't kicking in, but not actually realizing they had landed gear-up.

[Check Airman]

It would/will be very interesting to see how they managed the dual engine failure, after all the mess that happened right before...

Well given how they acted in a normal situation, do you really want to imagine their response to a non-normal situation?

[Teddy Robinson]

My question is 1) when did they realize they had dual engine failure and 2) had they already put the gear back down the final time? Or did they somehow know they had no engines YET put gear down anyway, not realizing it would kill their glide range?
RIP all.

Again we will have to wait for the full report.

From the videos of the final moments, it looked to me as if he was trying to find alpha max, but the protections were gone with the gear extension.
Despite all the cock-ups, it does appear that they were tantalising close to making the undershoot area, and perhaps walking away.

Just another marker in a sad catalogue of failures.

[Escape Path]

Well given how they acted in a normal situation, do you really want to imagine their response to a non-normal situation?

From a pure accident investigation point of view, particularly of the human performance, I’d be really interested to know what happened after the go around. But my guess, also stemming from what we know that happened before the ahem, “landing”, is that it most likely was absolute chaos. Few things produce as much sensory overload as an A320 losing all power (both engine AND electrical) and getting into emergency electrical configuration. Not to mention the fact that it was stacking up over what was already quite a messy approach and... “landing” :rolleyes:

As vilas pointed out, whether they started the APU or not, little was going to change their fortunes; a handful of electrical things spurring back into life (in daylight VMC), but no engines and no change in flight control laws (it would remain in direct law if my knowledge doesn’t fail me) wasn’t really going to help them that much. The gear down, ironically, is what drove the final nail in the coffin

[lomapaseo]

What kind of performance loss with gear down during landing approach?

Would you expect an undershoot of a mile or so? with no thrust available

[Check Airman]

Never having tried it, I can’t speak from experience, but the second attempt was the one that would have benefited from the gear being up. The gear works better than the speed brakes in the 320. If I’m not mistaken, they crashed about a mile from the runway.

With the absence of the FDR data, we probably won’t know exactly when they lowered the gear, but I’m guessing if they’d waited until ~200ft to drop it, they may have walked away.

That of course assumes the windmilling engines would produce sufficient pressure to lower the gear and support the flight controls. That procedure would take a bit of planning and thought, which in fairness, even on a good day, would probably be difficult under the circumstances.

In my opinion, starting the APU would definitely have helped.

[autoflight]

Can someone enlighten me as to whether the Insurers are likely to pay out given what has all the hallmarks of grave Gross Misconduct by the crew.
Add to that, the issue of whether any evidence is uncovered as to whether the licences were issued “fair and square”, and their continuing validity iaw licensing regulations.
Simply asking the question. I have no information one way or the other.
This is a very significant consideration. In at least a couple of my airline contracts, there seemed to be an involvement of national government in the insurance cover. For a national airline, that seems to be a conflict of interest, even with re-insurance. If an insurer had an opportunity to escape payment, it seems that that it would do so. If the airline was sufficiently negligent, like habitually allowing beaches of SOPs that would have prevented the accident, there might be a question mark over claims. If the airline did not know of breaches, but should have known, same question mark.
A friend of mine was a pax in an A320 accident at Bahrain. Religious considerations meant his wife did not get any compensation, but his closest male relative did and did not share it with the wife.

[vilas]

In my opinion, starting the APU would definitely have helped. Am I missing something? APU gets you out of ELEC EMER that brings CM2 instruments, it can take over pressurization, main use is starter assisted relight which wasn't going to happen. None of this would change PK8303 fate. Sully started APU from memory as good airmanship to get an engine going but once that didn't happen he also got no other help from APU. It doesn't get you out of G+Y. In PK8303 once they lowered the gear they were done in. Even if they could raise it they would've lost more height.

[Fursty Ferret]

Can someone enlighten me as to whether the Insurers are likely to pay out given what has all the hallmarks of grave Gross Misconduct by the crew.

I am not an expert, but I think it's almost certain that the insurance company will pay out. Typically an insurance company can't refuse their liability to a third party, but they can seek to recover that from the insured in the event that negligence is the cause.

If an insurance company (actually, the underwriter whether that's a name, another insurance company, or the Government as last resort) is unhappy with the potential risk then it's their problem and their responsibility to either ensure the problem is fixed or deny cover in the first place, at which point the airline wouldn't fly.

[Auxtank]

Again we will have to wait for the full report.

From the videos of the final moments, it looked to me as if he was trying to find alpha max, but the protections were gone with the gear extension.
Despite all the cock-ups, it does appear that they were tantalising close to making the undershoot area, and perhaps walking away.

Just another marker in a sad catalogue of failures.

The ALPHA PROT was long gone after the engines failed.

[FlightDetent]

@vilas I am away from the books. Does APU elec supply restore ALT law with AoA protection? That is for the Hudson (gear up) case.

Sully is a short-hand for "the crew of US Airways 1549", I suppose. 😉

[vilas]

ELEC EMER itself is in alternate law with reduced protections. With dual Engine flame out APU doesn't restore anything except AC Bus2. Even AC essential bus remains locked with emergency generator.

[MikeSnow]

Am I missing something? APU gets you out of ELEC EMER that brings CM2 instruments, it can take over pressurization, main use is starter assisted relight which wasn't going to happen. None of this would change PK8303 fate. Sully started APU from memory as good airmanship to get an engine going but once that didn't happen he also got no other help from APU. It doesn't get you out of G+Y. In PK8303 once they lowered the gear they were done in. Even if they could raise it they would've lost more height.

From the Flight 1549 accident report:

Starting the APU early in the accident sequence proved to be critical because it improved the outcome of the ditching by ensuring that electrical power was available to the airplane. Further, if the captain had not started the APU, the airplane would not have remained in normal law mode.
[...]
The NTSB concludes that, despite being unable to complete the Engine Dual Failure checklist, the captain started the APU, which improved the outcome of the ditching by ensuring that a primary source of electrical power was available to the airplane and that the airplane remained in normal law and maintained the flight envelope protections, one of which protects against a stall.

Full report: https://www.ntsb.gov/investigations/accidentreports/reports/aar1003.pdf

[vilas]

Quote:
Starting the APU early in the accident sequence proved to be critical because it improved the outcome of the ditching by ensuring that electrical power was available to the airplane. Further, if the captain had not started the APU, the airplane would not have remained in normal law mode.
[...]
The NTSB concludes that, despite being unable to complete the Engine Dual Failure checklist, the captain started the APU, which improved the outcome of the ditching by ensuring that a primary source of electrical power was available to the airplane and that the airplane remained in normal law and maintained the flight envelope protections, one of which protects against a stall.
In Flight 1549 there are two aspects. They had damaged Engines with low N1,N2 not failed Engines. They had all hydraulic systems working but generators could could have got disengaged unpowering the AC1 &AC2 getting in ELEC EMER config and alternate law which was avoided by APU start. In PK8303 case it is at least clear that their both generators failed because RAT was deployed and they were in alternate law. If they had the required hydraulic pressures in Green and Yellow systems is not known, left engine the report said needs investigation. If they didn't have then they would have remained in alternate law even with APU on due to G+Y fail. If they had and AC buses were intact APU was able to connect then they would have been in Normal Law. But then they would have activated alpha protection to hit the buildings even harder. It even happened to flight 1549. Sullenburger had dropped his 19kts below VLS which triggered alpha protection . So either way APU or no APU PK8303 was doomed.

[FlightDetent]

The decision making was obviously there with Capt. Sullenberger and J. Skilles, aiming outside the built-up area.

[lomapaseo]

I've never known a pilot not to do that, if able

[Joejosh999]

I recall from the movie (assume accurate) that Sully started APU nearly immediately, and also that on QRH it was actually pretty far down the list of things to do, like 15th or 17th, such that you wonder how things might have worked out if they’d gone step by step thru QREf (or if they’d even had time to do so...)

[FlightDetent]

I've never known a pilot not to do that, if ableThat may have changed on the day this thread started.

[Escape Path]

It’s pretty ingrained in almost all of us, apparently, to fire the APU at the hint of a dual (or even a single!) engine hiccup. However, I’m with vilas on this one: it wouldn’t have made any significant difference in the final outcome.

MikeSnow: Notice the report says “normal law”. As vilas pointed out, this means the aircraft always had at least one normal generator working, meaning the APU generator came online before the second generator got offline (if it ever did, as one of the engines had only partial thrust loss). As sufficient hydraulic pressure is generated with very low N2 values, losing only one hydraulic system (I.e. the one supported by the completely dead engine) doesn’t get the aircraft out of normal law, and most likely if the generator wasn’t kicked offline, then the partially failed engine was still supporting its hydraulic system.

It seems the PIA case is quite different, as the photos of the airplane with the gear up show the RAT deployed, meaning it did lose power to both AC busses (read: generators). If I venture a little analysis of the altitude and speed charts in the preliminary report, we see the airspeed after the go around never got above 250-ish, then it goes down to about 200 and stays there until the end of the plot. The point where the speed starts to decrease from 250 could be where the first engine failed, then they seem to have traded speed for altitude (since that one kept going up), speed stabilized in regions consistent with normal green dot speeds, and it’s just one mile (starting from the runway) since the speed starts to go down to the end of the plot, which is when the second generator got offline (I.e.: second engine failure). You need a whole minute to get the APU running and online in the A320. There was never going to be enough time to get it running. And even then, the second engine still failed, so they would’ve gone into alternate law anyway. They only would’ve had double instruments, the critical bits of the plane would be the same as without APU. And obviously that didn’t help them before... :rolleyes:

lomapaseo: I think yours is a very difficult question to answer with the information we have available, at least to guesstimate where this particular aircraft would have (crash)landed. They weren’t at typical values of speed, altitude and configuration to try and estimate the flight path. And I guess it all depends on when did they lower the gear

[MikeSnow]

It’s pretty ingrained in almost all of us, apparently, to fire the APU at the hint of a dual (or even a single!) engine hiccup. However, I’m with vilas on this one: it wouldn’t have made any significant difference in the final outcome.

I agree, although it probably wouldn't have hurt to attempt to start it. My reply to vilas was only to counter this part of his post: "Sully started APU from memory as good airmanship to get an engine going but once that didn't happen he also got no other help from APU.". Because according to the NTSB the APU helped with more than that, in that particular situation.

[vilas]

I repeat again APU in 1549 case didn't do anything else. In dual Engine flame out checklist the APU start is way down because in ELEV EMER. you cannot start APU above 25000ft. and because of high speed windmill relight is available at higher altitude. He started it from memory and it would have been life saver had a flamed out Engine restarted. But Engines had not flamed out they remained crippled. Normal Law or alternate law makes no difference to ditching. In normal law due to dropping speed he got into alpha prot and couldn't flare sufficiently and in alternate law he would have got stall warning and he would have pushed the nose down but the result would have been same, hard impact.

[MikeSnow]

I stand corrected, reading an interview with Sullenberger confirms that being in normal law didn't help them, because they didn't reach the limits that would have triggered the envelope protections. But he felt that having them available was a good thing, he said about the protections "I had that as an ace in the hole".

https://www.historynet.com/sully-speaks-out.htm

So we stayed in normal law—all the flight envelope protections were intact. That helped provide essentially guardrails to prevent us from exceeding certain extremes in terms of speed or attitude, for example. So I had that as an ace in the hole. It turns out we didn’t need those protections; we never got to the limits at which they would have protected us from ourselves.

So, not sure why the NTSB felt that starting the APU was so critical for the outcome.

[vilas]

The main issue with flight 1549 was that the crew was faced with a serious emergency not practiced nor was there a precise check list suitable for the situation. Sullenburger's greatest virtue was that in one minute he decided he will land in Hudson, going back as he rightly realized would have deprived him of any change later. That ensured nobody was going to die, full credit for that. However as we know now all other things like starting the APU or asking the copilot to restart Engines turned out superfluous and distracting. The Engines had not failed they were not going to restart to new life. Had he not done that the copilot would have guided him to maintain correct speed and proper flare would have prevented serious injuries. Even selection of Flap3 may have released from alpha prot. Anyway that is for others to understand for the future.

[WillowRun 6-3]

vilas, does your description of the events of 1549 and the flight crew's decisions lead to any conclusion about whether or not algorithms alone could have dealt with the emergency as well? I get that this might be thread drift but . . . . I haven't yet been able to understand how a batch of code could cope with an "omitted case" - like no checklist for this situation specifically.

[FlightDetent]

Never.

There will be more and more automation, replacing human handling skills. Yes, perhaps a ditching flare mode one day.

But never a reliable system that can take decision and prioritize, adapt and reevaluate in the real time.

Automated yes, autonomous never.

Liveware will stay for two reasons:
- backup and takeover from the automation, beyond its programmed scope
- public perception, marketing

The second will be the more important, especially as various dirty games about autonomous vehicles will come to light.

[vilas]

WillowRun 6-3

It's not impossible. NTSB in 1549 inquiry gives some references about research on systems that were to give more precise state of Engine damage to Pilots. They were given up due to lack of funding. If it was available then crew wouldn't have wasted time on relight. Now in A350 Autopilot is available with dual Engine flame out. Automaic decisions and executing a landing or ditching should be possible.

[lomapaseo]

It's mostly a pinch point on time vs prioritization of tasks flying the airplane. If EGT% is pegged out at max, you don't have a chance unless you shut it down as the turbine will melt, not just overheat. Sometimes you don't have time to even care (as heard in CVRs). If the egt is simply overlimits you might be able to recover some thrust by reducing the throttles or restart if you have the time, but otherwise just leave it alone and work higher priorities (damaged engines rarely cause significant hazards after the first seconds)

If you have time to even think about the engines, then consider the restart itself needs time (airspeed, altitude or APU). The only problem I can see in past history has been the prioritization of tasks or not reducing the throttles for simple overheats

[ferry pilot]

The backup and takeover could be done from the ground, public perception and marketing with the same smoke and mirrors applied to everything else..
There will always be a shortage of experienced pilots in remote places but maybe not so likely in the major airlines of the future.

[Loose rivets]

But never a reliable system that can take decision and prioritize, adapt and reevaluate in the real time.

In the event that future aviation gets back to its former glory, I have little doubt that total automation will become the norm. What we can't have is humans on a flight deck cluttered with machine-human interfaces. A bewildering number of incidents are caused by this small void.

Systems will have an encyclopaedic knowledge every air accident ever recorded and know how to calculate around a reoccurrence. It will know the world's weather with fine detail on the route. It will know the the location of hostile armies and the moment planning permission is granted for the simplest tall object. It will create pages of ACARS while acting on the information - scrolling lists of horrors will not faze it one jot. It will never lose situational awareness, knowing where it is relative to the planet and what used to be called the fixed stars. It will not suffer stress, or any other kind of work overload - in fact it will rarely use a significant proportion of its computing power.

Decades away? Probably, but the incredible thing is we are within touching distance of such technology now. The public's acceptance? Quite a different matter.

[FlightDetent]

Loose Rivet Today the decision making element does not need to be certified.

If the umpteenth next generation was to be what I called autonomous, the software "AI" would need to be formally reviewed and approved.

​​​​Through that the development cost will be enormous and unpredictable as well. Not to make a code that works, but a code that you can prove won't do anything else apart from what it says on the tin.

My take is that the investors would not approve a launch of a project where the worst case cost are impossible to estimate.

You can pretty y much always fix and aeroplane but code sometimes just cannot be. And a replacement one is prone to another full set of unknown bugs, just like the original one.

[FlightDetent]

The backup and takeover could be done from the ground, public perception and marketing with the same smoke and mirrors applied to everything else.. The technology is there already. This will surely be the future one day for cargo aeroplanes, considered their payload is more easily expandable w. r. t. keeping the business after a total crash and settlement of the insurance cost.

For PAX ops, I do not think so. Whilst I agree about your smoke and mirrors observation, it still feels like there are sufficient number of sub-critical masses to keep a human element inside a steering chamber on board forever.
Yes, words flight deck or pilot will become obsolete.

[ATC Watcher]

Yes the automated technology is there and already on trial ( check Airbus ATTOL on google) Autonomous , not yet and not for a long time I would say .

As to the critics about automated in modes of transport, we should remember we are in the very early beginning of automated cars.sea and air transportation .
The first one that tried was the railroad : 2 dimensional . There are numerous trains and metro systems that are automated today . Public resistance and of "it will never work" cries by professionals were similar in the 1970-80's when they were introduced.
To take an example today 2 main metro lines in Paris are fully automated since years , run every 2 min at peak times ( compared to 4 before) and were the only lines operating without interruption during the long strikes last winter..
That last part also is an interesting one regarding automation and public acceptance..

[Volume]

Certain trains between airport terminals run autonomous since 20 years... Not at all the same technology you would need for autonomous flight.
But maybe we do not need it anyway, as our conventional aviaton today is also not fully autonomous but mainly ground controlled. We only talk about a different level of ATC. Which, as we can see in this example, may have saved the day.

[double_barrel]

That last part also is an interesting one regarding automation and public acceptance..

Public understanding of risk is insane.


Right now we have people complaining about the cost of actions to prevent the spread of a disease that kills or injures a few people per 100. But imagine the uproar if an aircraft manufacturer said, "it's too expensive to introduce a technology that would prevent one crash per 10,000 takeoffs" !

[tdracer]

WillowRun 6-3

It's not impossible. NTSB in 1549 inquiry gives some references about research on systems that were to give more precise state of Engine damage to Pilots. They were given up due to lack of funding. If it was available then crew wouldn't have wasted time on relight. Now in A350 Autopilot is available with dual Engine flame out. Automaic decisions and executing a landing or ditching should be possible.

Just a clarification - it wasn't lack of funding so much as a lack of knowledge of how to determine the health of a system that - by definition - had just failed. When the feds came to us propulsion types and said 'we want you to put up a message if the engine is damaged to the point that it won't restart' we basically responded with dumb looks, followed by 'how the :mad: are we supposed to do that?' It was literally a case of not knowing where or how to start.
There are plenty of engine monitoring algorithms that measure the health of the engine and send out reports (e.g. ACARS). But they all depend on the same thing - the engine has to be running before they have viable inputs. I think some of the R&D types went off and started thinking about the problem (particularly at the engine companies), but I doubt there is much that can be done with current technology.

[lomapaseo]

All true

to add
Fancy thinking has a way of biting your a$$ sometimes when it interacts with human performance under emergency conditions. Pilots with negative buoyancy may react in ways that negate the automatics. Then there is the difficulty of how to handle things like ash ingestion, where the engines likely were not restartable initially until repeated attempts finally wore away enough ash-buildup to get one or two going again.Like I said earlier, I can find fault with the pilots only in the first minute of an event whilst realizing minutes later no amount of engine restart software is likely to help

[WillowRun 6-3]

IFALPA has issued a Safety Bulletin: Unstable Approaches During Reduced Operations; it does not reference the Karachi accident in any manner yet, an unstable approach was a factor in the accident (was it not?) and thus, the bulletin would seem pertinent here.

https://www.ifalpa.org/media/3550/20sab06-unstable-approaches-during-reduced-operations.pdf

[Lonewolf_50]

from the last paragraph (https://www.ifalpa.org/media/3550/20sab06-unstable-approaches-during-reduced-operations.pdf).
It is important to highlight that the decision to execute a go-around is not, in any way, an indication of poor flight crew performance but rather prudent decision-making. There should be a clear non-punitive go-around policy.
​​​​​​While this is hardly controversial, it might be worth considering the formal and informal norms in a given company.
The formal norms are a written policy, SOP, rules, etc. The informal norms are the unwritten rules, incentives, and 'reputation points added and subtracted' based on various decisions made. ​
How many of you have been in companies where the informal norms and the formal norms (policy) didn't quite match? (*There is a current thread on R&N in re Easy Jet that seems to cover this mismatch a bit regarding sickness...)
Can anyone comment from their own experience in this airline? (PIA)

[lpvapproach]

Have they posted the full cvr transcript leading up to this accident yet?

[Ray_Y]

I'm afraid there'll be long wait: CAA published the Preleminary Report within the usual month after start of investigation. At the end of this report they refer to the final report draft process. Expect Final Report no earlier than 1 year after.

Of course leaks are not totally ruled out. And possibly govt/parliament asks for another interim report.

[FlightDetent]

On practical terms the final report will be of limited added benefit. What is known so far has already painted a complete enough picture to see what happened, the crew crashed a functional aircraft on their own.

The particular and perplexing sequence is something a crime-story novelist could have come up without much creativity at all, simply by combining elements from historical accidents. Probably even from the last decade, the age of information.

Besides, researching the hows and whys is not the reason for the investigation in the first place. Going back to the definitions, the sole purpose is preventing a re-occurrence by defining and implementing mitigation measures (which might also come in simple terms of re-focusing on safety targets already known before).

The pertinent questions, after the full report is out, would be (random order):

1) What could the ATC possibly do to break-up an identical chain of events the next time?
2) What could the aircraft / engine manufacturers possibly do to break-up an identical chain of events the next time?
3) What could the first officer possibly do to break-up an identical chain of events the next time?
4) What could the captain possibly do to break-up an identical chain of events the next time?
5) What could the airline operations managers possibly do to break-up an identical chain of events the next time?
6) What could the airline S&Q managers possibly do to break-up an identical chain of events the next time?
7) What could the CAA possibly do to break-up an identical chain of events the next time?

My suggestion is the understanding today is on a sufficient level to get moving on each of the separate points above. On top of which: The existence of an SMS system utilizing FDM / FOQA elements, long mandatory for airlines such as PIA themselves, would had prevented this completely unnecessary loss of life.

[EDLB]

A fish starts stinking from the head. So you missed in your numbers the PIA top management. That a captain gets away with those sort of cowboy approaches is the direct consequence of top management style. If every manager looks the other way, will, at a certain point, lead to this outcome. That the CRM did not work and the Co was not preventing this has the same reason.
Number 1 and 2 is a distraction and has no relevance.
7 should have pulled the AOC long ago.

[FlightDetent]

Yes, the whole thing is skewed on all fronts. I deleted parts here and there to regain a bit of clarity for the original message - there is no need to wait for the final report before fixing things.

You are correct in what you say. 1) Will be researched and some tweaks found, 2) come up with "no tangible solution available".

Why 7 did not act as you describe goes beyond what can be achieved from within the industry :sad:. Specifically EASA did find "no-go" issues with the airline before the crash.

[Less Hair]

On a positive note: They started to admit this and talk about it. Step one to improve things. We have had non-qualified pilots flying for a living in other places of the world before. So the overall problem must be solved. If you look at how you can track your cars previous owners's repairs and mileage over time maybe some sort of shared pilot logbook database (without certain details) could be helpful to verify qualification, experience and checks?

[flash8]

On a positive note: They started to admit this and talk about it. Step one to improve things.Having had the dubious benefit of working in this area of the world, anyone here will tell you that this is the narrative always spun after a catastrophic event, if any are expecting a KAL type damascus conversion here they'll be sorely disappointed, it will (after suitable cosmetic alterations and bare faced lies) be business as usual, or at least as much as they can get away with.

[PFD]

Unfortunately, this will continue until position in society and money are not factors in who gets to manage a company or pilot an aircraft. It should be knowledge, skill and capability that matter. It requires a cultural shift that will happen, eventually, I hope. This in no way takes away from the fact that there are good pilots in these environments, but not all, and that's the problem.

[Willie Nelson]

Maybe this has been mentioned before but one of the most troubling aspects of the crash for me is almost certainly (yet to be confirmed) the likely lack of flight data oversight. It seems obvious to me that the crew knew that they would not be pinged by flight data monitoring. That is to say the such a cavalier approach could be flown with no adherence to conventional flight envelopes that would surely be at least loosely spelled out in company procedures let alone the complete failure to satisfy the stable approach criteria. They must have known that there was never going to be blow back over this, perhaps this will be shown to be incorrect but I have my doubts, this can’t be the first time these guys flew like this.

Where I operate, you can be sure that should you get an EGPWS hard alert, or caution for that matter or a GEAR NOT DOWN alert and fail to bug out, you will get a phone call. You’ll need to submit a report either way and if you don’t.......once again, you’ll get a phone call. It’s a double edge sword of flying with big brother in the jump seat at all times and yet knowing that your colleagues and family are much safer whenever they step on board. Seems to have served us very well over time.

I wonder if Airbus and Boeing might consider pushing regulators to step up random audits of flight data, it would at least be in the interests of underwriters if no one else.

Thoughts?

[hans brinker]

Could not agree more. I would guess there are still a lot of places where a Go-Around would be a call into the office, but an unstable approach would not because of a lack of monitoring. My company gives me a lot of leeway, and I like that, but in recurrent we will see examples of people taking it too far. It does help to know there is no punishment for screwing up the approach if you pull the plug in time.

[etudiant]

That is the most constructive suggested response to this tragedy yet.
It also helps address the problem of CRM when there are social gradients in the cockpit, because the junior individual can correct the more senior by referring to the risk of the data audit.

[CirrusSurfer]

There is a reason that limits are set, either by the manufacturer or the operator. If you operate outside of the limits, and are routinely allowed to get away with it, this is the outcome. Poor skills, poor CRM, poor oversight, poor outcome.

[Willie Nelson]

TACA110 is indeed an interesting video, The Gimli glider (B767) and an air Transat A300/330 have also done the same. Perhaps this is not what was being referred to?

[Escape Path]

Interesting point Willie Nelson. It could be a possibility that FDA is not properly monitored or followed up, hence the violation of all possible stabilization criteria becoming something usual: the popular normalization of deviation. Certainly something for investigators to make a question or two.

However, it seems as if the problem goes up higher than a simple flight safety/standards department. Taking from what others have said here before, it could go as high as the government; the whole system maybe permeated by obliteration of rules

[fitliker]

When can we expect the official reports ?

[ATC Watcher]

pvapproach

No, and they do not have to either. Maybe on the final report . we'll see


fitliker :

You mean the final report ?Sometimes between 1 and 5 years from now.I would guess.

[Willie Nelson]

Escape Path

Absolutely the problem goes higher, as EDLB puts it: “A fish starts stinking from the head” but you can cut to the chase by looking at the company’s safety management system directors and their direct reports when looking for who had control of the culture. For example if there’s a record of discussion as to how a flight data audit program might be designed, managed and who has oversight of it.

As the preamble on all crash comics always state, it’s not as important at least initially, to state who dropped the ball as It is to find how it was dropped. I have no doubt that Personal/ corporate liability tends to ultimately become self evident after that.

My outfit runs a pretty tight SMS involving a high level data oversight program and a closed loop incident oversight process with regular LOS audits (line observation safety audits) with very well trained staff for these purposes. We learned from previous incidents and it’s served us well.

I’m doubtful the PIA culture or regulatory oversight for that matter could be sufficiently remediated to be honest but looking at their full safety management system would be one of the most productive lines of inquiry from a root cause analysis perspective.

[unworry]

ATC Watcher

A former colleague bought himself a new VisonJet with the the autoland (Safe Return) feature

There's a number of youTube clips on the Garmin Emergency Autoland flight trials - worth checking out.

Easy for me to say in retirement, but the transition from augmented to autonomous flight control is not as far away as we might think

[vilas]

As more and more human factors accident are discovered it's natural to think of replacing them. After all humans are in the cockpit only because machines can't do it.

[parkfell]

.......I’m doubtful the PIA culture or regulatory oversight for that matter could be sufficiently remediated to be honest but looking at their full safety management system would be one of the most productive lines of inquiry from a root cause analysis perspective.

If PIA hope to resume flying into EU airspace, they will undoubtedly have to produce evidence that a significant improvement has occurred, and the necessary standards will be maintained and subject to monitoring by EASA on a regular basis.

More than just one Munro to climb?

[Compton3fox]

vilas

Until machines can think for themselves, the human factors issues will move from the liveware in the cockpit to the liveware in the software/hardware development labs... We saw this with the advent of the FBW generation of A/C in the late 80's. You can have the best technology in the world but surround it with poor processes and/or excellent processes not followed, and the technology becomes a witness to the incident.

[FlightDetent]

True, but you can fix faulty software written by erring humans. Not so much with erring humans killing their passengers directly in numerous ways both completely new and well know for a century.

You can develop both, but one of them is constantly trying to self-implode. The software does not forget to run coded sub-routines, humans tend to ignore lessons learned. At the same time, modern-day SOPs are already well algorithmized. All that is needed is an operator who/that will follow the script without ommisions due to lack of attention, guilt inflicted denial of facts, and egotistic creativity.

Even if you did find a solid, proper material and built a pool of trustworthy professionals, they will go retire, seek out better pastures or you need to let them go at the next downturn. And you start over and over again.

One of the best advices for aviators you'll find appeared in a post from hans brinker in the command upgrade SIM thread: "Do not do anything surprising". Software is capable of achieving that, live people are not.

[Compton3fox]

Ask the crew of QF72 if software isn't capable of doing something surprising... I have been involved with Software for many years and have lost count of how many times I've seen it do something surprising. It isn't surprising to the S/W as it's doing as it was told but it's surprising to the human as he/she wasn't expecting it to do what it did! That's the human element in software, hence my original comments. The more complex the S/W is. the more opportunities for surprises.. :-) Oh and throw hardware anomalies into the mix and it gets even more complex.

[WillowRun 6-3]

Though only SLF, a strong opinion follows (oh right, I'm also an attorney, so . . .)

We're communicating over the internet's pathways which undeniably have advanced rapidly in a comparatively short period of time. With great benefits.

And great problems along the pathways traveled. Criminals exploit the internet; there's a bit of smut here and there; hostilities and even outright threats pop up from time to time; and of course, there are vulnerabilities to old technology, decidedly earthside-bound, like electricity generating and distribution networks (not to berate an impersonal internet, but also there are vulnerabilities to the very same information-intensive computer and communication systems and networks which little things like hospitals and other public utilities (e.g., Chicago Center) rely upon all day and all of the night). Why this is relevant is....

Because the same logic which tells us that software and cockpit automation takes the errant human off of the controls of the civil aviation aircraft overlooks, or even ignores, the existence of potential for unwanted trouble being caused by the human programmers and coders. Humans are said to be failure-prone (which is kind of, undeniable). Why then is it assumed that the coding and algorithms and so forth will be: Pristine! Perfect! No Back Doors, Trap Doors or Stuck Exit Doors, Not Ever!!

Besides, I am still waiting for one of the "automation" gurus, or even mavens, to demonstrably prove that, just to take a probably fairly mundane or even simple example, that a set of algorithms can be written today, in 3 years, or anything not "futuristic" with regard to timeframe, which could fully account for safe operational necessities of the Delta flight over LA which dumped fuel and caused at least a publicity uproar when some of the fuel visited a schoolyard. I have said, demonstrably prove, because, I would want to see what courtroom types know as demonstrative evidence. Show me the algorithm, show me it works in a full-fidelity simulator in which positively zero of the operational variables have been, you know, slightly rounded off to make the coders' jobs look classier.

No one should or can deny automation is increasing. But the inconsistency between scoring the humans wearing three- and four-stripes on the one hand, but lofting (or is it lifting) coders into rarified air of perfect performance, just seems too much. Oh by the way, Happy Labor Day (computers, this is NOT for you).

[Big Pistons Forever]

Willie Nelson

Korean Airlines was in a similar situation in 20 years ago. A completely dysfunctional culture with no accountability for crew actions eventually had consequences that could not be ignored if they wanted to continue flying outside of Korean airspace. A team from Delta Airlines was brought in an the result was pretty profound changes. Korean Airlines is not perfect but it is light years ahead of where it was. Like the old saying "Sometimes things have to get worse before they can get better", maybe this accident will the catalyst for change as the circumstances are so egregious.

[flash8]

If I recall from the time (and as I have also mentioned earlier in this thread), the Korean report was "leaked" and made sober reading. I have a lot of respect from them as they cleaned up their act and frankly realized it had to be done, there were no half-measures. As for PIA, suspect nothing of the sort will ever occur, too many intertwined interests that threaten the status quo, cultural issues will never allow anything of this sort ever to see the light of day. By all means quote Korea (a good example) but those that expect a Korean style epiphany will be waiting a damned long time because it won't happen.

[Willie Nelson]

The leaked KAL LOSA audit is legendary, which makes me suspect that some of it at least may be doubtful, who knows, their remediation is also legendary. My understanding is that they were facing the likely prospect of being uninsurable they got in some expertise and cross cultural experience to break open the closed, face saving, practices and extant culture.

I’m not sure if things need to get really worse before they get better. Surely this is where regulators could play a useful role in being proactively engaged in airline safety management processes rather than passively reactive to these horrific inexcusable crashes that, let’s be honest, are some of the more common phenomena in the current iteration of modern crash comics, think of Garuda’s Jogjakarta crash as an example.

[Check Airman]

Willie Nelson

Any idea where somebody could get a copy of that file? Wasn't able to find it on google.

[fgrieu]

KAL Line Operations Safety Audit (http://www.flight.org/downloads/pdf/korean_airlines_safety_audit_report.pdf#page=2)

[ATC Watcher]

unworry

The Garmin safe return is an emergency tool based on existing technology , I have no doubt that a more advanced version that will include vacating the runway , taxi and parking is not far away , however certifying an emergency tool is far easier that a standard feature with paying pax on the back . I am rather a believer that the future will be on Single man ops augmented with full automation and a man on the ground supervising the whole thing for more aircraft .
Time will tell, the Covid crisis might accelerate or delay the whole thing depending on which side of the fence the power will be.

[Anti Skid On]

https://www.airbus.com/newsroom/stories/autonomy-aerial-mobility.html - it's already way ahead

[ATC Watcher]

Oh yes, great plans with Airbus . the problem is that this technology will be expensive and was driven on pre Covid-19 thinking , which you find on the first page of the site link you gave : air traffic is expected to double by 2037 (https://www.iata.org/pressroom/pr/Pages/2018-10-24-02.aspx). This will necessitate approximately +37,000 new passenger and freight aircraft (https://www.airbus.com/aircraft/market/global-market-forecast.html)—and more than half a million new pilots to fly them. Given this expected increase in air travel, other solutions will be required to support pilots in aircraft operations.
Covid -19 has already changed that .
That said , one old management sentence keep on coming back in my thoughts these days :
" Do not waste the great opportunities a good crisis gives you"

[Check Airman]

Thanks a bunch!

[Anti Skid On]

It was a great read, if a little dated. Does anyone remember the KAL pilot who gained his IR on an aircraft that had no engines, because it was in maintenance?

[Zeffy]

https://youtu.be/kH-61DEHRKc

[neilki]

WillowRun 6-3

Actually. thats not correct: The Internet Pathways you refer to are (almost by definition) unchanged from the original DoD TCP/IP specifications from the mid 1970's.
The Internet infrastructure is fundamentally insecure. Many corporate and private networks have added layers of security, but the internet backbone is something of a provinciaL Wild West outpost.
As a Cirrus instructor I'm well aware of Safe Return, the autonomous autoland. It's impressive; and based on 2018 processing power. It works (aside from ATC blind broadcasts) in isolation. It is one thing to select a GA Airport; quite another to land safely in a busy traffic pattern.
I love my day job seat in the A320; but the 1980's processing power afforded to the jet is great for envelope protection and flight automation. It won't play nicely in the real world for a long time yet...

[Connie Wings]

ATC Watcher

Yeah, only time will tell, totally agree.

[Big Pistons Forever]

Bottom line is simple. KAL was a :mad: show and was close to losing access to primary international markets and insurance cover unless they cleaned up their act. The Delta guys came in and pointed out what they needed to do. To KAL’s credit they made some wrenching internal changes and fixed most of the issues. FWIW a friend of mine had first hand knowledge of KAL in the bad old days and almost everything in the report I referenced mirrors what he told me.

PAL and the Pakistani regulators are at a crossroads. They can effect structural change and adopt a modern flight safety culture or they keep on with cosmetic changes that everyone can see through while continuing to crash airplanes. If that is the way they chose to go then they will be a regional only airline going forward.

[Seat4A]

"KARACHI, Pakistan, Jan 29 (Reuters) - Pakistan’s top investigation agency arrested six people on Friday for their alleged involvement in a scandal involving fraudulently obtained pilots’ licences that came to light after a Pakistan International Airlines jet crashed last year, officials said."

https://www.reuters.com/article/pakistan-aviation-arrests/pakistan-arrests-aviation-officials-over-pilots-licence-scandal-idUSL4N2K44XW

[AOB9]

If this is true, it is absolutely frightening to think that a person feels he/she has the right to assume such a responsible job without the proper credentials.
And even more frightening to learn that aviation officials aided such criminal behaviour.

[aterpster]

It was widely reported at the time of the accident. I'm surprised you are surprised.

[osborne]

I'm surprised that you are surprised and that they got found out. Tip of the iceberg.

[atakacs]

Indeed
unfortunately much more to the story 😐
That being said it seems both pilots in this case had proper paperwork. Not that it really mattered.

[autoflight]

It seems that that PIA8303 is normally scheduled to depart Lahore at 10:00 local time. Based on the accident time, it is likely that the actual departure was delayed by about 3 hours. The cause of the delay may shed light on possible waiting conditions of the crew. At midday, the temperature in Lahore was 42C.

It will be interesting to eventually know if the accident investigation considers what time the flight crew actually showed up for duty and under what environmental conditions they waited for late departure. Could the pilots have been fatigued or otherwise impaired?

If the APU was not available due to unserviceability, company procedures for extended ground use, or insufficient fuel to accommodate extended APU use, the aircraft interior temperature could be very high with OAT of 42C or greater.

[Timmy Tomkins]

Impaired or not, they were not conducting them selves in a profesional manner according to the government minister and were non standard throughout

[parkfell]

This remarkable tragic accident occurred 22 May 2020.

update edit: We await the official final Pakistani report with interest.
AV Herald has an update 21/5/2021

[DaveReidUK]

I'd estimate that the average time taken for the investigation report into any fatal airliner accident to appear is around a year, maybe longer.

For example the NTSB's report on the October 2019 Penn Air accident in Alaska is still awaited, more than 18 months after the event, so it's a tad unfair to single out the Pakistan AAIB.

[waito]

at least there's an interim statement of Pakistan CAA today.

[RoyHudd]

Really? Where is it published? Please provide a link...I am assuming it is translated into the English language.

[568]

Is there rear fuselage damage underneath towards the tail looking aft of the left cabin door? The picture does show RAT extended and damage to both engine nacelles.

[Chris2303]

RoyHudd

It's in here, just scroll down until you get to it

Crash: PIA A320 at Karachi on May 22nd 2020, impacted residential area during final approach, both engines failed as result of a gear up touchdown (http://avherald.com/h?article=4d7a6e9a&opt=0)

[FlightDetent]

568

No, it's quite unlikely given the geometry.

The element sticking out below the aft door is a water drain mast. Often gets damaged first during tail scrapes, seeing it intact has a meaning of its own. The other blurred part under the tail cone is the contour of APU inlet door overlapping the visible part of the elevator from the far side.



https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/785x320/gear_up_scratch_da1814245c3b5621ebf449904c4d8aef09f2e02e.jpg

[fox niner]

Airplane Geometry is not a factor. As you can see in this photo the engine nacelles are the only parts of the airplane structure that is in contact with the runway.

https://cimg3.ibsrv.net/gimg/pprune.org-vbulletin/750x667/8532b547_7f49_485e_969f_fa600d171ace_21ff95ef8eeb7dbbf76ed48 bf9603c3ace709f1d.jpeg

[FlightDetent]

So, it is a factor for NOT scraping the tail, right? With wheels up, the tear would be much forward.

​​​​

[568]

Thanks for the brilliant graphic and response.

[autoflight]

Is there an official comprehensive final report yet for this accident?

[parkfell]

PIA 8303
Today is the third anniversary of this tragic accident.
Although a preliminary report has been published, the final report has yet to be released.

[Hartington]

Many years ago I was running some tests on a piece of commercial,non aviation, software when it "misbehaved".
I showed it to the programmer who looked quizzical and said "I wondered if it would do that".
Software, in all environments, has evolved but testing still depends (to a degree) on the tester trying to outwit the programmer!

[autoflight]

Impaired or not, they were not conducting them selves in a profesional manner according to the government minister and were non standard throughout
Hi Timmy,
it seems reasonable, pending a final report, to assume the crew was not following standard procedures. The big question is “why not?”. If it is because of impaired physical or mental state, a target of the enquiry might be along those lines, rather than concentrating on the mechanics of the the destruction of an apparently serviceable aircraft and the deaths of those on board.
P.S. My money would be on severe dehydration with resultant adverse mental state.
P.P.S. If I’m right, how confident could one be that this appears in the final report?

[Boeingdriver999]

Hi, the report already states they were not following SOPs during the entirety of the flight so that’s a confirmed fact found.

I haven’t read the entire 43 pages of this thread but did read the report. Why do you hypothesise they were extremely dehydrated?

Thanks,

BD

[jumpseater]

Hi, the report already states they were not following SOPs during the entirety of the flight so that’s a confirmed fact found.

I haven’t read the entire 43 pages of this thread but did read the report. Why do you hypothesise they were extremely dehydrated?

Thanks,

BD

Back in the pages there was comment regarding fasting I believe

[fdr]

KAL Line Operations Safety Audit (http://www.flight.org/downloads/pdf/korean_airlines_safety_audit_report.pdf#page=2)

Bottom line is simple. KAL was a :mad: show and was close to losing access to primary international markets and insurance cover unless they cleaned up their act. The Delta guys came in and pointed out what they needed to do. To KAL’s credit they made some wrenching internal changes and fixed most of the issues. FWIW a friend of mine had first hand knowledge of KAL in the bad old days and almost everything in the report I referenced mirrors what he told me.

PAL and the Pakistani regulators are at a crossroads. They can effect structural change and adopt a modern flight safety culture or they keep on with cosmetic changes that everyone can see through while continuing to crash airplanes. If that is the way they chose to go then they will be a regional only airline going forward.

The "Delta audit".... wasn't. The authors were not qualified as auditors by any international standard, and while interesting reading, it was not an audit comparing policy/procedures/practices against objective observations. The guys were doing the best they could do, they were also ill equipped to do a report.

The situation at KAL in the closing days of 99 was particularly problematic, and the company's CEO, Old Man Cho took the action to make substantive change, and that was a double edge sword. Comment is made on a KAL pilot passing an IR on an aircraft with no engines, I'm not sure of that, but I was involved in looking at sims that were signed off without the staff turning up, which was quite annoying. OTOH, there were also investigations on a number of foreign pilots who turned up at KAL with P-51 time, enough of those to be bloody annoying.

The most competent pilots at KAL included local Koreans, an Ethiopian, and various other groups. Some national groups irritated the locals no end, but they did the same at other airlines.

I'n 9,000 hours there, I had zero, repeat zero MEL that needed to be applied to an aircraft. Occasionally stuff failed, but the aircraft were generally well kept compared to any other airline that we audited.

Much criticism of KAL is deserved at that time, and much is not. Given the scrutiny that the company was under, it acted quite well given the pride of the nationals, a group that are in a continuous state of frozen hostilities with an unpleasant neighbour.

It was not a Korean that blew into Anchorage at 340kts into the circuit, missed the runway by 600' vertically, did a 360 and missed it again. Local crews did some fascinating things with aircraft as well, that kept me busy along with a number of local and foreign crew that were intent on resolving the issues the airline had.

On the death of the Old Man, his son Cho Yung Ho assumed his place at the helm, and he tried to make KAL a center of excellence, it always was from an engineering viewpoint, the problems tended to be related to a rather brutal and pathological management style, which was a hangover of it's recruiting of crew from the defence force. There are many learning points from KAL, CAL, and similar operations, there are many people that have worked to make things better and there were also a number of crews that took the money, bitched and did not engage with the locals to be a productive part of a solution. Having assessed for the company many incidents and accidents, I am not able to support much of the "audit" that was presented to the world as a competent audit, I don't consider it a competent, unbiased objective assessment. The foreign crew could have reasonably have been expected to be statistically lower on incidents than the crew that they were to support. That was not supported as a hypothesis with the incident occurrences that I investigated. There was sufficient incidents tracked by the FOQA system to make such a determination had it been valid... The 80:20 rule existed in all camps, except for one; there was only one Ethiopian, and he was an absolute pleasure to watch operate a 744, every airline he went to he was a blessing.

And while we are watching Putin cause genocide and war crimes, a couple of the Russian pilots were exemplars of Human Factors and CRM application. Almost all of the Russians that were there were a delight to work with, and I wish them fair skies and happiness while they keep their families safe and far away from the depravation of Putin on Russia and the future of their countrymen while this tragedy plays out in Ukraine. Slava Ukraine.

KAL was not for the faint hearted, but it was definitely interesting. damned good engineers in general.

[Piltdown Man]

Below are two quotes from a post above:

it seems reasonable, pending a final report, to assume the crew was not following standard procedures. The big question is “why not?”

P.P.S. If I’m right, how confident could one be that this appears in the final report?

My money would be on this report throwing the crew under the bus for not following SOP’s. But is that really the full story? When no data monitoring exists, when an airline has a poor training, checking and management, when the oversight authority doesn’t understand the industry, when local culture allows perceived seniors to really make a Horlicks of things and get away with it then it will not be surprising that SOP’s will not followed. On Page 83 FlightDetent asked some really good questions. I’ll bet few if any of these have been considered.

SOP’s arise as a result of having the core foundations well established. They are not an end in themselves. They are merely a way of operating complex systems in such as way so that everybody understands what is going on.

[Boeingdriver999]

Certain studies have observed an increase in road traffic injuries around sunset during Ramadan. The paradigm suggested is that fasting during daylight and societal behaviour around sunset lead to physiological & physiological changes that are suboptimal leading to worse decision making/reaction times.

Reference here: https://www.sciencedirect.com/science/article/pii/S1658361222001111

[WideScreen]

The "Delta audit".... wasn't. The authors were not qualified as auditors by any international standard, and while interesting reading, it was not an audit comparing policy/procedures/practices against objective observations. The guys were doing the best they could do, they were also ill equipped to do a report.
......

I don't know the report, though let me 100% accept your qualification of it.

A major aspect is:

Result = (quality of the solution) * (acceptance of the solution).

I think, IF a report was written having the quality you would like to see, it would have been completely unacceptable for all involved and as such, thrown aside.

The marginal quality report they got, it got accepted internally and (as a first step) implemented. From there, the next steps would be the way to go, as has been done.

Compare that with an ISO-9000 quality system. Very nice, but the ISO-9000 doesn't have a growth path towards a higher quality level, it just "nails" the level and find out yourself, how the organization does reach the described quality level. When the step from the current situation isn't that big, it's somewhat manageable. When the current situation is pure chaos, introducing a QA system will be a nightmare and outright fail to get implemented. See my earlier writings, on how difficult it is to significantly change the culture (IE implemented QA level ....) of an organization.

Software development did go through that process, by what is called SPI (Software Process Improvement). It defines 5 levels, with each level having a lot of specific subjects to cover to improve the software development process. This stepwise refinement takes care, all the subjects get improved in a useful (and for the organization acceptable) order. The higher the level, the longer the planning horizon becomes, though. Level 1 is the current chaos, Level 2 brings you actions to describe what you have, and take care it doesn't get lost. Level 3 takes care of one start to plan for changes (and track those). Level 4 takes care of it, it's organization-wide, etc. The higher the level, the less flexible the organization becomes. Most organizations should not go beyond level 3, since it hurts flexibility too much, to be able to be competitive and react to market changes.

[fdr]

I don't know the report, though let me 100% accept your qualification of it.

A major aspect is:

Result = (quality of the solution) * (acceptance of the solution).

I think, IF a report was written having the quality you would like to see, it would have been completely unacceptable for all involved and as such, thrown aside.

The marginal quality report they got, it got accepted internally and (as a first step) implemented. From there, the next steps would be the way to go, as has been done.

Compare that with an ISO-9000 quality system. Very nice, but the ISO-9000 doesn't have a growth path towards a higher quality level, it just "nails" the level and find out yourself, how the organization does reach the described quality level. When the step from the current situation isn't that big, it's somewhat manageable. When the current situation is pure chaos, introducing a QA system will be a nightmare and outright fail to get implemented. See my earlier writings, on how difficult it is to significantly change the culture (IE implemented QA level ....) of an organization.

At the time, a formal IOSA type report conducted by IOSA competent auditors would have been beneficial and indeed those reports were done later, and are appropriately not public domain.

[MissChief]

After over 3 years, no official report is forthcoming. PIA and the Pakistani authorities are clearly up to their old tricks.

I'll avoid flying in any airline of that country, simply because of safety concerns. PIA are statistically the worst.

[parkfell]

After over 3 years, no official report is forthcoming. PIA and the Pakistani authorities are clearly up to their old tricks.

I'll avoid flying in any airline of that country, simply because of safety concerns. PIA are statistically the worst.

Embarrassment that such unbelievably gross errors can occurred are in part a reason why no final report has been published.

[flash8]

Embarrassment that such unbelievably gross errors can occurred are in part a reason why no final report has been published.I'd call it multiple gross criminal negligence, not unusual in that region.

[Asturias56]

After over 3 years, no official report is forthcoming. PIA and the Pakistani authorities are clearly up to their old tricks.

I'll avoid flying in any airline of that country, simply because of safety concerns. PIA are statistically the worst.

I think it took 4 years to publish the AF447 report - and I 'm sure soem others have taken longer

[DaveReidUK]

I think it took 4 years to publish the AF447 report

Though 2 of those 4 years were spent searching for the flight recorders.

[Daidaidionsyus]

This is the most staggering air disaster of the modern era that has gotten such little media attention. Its quite odd.

[Asturias56]

Though 2 of those 4 years were spent searching for the flight recorders.

yes but Pakistan isn't the only place that is very slow to publish Final Reports

[andrasz]

Simon has managed to obtain the Final Report that was released today:
http://avherald.com/files/(PUBLIC%20VERSION)%20FINAL%20INVESTIGATION%20REPORT%20PIA%20 8303%20AP-BLD.pdf

160 pages of mostly repeating what we already know in hair-raising detail, but much to my surprise, it is actually acknowledged that "the judgement of both flight crew was probably impaired due to effects of fasting while flying".

Other noteworthy quotes from the report:

"[Captain] was of bossy nature, firm, dominant and overbearing. He had below average intelligence. He tends to have little regard for the authority. He had low mechanical comprehension with low comprehension of space relations. His level of stress tolerance was also quite inadequate."

"Captain flew 289 flights in last 12 months prior to accident, out of which only 06 flights were analysed. Overall FDA rate for PIA was less than 5% and dedicated Flight Data Analyst was not available in PIA Safety Department till event flight."

"Flight history of Captain for last 12 months had numerous triggers during approach related to High Speed, Path High, High Rate of Descent, Long Flare Distance and GPWS Warnings. There was no Go-Around initiated and several Unstabilized Approaches were continued."

[fox niner]

Well, at least the pilots were properly licenced!

[atakacs]

TBH not sure how they lasted 14k hours - this is just unbelievable.

[Fursty Ferret]

Interesting to see the impact that hypoglycaemia has - worse than being drunk.

[atakacs]

Captain had quite the rap-sheet (when it comes to flight safety)...

[CVividasku]

It's going to be a delight to read, thanks very much !

[cessnapete]

It's going to be a delight to read, thanks very much !


Surprisingly I don’t read any criticism of the co-pilot in the report.
Obviously the Capt is in Command but why the Co,pilot sat, not taking over control in such extreme circumstances, and letting the Capt. kill him, is unbelievable. Presumably no CRM in their SOPs.
Shades of the Korean 777 accident at SFO where the supervisory Capt and Copilot were afraid to speak up against a more Senior Capt.. Seems to be a cultural personality trait, which still prevails in certain parts of the aviation world.

[Maninthebar]

Skybrary lists 71 accidents or incidents for which 'Authority Gradient' was listed as a contributory factor in formal reports. I leave it to finer statisticians than I to allocate these to specific cultures or geographical entities

Accidents and Incidents | SKYbrary Aviation Safety (https://skybrary.aero/accidents-and-incidents?f%5B0%5D=hf%3A1830)

[CVividasku]

Skybrary lists 71 accidents or incidents for which 'Authority Gradient' was listed as a contributory factor in formal reports. I leave it to finer statisticians than I to allocate these to specific cultures or geographical entities

Accidents and Incidents | SKYbrary Aviation Safety (https://skybrary.aero/accidents-and-incidents?f%5B0%5D=hf%3A1830)
I clicked on one randomly and could not see any link to authority gradient !
Maybe find another metric...

[Capn Bloggs]

I clicked on one randomly and could not see any link to authority gradient !
Maybe find another metric...
If you click on the search criteria you will see "Authority Gradient" is marked.

I clicked on a random entry:
https://skybrary.aero/accidents-and-incidents/at72-mumbai-india-2009
and while the words "authority gradient" aren't in there, the report indicates a submissive FO who didn't have much input into the approach or obvious reasons.

So yes, IMO Maninthebar has provided a good link.

[RudderTrimZero]

In Eastern cultures, an older man is to be considered in the same light as your very own father. You don't raise your voice at them, criticize them or complain about their behaviour for fear of being seen as rude. We in the Western world were there too once upon a time. It won't change for another 30-50 years I'm afraid.

[krismiler]

"[Captain] was of bossy nature, firm, dominant and overbearing. He had below average intelligence. He tends to have little regard for the authority. He had low mechanical comprehension with low comprehension of space relations. His level of stress tolerance was also quite inadequate."

That reminds me of a few Captains I used to fly with.

I try hard to avoid an authority gradient but it can be difficult with an F/O who’s young enough to be my child and only has a few hundred hours. I flew with one a couple of months ago who carried a notebook and kept writing down what I had said. She flew well and was very keen to learn but I doubt she would have challenged a poor decision or spoken up.

[340drvr]

Blancolirio (Juan Browne) discussion here.
Pakistan International Airlines #8303 Shocking Final Report! (youtube.com)

[J.O.]

Juan Browne succinctly captures the absolutely disgusting operational culture and cockpit dynamics that contributed to this crash. This is one airline that I would never choose for my travel plans.

[Amadis of Gaul]

Juan Browne succinctly captures the absolutely disgusting operational culture and cockpit dynamics that contributed to this crash. This is one airline that I would never choose for my travel plans.
I wonder what his real name is. There is no Juan Browne or Brown anywhere in the FAA database...

[megan]

I wonder what his real name is Probably Thomas "Juan" Browne.

https://www.theunion.com/news/grass-valley-pilot-safely-lands-757-after-one-engine-quits/article_d5d5e449-58d2-5d7e-81e8-16b309dcdb94.html

[thnarg]

Sobering stuff and further comments are pointless, other than voicing increased respect for Airbus designers. Ironically, keeping the gear up on the second approach could have improved the outcome.

Question from a long retired bus driver: was the route stored or downloaded from PIA with the SABEN hold already in it (ie other crews would have encountered the scenario) or was it manually inserted by this crew? Of course, a basic altitude/dtg check somewhere would have been useful, but then so would a bacon sandwich.

Next week I hope to enjoy a westbound daylight flight with a reputable Middle East airline. I will enjoy it more if you sandpit chaps can assure me there will be no fasting at the front…

[champair79]

I suspect the SABEN hold was inserted automatically when retrieved from the nav database memory when the ILS procedure was loaded as it is part of the procedure. The crew would likely have been familiar with this ‘gotcha’ but having not flown regularly because of the pandemic, not concentrating on the task in hand and fasting, they missed it. Also pre-pandemic, perhaps getting the shortcut to the ILS was less common as the traffic environment would’ve been busier. OM-C would likely have warned of this trap too (or maybe not in PIA!) but the crew were overconfident and had likely flown this domestic route many times and became complacent.

[Amadis of Gaul]

Probably Thomas "Juan" Browne.

https://www.theunion.com/news/grass-valley-pilot-safely-lands-757-after-one-engine-quits/article_d5d5e449-58d2-5d7e-81e8-16b309dcdb94.html

That sure sounds like our Juan.

[India Four Two]

That sure sounds like our Juan.

It does indeed!

​​​​​​​... and yours truly flew a flawless single engine (Instrument Landing System) into LAX with crummy weather – 500 feet broken/mist.

[megan]

​​​​​​​... and yours truly flew a flawless single engine (Instrument Landing System) into LAX with crummy weather – 500 feet broken/mistA little promotion might be excused as his Mother, Juanita Kennedy Browne, also wrote a "100 Years Ago" column in the '80's for the paper, Father was an engineer working for Aerojet on the Space Shuttle. Paper seems to take a local boy made good view of Juan. Good for him, something positive.

[FlightDetent]

In Eastern cultures, an older man is to be considered in the same light as your very own father. You don't raise your voice at them, criticize them or complain about their behaviour for fear of being seen as rude. We in the Western world were there too once upon a time. It won't change for another 30-50 years I'm afraid.
Doesn't need to apply for aviation, on-board and it should not.

It's a responsibility of the F/O too not to get killed. As a part of their professional qualification they shall know how to.

P.
A.
C.
E.

I learned that as en ex commie kid 25 years ago. No need to invent a new horse.

[Uplinker]

In my training that was only ever briefly mentioned in passing. Never practised or used in any scenario in the Sim.

It is not easy for a young or new F/O to challenge an older and very experienced captain - especially an autocratic captain.

It's not enough to say "this is what you do". Like everything in flying, it has to be rehearsed and practised.

We were never given the mindset of being equal flyers; and taking control was only ever practised for captain incapacitation - where there is no argument or opposition - or when F/Os were given an exercise being the PIC and the captain was their F/O.

[Discorde]

From a recent edition of The Times newspaper (UK):


https://cimg3.ibsrv.net/gimg/pprune.org-vbulletin/600x840/times_martha_s_rule_anon_408dda4bbaeeabbd63e8a048c8155d62ac8 6a490.jpg

[megan]

"Captain, you must listen" written in our ops manual and that was three decades ago.

[Big Pistons Forever]

Mr. Khaqan Murtaza
Director General of Civil Aviation Authority (CAA) of Pakistan,

You Must Listen……

[aeromech3]

Not being a pilot, but I have wondered why "Direct to" was not often given during my trips up front with a Jeppesen in my lap,
In the late 70's my L1011 training included Nav and I was shown the capability of the triple system in this aircraft and capability to arrive at destination spot on time, but with multi ATC areas and rules being excluded.
Why offer "pilot discretion proceed direct MAKLI" if this would entail a follow on LH hold pattern (over a populated areas), what advantage?

[Capn Bloggs]

Why offer "pilot discretion proceed direct MAKLI" if this would entail a follow on LH hold pattern (over a populated areas), what advantage?
It may not force you into a hold, depending on the exact situation (eg weight, wind, crew skill). For example, the crew could throw out the speedbrakes and stuff the nose down on a "direct to" MAKLI, getting there close to profile for a straight-in and obviate a hold. Doing so would save time and fuel.

[thnarg]

As the Capn implies, short cuts and “straight-ins” are not uncommon but it’s up to both pilots to agree about their aircraft’s potential and kinetic energy. If the crew is unhappy with the offer, possibly because tiredness, either a polite refusal or a request for more track miles is the correct response and is always respected.

So a very quick mental calculation and discussion for those who are well trained, well rested and well fed.

[bille1319]

At least crying Inshallah sounds better than Alahu Akbar in their final CVR during their final minutes and shows they had not lost their nerve completely.

[CVividasku]

I looked into this accident today.
I'm really shocked to find out that most likely all of the deadly mistakes that day were committed by the F/O.
Of course you could say that the captain stubborness to land at all costs was the cause of this accident. But the F/O really didn't help.
He was most likely the one to retract the landing gear before landing. Had he not done that, the aircraft would have probably been able to stop on the runway with the gear down.
He's the one who called for a go around, with engines scraping the runway. Had he not done that, they would just have made a runway excursion, with possibly 100% survivors depending on how much the airplane would have slowed before encountering the first obstacle.
He was the one calling for right engine idle after the "go around". Had he not done that, the airplane would have had more altitude when the engines would give up (after having lost all of their oil)
He was most likely the one to get the landing gear out again after the ATC called them about it. Had he not done that, the airplane most probably could have flown the 1300 meters that it was missing from the runway. And it's likely everybody would have survived, if the gear had been extended at the right time (30s before touchdown).

To sum up, the captain would have transformed a normal standard flight, into a very unstandard flight but certainly without any scratch to the passengers or airplane. The captain could have crashed the airplane, but some other day.
On the other hand, the first officer transformed the very unstandard flight without any damage, to a fatal crash, then and there.
And he committed at least 4 actions that all converged to do so. Abstaining from just one of them could have saved most of the lives involved and even the airplane serviceability (first one).

It's surprising that his role is not emphasized more.

Of course I'm not advocating for 7° slope approaches over stabilized approaches, but I will advocate for messy landings that don't kill anybody over crashes, all day long, all year round.

[Lookleft]

I'm really shocked to find out that most likely all of the deadly mistakes that day were committed by the F/O.

That doesn't let the Captain off the hook. At no point during a flight does the Captain relinquish command even more so when he is also the PF. Both pilots were making deadly errors that day but it is the Captain who was ultimately responsible for their consequence. He could have told the F/O to leave the gear down and he did not have to execute a go-around just because the F/O called for it. Some days the F/O's performance is not very good and some days the Captain's performance is not very good. On this day neither pilot was operating to even a minimum standard with unfortunate results.

[andy148]

Mentor pilot has done a very good debrief of this accident on his Youtube channel Mentor Pilot
It makes for sombre watching.

To counter CV's post above regarding the FO and the landing gear before the crash. The tower controller asks the crew about the landing gear which is than acted upon by the crew. Who moved the lever is unknown. If the controller had not mentioned this it would have moved one of the proverbial holes in the swiss cheese and the landing gear may have been kept stowed for longer.

Also mentioned is the order of warnings that the Airbus logic issues. The 'too low, gear' warning was not given on the first attempt. Can anyone eleberate on why, in my opinion a critical warning like this wouldnt be given a higher priority?

[CVividasku]

That doesn't let the Captain off the hook. At no point during a flight does the Captain relinquish command even more so when he is also the PF. Both pilots were making deadly errors that day but it is the Captain who was ultimately responsible for their consequence. He could have told the F/O to leave the gear down and he did not have to execute a go-around just because the F/O called for it. Some days the F/O's performance is not very good and some days the Captain's performance is not very good. On this day neither pilot was operating to even a minimum standard with unfortunate results.
Not really. I don't know for Pakistan airlines but in my airline for example it's mandatory to go around if any pilot calls for it.
Not going around after a go around call is cause for failure in any sim examination (even if you call go around yourself then change your mind)

Also, maybe he didn't notice the F/O put the gear up. The fault lies with the F/O who didn't ask nor communicate it.

[tdracer]

Also mentioned is the order of warnings that the Airbus logic issues. The 'too low, gear' warning was not given on the first attempt. Can anyone eleberate on why, in my opinion a critical warning like this wouldnt be given a higher priority?

Apparently the warning is inhibited above a certain airspeed, since no sane person would attempt to land while going that fast. Instead I believe they got the GPWS warning - which of course they dismissed as a nuisance since they were landing (not read the report).

[Doug E Style]

Not really. I don't know for Pakistan airlines but in my airline for example it's mandatory to go around if any pilot calls for it.
Not going around after a go around call is cause for failure in any sim examination (even if you call go around yourself then change your mind).

Would you still go around if the call comes after your engines have been scraping along the runway for fourteen seconds?

[CVividasku]

Would you still go around if the call comes after your engines have been scraping along the runway for fourteen seconds?
The captain wasn't in a state of mind where he was able to do that sort of reasoning. Certainly he still didn't notice that the F/O had retracted the gear.
In that state of mind, he was easily convinced by what sounded like an order. "Take off sir, take off !" That's an order.

I would just have liked the report to point out that based on performance calculations, had the gear been kept down throughout the approach, the airplane would have been able to land at the beginning of the runway, on the correct profile, maybe with some excess speed.
The 3400m dry runway then would have been ample room to land even at a ludicrous speed.

Even without the deceleration provided by the gear, had they landed on their wheels, 1500m down the runway, at 200 knots, the airplane at its mass would have been able to stop within the remaining runway length. Worst case they would have made a low speed runway excursion.