Air Blue crash was caused by Captain
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From a public domain source, this link takes you to the poor quality scan of the report. Some diagrams are not readable, but the reasons for the crash can be easily determined. It is not comforting reading.
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No problem Maajam. We appreciate your effort. Perhaps you could search for some earlier Pakistani reports if you have the proper connection. It would be a great help.
Thanks again.
P.S. Some said earlier..."Is it officially released to the world? Don't want to step on anyone's toes". I don't think we should worry one bit about that as some countries seem to rarely if ever release reports like this and they should be released in the name of furthering aviation safety regardless of how many toes are stepped on.
Thanks again.
P.S. Some said earlier..."Is it officially released to the world? Don't want to step on anyone's toes". I don't think we should worry one bit about that as some countries seem to rarely if ever release reports like this and they should be released in the name of furthering aviation safety regardless of how many toes are stepped on.
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BOAC:
Poor quality as to diagrams, but certainly adequate as to text.
The circling area and the crash site location appears to be almost exactly what we went through here just after the crash.
My plotted position of the crash site differed 325 feet from the coordinates in the report. It is dramatic to see how far they strayed beyond the PANS-OPS circle to land protected area. As they approached the crash site no one was in control of that airplane.
I find it interesting that one of the recommendations of the report is the establishment of an instrument approach to Runway 12 if possible. As I demonstrated last year the only barrier to an RNAV IAP is political, not terrain. Further, unless the VOR station has performance issues, a VOR/DME approach is also feasible. Finally, unless the back course has issues, a BC/DME approach is also feasible.
From a public domain source, this link takes you to the poor quality scan of the report. Some diagrams are not readable, but the reasons for the crash can be easily determined. It is not comforting reading.
The circling area and the crash site location appears to be almost exactly what we went through here just after the crash.
My plotted position of the crash site differed 325 feet from the coordinates in the report. It is dramatic to see how far they strayed beyond the PANS-OPS circle to land protected area. As they approached the crash site no one was in control of that airplane.
I find it interesting that one of the recommendations of the report is the establishment of an instrument approach to Runway 12 if possible. As I demonstrated last year the only barrier to an RNAV IAP is political, not terrain. Further, unless the VOR station has performance issues, a VOR/DME approach is also feasible. Finally, unless the back course has issues, a BC/DME approach is also feasible.
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This is the long thread we had here at the time of the accident:
http://www.pprune.org/rumours-news/4...islamabad.html
http://www.pprune.org/rumours-news/4...islamabad.html
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I don't think there will be an ILS on 12 anytime soon. The new airport about 30 miles to the west should be in service in, I think, in 2012/3, and it is supposed to be world class with dual runways and all the works.
Yet this could have been done many years earlier at minimal cost since many aid donor's would have been happy to gives us a grant to finance the equipment and have their contribution acknowledged.
The pilot kept asking for a right-hand downwind even though he should have known that it is not available since that would mean flying over the heavily-populated twin city of Rawalpindi.
Yet this could have been done many years earlier at minimal cost since many aid donor's would have been happy to gives us a grant to finance the equipment and have their contribution acknowledged.
The pilot kept asking for a right-hand downwind even though he should have known that it is not available since that would mean flying over the heavily-populated twin city of Rawalpindi.
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Sir,
My information is that reports were always prepared even in the case of incidents. They were, for one reason or the other -- probably related to fear of litigation -- were never published.
With the judiciary hyper-active these days, once a petition was filed in two High Courts and accepted for hearing, it was only a matter of time before the authorities would wilt.
I am hopeful that this publication will open up a new era of transparency in the country in the field of civil aviation -- hitherto very much a sealed black-box.
My information is that reports were always prepared even in the case of incidents. They were, for one reason or the other -- probably related to fear of litigation -- were never published.
With the judiciary hyper-active these days, once a petition was filed in two High Courts and accepted for hearing, it was only a matter of time before the authorities would wilt.
I am hopeful that this publication will open up a new era of transparency in the country in the field of civil aviation -- hitherto very much a sealed black-box.
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May I ask those of you who have read the report to comment on it for my edification?
Now we know what.
What about "why"? Why did the captain do everything wrong, violate all procedures with such impunity and ignore the warnings from the EGPWS?
Over-confidence? Complacency? Arrogance? Subtle incapacitation?
Thank you in advance.
Now we know what.
What about "why"? Why did the captain do everything wrong, violate all procedures with such impunity and ignore the warnings from the EGPWS?
Over-confidence? Complacency? Arrogance? Subtle incapacitation?
Thank you in advance.
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I cannot begin to explain the Captain's performance but it does appear that possibly being ex PIA there was some perceived 'status' issue where he did not need any help thank you.
It is the F/O's behaviour I find very strange - to allow yourself to be driven into a hill without attempting to stop it. Are all PAF pilots that 'weak'? I am pretty sure that no amount of derision, whiplashing, abuse, shouting at etc etc from a Captain would cause a British mil pilot to sit there and do very little. As I said, the IAF must be rubbing their hands with glee.
It is the F/O's behaviour I find very strange - to allow yourself to be driven into a hill without attempting to stop it. Are all PAF pilots that 'weak'? I am pretty sure that no amount of derision, whiplashing, abuse, shouting at etc etc from a Captain would cause a British mil pilot to sit there and do very little. As I said, the IAF must be rubbing their hands with glee.
Last edited by BOAC; 27th Dec 2011 at 11:17.
It is the F/O's behaviour I find very strange
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Well, Sirs, the "pairing" was awful. One with 26,000 hours and very senior, well known and respected, having served a life-time in PIA, while the other, a young-buck, PAF-background or not. A steep gradient in rank -- and they should not have flown together. That would be Air Blue's failing.
Cultural factors? I suppose it played a part. Respect for and deference to elders, which CRM training was not able to overcome.
But is the culture issue only an "affliction" of eastern cultures?
Despite facing the prospect of imminent death, the F/O remained submissive. He did speak up, many times, and I would imagine with increased urgency in his voice as they got closer to the hills. Yet he did not take control.
To my mind, a needless and eminently avoidable tragedy which snuffed out the lives of all souls on board.
Cultural factors? I suppose it played a part. Respect for and deference to elders, which CRM training was not able to overcome.
But is the culture issue only an "affliction" of eastern cultures?
Despite facing the prospect of imminent death, the F/O remained submissive. He did speak up, many times, and I would imagine with increased urgency in his voice as they got closer to the hills. Yet he did not take control.
To my mind, a needless and eminently avoidable tragedy which snuffed out the lives of all souls on board.
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Centaurus, you are correct! Those guys are literally bred not to question the skipper. Crazy in our world (western) but thats how it is over there.
In that general area of the world.......CRM= Captain Rules Motherf@#@#r!
Yes, im sure there will be somebody telling me that they practice some sort of CRM..........BEEN THERE DONE THAT....read above!
A published report is half way to solving their problem! Ill pay that, but how many more before they get bloody serious about it?
In that general area of the world.......CRM= Captain Rules Motherf@#@#r!
Yes, im sure there will be somebody telling me that they practice some sort of CRM..........BEEN THERE DONE THAT....read above!
A published report is half way to solving their problem! Ill pay that, but how many more before they get bloody serious about it?
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maajam- you are correct, and in fact the thread title is incorrect as the crash was caused by both pilots, one by commission and the other by omission. In a normal world the reason for having two pilots should be to prevent just this event.
There would not appear to be any reason why the two experience levels should not 'mix' ok - if any protection is given to a 'newish' F/O it is normally NOT to roster him/her with a NEW captain. I do not see failing of AirBlue here, but of the apparent whole system in Pakistan's aviation, civil and military.
There would not appear to be any reason why the two experience levels should not 'mix' ok - if any protection is given to a 'newish' F/O it is normally NOT to roster him/her with a NEW captain. I do not see failing of AirBlue here, but of the apparent whole system in Pakistan's aviation, civil and military.
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Having flown for a year on contract with Biman Bangladesh a few years ago, sadly nothing I've read here is a surprise.
The Culture of the sub continent and CRM are often mutually exclusive. Never did I see a greater need for CRM by the majority of the captains, never have I seen it resisted so much.
Until one or other of these dilemmas is resolved, these type of accidents are going to continue. Sadly, until those first officers who've been trained within a culture of CRM reach 'maturity' and the LH seat, then resist the 'Might-is-Right' culture (having now 'got there'), I don't realistically envisage a change.
Such a crying shame.
The Culture of the sub continent and CRM are often mutually exclusive. Never did I see a greater need for CRM by the majority of the captains, never have I seen it resisted so much.
Until one or other of these dilemmas is resolved, these type of accidents are going to continue. Sadly, until those first officers who've been trained within a culture of CRM reach 'maturity' and the LH seat, then resist the 'Might-is-Right' culture (having now 'got there'), I don't realistically envisage a change.
Such a crying shame.
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BOAC,
Sir, I would have thought pairing with a more mature F/O who may have learnt some real-life CRM lesssons himself may have been more prudent. Not this young chap with less than 300 hours in-type. In his case, he should be been flying with a less experienced, younger captain, if you see what I mean. It would have made for better "vibrations".
F-16's in the PAF would not teach him CRM. So he must have taken one course during gaining proficiency in-type and who knows how much he absorbed.
Put someone old enough to be his father next to him with more years of flying experience than his age (34), and you have a very intimidated puppy. Not to mention the drubbing he got in the cruise.
And fate intervened. Capt. Choudhry was only rostered to fly the night before.
I am not making excuses for the F/O and, yes, BOTH, pilots were to blame, maybe the F/O more than the captain since the latter was confused and had lost SA. The F/O had not and knew where they were heading. "Terrain is coming, Sir".
The recent Air India Express accident at Mangalore was another example. That was a good report. Late descent meant they were coming down like a rocket. The F/O called "unstabilized" and then "go around" but that may have been more of a question. When they floated, he called "go around" again.
I could have some of the sequence wrong. Read the report some time ago.
In that case, deference to a "foreign" pilot?! They hate them because they feel they are taking away jobs from the natives. But complexes, also culturally ingrained, are not easily overcome. The captain was not a Brit., their former colonial masters. But he was "white".
Sir, I would have thought pairing with a more mature F/O who may have learnt some real-life CRM lesssons himself may have been more prudent. Not this young chap with less than 300 hours in-type. In his case, he should be been flying with a less experienced, younger captain, if you see what I mean. It would have made for better "vibrations".
F-16's in the PAF would not teach him CRM. So he must have taken one course during gaining proficiency in-type and who knows how much he absorbed.
Put someone old enough to be his father next to him with more years of flying experience than his age (34), and you have a very intimidated puppy. Not to mention the drubbing he got in the cruise.
And fate intervened. Capt. Choudhry was only rostered to fly the night before.
I am not making excuses for the F/O and, yes, BOTH, pilots were to blame, maybe the F/O more than the captain since the latter was confused and had lost SA. The F/O had not and knew where they were heading. "Terrain is coming, Sir".
The recent Air India Express accident at Mangalore was another example. That was a good report. Late descent meant they were coming down like a rocket. The F/O called "unstabilized" and then "go around" but that may have been more of a question. When they floated, he called "go around" again.
I could have some of the sequence wrong. Read the report some time ago.
In that case, deference to a "foreign" pilot?! They hate them because they feel they are taking away jobs from the natives. But complexes, also culturally ingrained, are not easily overcome. The captain was not a Brit., their former colonial masters. But he was "white".
Controversial, moi?
The inference that an experienced captain should not fly with an inexperienced FO is a false premise.
CRM first came to prominence when several accidents occurred and were caused by the resources (crew) and their skills being poorly managed and having a direct bearing, if not sole cause, on the ensuing accident.
One notable example was the DC10(?) which flew into the ground (Florida I think) while perfectly serviceable because all three flight crew were pre-occupied with what turned out to be a failure of one of the three landing gear green lamp indicators. Nobody was flying the aircraft.
In more recent times in the UK the British Midland B737 crash at East Midlands Airport gave us all some strong lessons in how the CRM aspects of the flight could have been handled better. I know that in BA it led some some changes in emphasis during recurrent training.
My point is that until the national authorities force airlines like Air Blue to design and implement initial and recurrent CRM training courses for all their pilots only then will avoidable accidents like the one in question be prevented.
The first CRM course I attended was the initial BA offering. It was residential and lasted three days. There was opposition but the flight deck culture slowly and surely changed for the better. The days where BOAC captains only spoke to the junior first officer through the flight engineer or senior first officer were finally laid to rest.
In the early 1990s I recall one former BA cadet, who had not long graduated and completed his line training, who took control from an experienced captain and flew a go-around when he was unhappy with the what he judged to be a flare at too great a height. As it happens he was wrong and he was suitably de-briefed on the incident. But which would you prefer a co-pilot sufficiently well trained and confident enough to be aware that he has a responsibility and duty to safeguard the safety of a flight, physically intervening if he has to, or one like the hapless Air Blue co-pilot? In the BA incident what he did may have been an error of judgement caused by great inexperience but what he did was not actually dangerous. The alternative, in a situation like the Air Blue crash, is often fatal.
Of course it all costs money so please don't hold your breath waiting.
CRM first came to prominence when several accidents occurred and were caused by the resources (crew) and their skills being poorly managed and having a direct bearing, if not sole cause, on the ensuing accident.
One notable example was the DC10(?) which flew into the ground (Florida I think) while perfectly serviceable because all three flight crew were pre-occupied with what turned out to be a failure of one of the three landing gear green lamp indicators. Nobody was flying the aircraft.
In more recent times in the UK the British Midland B737 crash at East Midlands Airport gave us all some strong lessons in how the CRM aspects of the flight could have been handled better. I know that in BA it led some some changes in emphasis during recurrent training.
My point is that until the national authorities force airlines like Air Blue to design and implement initial and recurrent CRM training courses for all their pilots only then will avoidable accidents like the one in question be prevented.
The first CRM course I attended was the initial BA offering. It was residential and lasted three days. There was opposition but the flight deck culture slowly and surely changed for the better. The days where BOAC captains only spoke to the junior first officer through the flight engineer or senior first officer were finally laid to rest.
In the early 1990s I recall one former BA cadet, who had not long graduated and completed his line training, who took control from an experienced captain and flew a go-around when he was unhappy with the what he judged to be a flare at too great a height. As it happens he was wrong and he was suitably de-briefed on the incident. But which would you prefer a co-pilot sufficiently well trained and confident enough to be aware that he has a responsibility and duty to safeguard the safety of a flight, physically intervening if he has to, or one like the hapless Air Blue co-pilot? In the BA incident what he did may have been an error of judgement caused by great inexperience but what he did was not actually dangerous. The alternative, in a situation like the Air Blue crash, is often fatal.
Of course it all costs money so please don't hold your breath waiting.
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One notable example was the DC10(?) which flew into the ground (Florida I think) while perfectly serviceable because all three flight crew were pre-occupied with what turned out to be a failure of one of the three landing gear green lamp indicators. Nobody was flying the aircraft.
Eastern Air Lines Flight 401 - Wikipedia, the free encyclopedia
You are right, the only aircraft malfunction was burned out filaments in a landing gear indicator.
"I admit the human element seems to have failed us here." - General Buck Turgidson in Dr. Strangelove (1964)
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There is mention of the FO's lack of assertiveness in taking command of the situation knowing their treacherous predicament. But you have to wonder, had that FO been assertive and taken over, what would be the result? The kind of airline that maintains the employment of such a Captain sounds to me as and airline that would not investigate and would terminate the career of someone questioning someone of higher rank. That needs to be addressed as it is a very big factor in this accident. All the CRM courses in the world will not fix a lack of safety culture.
Not that it would affect my reaction if in the same situation. I would rather be fired than dead. It just makes you wonder what it takes to move those priorities, it seems like certain regions of the world suffer greatly from this lack of prioritization. This accident reminds me of the GFA A320 that flew right into the gulf. The FO even said a little prayer before they hit the ground, the CA didn't even know what hit them (or more appropriately, what he hit).
Not that it would affect my reaction if in the same situation. I would rather be fired than dead. It just makes you wonder what it takes to move those priorities, it seems like certain regions of the world suffer greatly from this lack of prioritization. This accident reminds me of the GFA A320 that flew right into the gulf. The FO even said a little prayer before they hit the ground, the CA didn't even know what hit them (or more appropriately, what he hit).