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Air Blue crash was caused by Captain

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Air Blue crash was caused by Captain

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Old 27th Dec 2011, 18:47
  #61 (permalink)  

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All the CRM courses in the world will not fix a lack of safety culture.
Agreed.

When I said that the relevant authorities would need to force the implentation of CRM training it would mean that the authorities had to recognise that they had a serious safety culture issue in the first place.

I believe modern CRM developed from NASA research into the causes of air transport accidents. The research identified the human error aspects of the majority of air crashes as failures of interpersonal communications, decision making, and leadership.
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Old 27th Dec 2011, 18:59
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I think something that people are perhaps failing to take into account when laying blame on the F/O is that the action to be taken was hardly straight forward.

Essentially, the F/O was convinced that the aircraft was in trouble. The Captain was convinced that the aircraft wasn't in trouble, and that doing what the F/O wanted to do was the incorrect form of action.

Both of you are confident you are right. Are you going to let go of the yolk?
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Old 27th Dec 2011, 19:08
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before landing checklist:

I think we can all agree that adding the ILS on 12 will not solve this type of problem.
Which problem? The captain's rants or the crash?
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Old 27th Dec 2011, 19:26
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for the record i never defended the captain.

"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."

you have no idea how true that is here.

one factor which everyone is overlooking is the intense rivalry between civilian pilots and ex-military. civilians in command will do anything to make life hard for ex mil in the right seat for the sole reason the ex military pilots are the preferred pilots in the Pakistani market.

you are never allowed to fly a circuit south side of the field at OPRN. you get way too close to the GHQ and the ministry of defense. the GHQ is 2.7 nautical miles from the threshold of 12,Ministry of Defense is 2NM from the threshold, PAF sector command is also less than 1.6NM away and all of them are south of the field and inside the Prohibited area shown on the ILS-DME 30 plate OP(P)254. yes they are that that close.

so the captain asking for for a right downwind on runway 12, is something he knew he wouldnt get.
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Old 27th Dec 2011, 19:32
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Yes, it is pertinent to ask what would have happened to that F/O if he had pushed that "side-stick priority" button in front of him and announce firmly: "MY aeroplane".

Well, they would all be alive to begin with. The Capt. would have thrown his considerable weight about and charge the F/O with mutiny and insubordination but given the mood of the judiciary and the vibrancy of the Pakistani media, the story would have got out. The F/O would have leaked it himself if he felt threatened and he would have petitioned the High Court/Supreme Court if his services had been terminated.

I would like to think the ending would have been a good one, a wake-up call to other god-like captains with all F/O's around the world feeling a new sense of empowerment!

I accept all the valuable points made about CRM by the writers above. Sadly, this young fellow did not have it in him (youth, inexperience, humbled and over-whelmned) even as he knew, as he surely did by his words, that his inaction would lead to his end.

But I take comfort from the fact that the good pilots out-weigh the bad by an overwelmning margin which helps make commercial flying as safe as it is -- despite the recent spate of accidents about which I have read here -- analysed with great clarity and insight.

This forum should be required reading for every airline!
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Old 27th Dec 2011, 19:41
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Hi All

I found a video of a PIA 747 takeoff from Karachi operated by Captain Pervez from the ill fated Airblue flight. Below is the link, is there proper CRM taking place in the cockpit?

I am not a professional pilot, just a private pilot. It is scary reading about this CRM issue and the human factors / egos involved. Also if a junior pilot wants to take away control from the captain, does he just grab the control stick away forcibly?
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Old 27th Dec 2011, 20:05
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denlopviper,

Saying there is a lack of a safety culture is a bit extreme. PIA and the other private airlines operating in Pakistan (with more to come, we are told), don't lack a safety culture. It is not a glaring issue.

I believe their procedures are checked out and cleared by safety audits all the time. If there are concerns, they will be warned and then they will be banned from European and US airspace (the former has already happened and I must confess to hanging my head in shame where a once-great airline, the best in Asia, had to suffer such indignity).

Times have changed. There is too much transparency that is now forced upon you -- via the inter-net and/or the media. You cannot hide. This is not some bush operation out of Africa that you can keep hidden from the world and still expect to fly into their airspace and airports.

By all accounts, Air Blue was a sound operation with only a couple of incidents such as a tail-scrape, until the "Margalla Tragedy".

I heard that after that, they dismissed all their ex-PIA pilots over the age of 60 whom they had re-employed (since the new retirement age was 65). That must surely be the dummest thing they could have done. I am not aware of any robust correlation between age and accidents. Robust, that is. Not a spurious correlation that fails a "t-test".

Asking for a right-hand downwind was indeed very strange. Surely Capt Choudhry knew that was not available because of the twin city of Rawalpindi but also because, as you have reminded us, the great gods of GHQ!

Imagine, the sounds of a noisy jet flying over their hallowed headquarters when they are busy THINKING.

Anyway, let this not degenerate into a civilian-versus-military conflict (although you hear about that even in the US and UK0.

I don't know where the airlines get the majority of their pilots from but I would not be surprised if it is still from the various flying schools in the country, as well as PIA's own Flight Academy -- and not from the PAF.

But I stand to be corrected.
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Old 27th Dec 2011, 20:11
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I have seen the vidoe above. We cannot tell about CRM and check-lists since the audio is not very clear. But it does show a commander that is supremely confident.

You would be if you had been flying the 747 for 15 years and knew her like tha back of your hand.
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Old 27th Dec 2011, 22:22
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More than CRM

CRM is a major issue here, it seems. But neither the Captain nor the FO were competent enough to read the FMA, which immediately informs the status in NAV or HDG. The Captain seemed too overloaded to pull HDG, and the a/c stayed in NAV, hence heading towards high ground.

Do Air Blue SOP's demand FMA call outs by PF, with "Check" from PNF when checked? If not, then SOP's are partly to blame. If so, then the pair managed to ignore SOP's and drive the a/c towards the Margalla Hills. Other issues, such as the a/c turning the shortest way when HDG was eventually pulled, indicate that the CM1 was not competent on type, and the CM2 was not monitoring correctly. (Or scared to inform his Captain that he had made another mistake)

A sad and unnecessary crash, caused by 2 pilots who were simply not competent as a team.
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Old 27th Dec 2011, 23:39
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denlopviper,

Saying there is a lack of a safety culture is a bit extreme. PIA and the other private airlines operating in Pakistan (with more to come, we are told), don't lack a safety culture. It is not a glaring issue.


i fly in pakistan and trainined pilots for Etihad (EY). i didnt say there is a lack of safety culture. i said there is intense rivalry amongst civil and military pilots. i am caught between the war so i know. each group feels threatened by the other.

Times have changed. There is too much transparency that is now forced upon you -- via the inter-net and/or the media. You cannot hide. This is not some bush operation out of Africa that you can keep hidden from the world and still expect to fly into their airspace and airports.

By all accounts, Air Blue was a sound operation with only a couple of incidents such as a tail-scrape, until the "Margalla Tragedy".


im guessing your currently not in the field?

what transparencies? if you mean this report getting published, i already said that all the reports are available from all the incidents. you just need to find them.

I heard that after that, they dismissed all their ex-PIA pilots over the age of 60 whom they had re-employed (since the new retirement age was 65). That must surely be the dummest thing they could have done. I am not aware of any robust correlation between age and accidents. Robust, that is. Not a spurious correlation that fails a "t-test".

there were only a few 6 or 7 i think.


Asking for a right-hand downwind was indeed very strange. Surely Capt Choudhry knew that was not available because of the twin city of Rawalpindi but also because, as you have reminded us, the great gods of GHQ!

Imagine, the sounds of a noisy jet flying over their hallowed headquarters when they are busy THINKING.

Anyway, let this not degenerate into a civilian-versus-military conflict (although you hear about that even in the US and UK).


one of those Gods as your proclaimed them just happens to my dad. there are no fly zones and prohibited areas around most if not all sensitive installations around the around, not just in pakistan. have you seen the number of prohibited and restricted areas in the UAE?


I don't know where the airlines get the majority of their pilots from but I would not be surprised if it is still from the various flying schools in the country, as well as PIA's own Flight Academy -- and not from the PAF.

as far as PIA goes. they have inducted about 300 pilots since 2005 till today. before that last last regular induction was in the mid or early 90s. thats over 10 years without a single cadet pilot course.

for PIA about 25 to 30% ex military

Airblue and Shaheen, sorry to disapppoint but 80% plus of their crew are ex military.

Bhoja and Indus which are opening up, and average of 60 to 70% of their crews are ex military.

as far as flight schools go, PIA training academy, Rawalpindi flying club, Peshawer flying club, Hybrid aviation, Lahore flying club and Multan flying club have ex military chief flight instructors. that only leaves out Schon who i know have ex military instructors.

list goes on...


PS. i dont have any grudges against military pilots, i have a huge respect for the guys.

Last edited by denlopviper; 28th Dec 2011 at 14:22.
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Old 28th Dec 2011, 11:01
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RoyHudd,

Sir, you make some very valid points. The fact that the Capt. did not know why the a/c was not turning left and the F/O did not know either gave me the willies too.

Just disconnect the damn AP and fly the aircraft yourself! You can figure it out later.

Denlopviper,

Thank you for all the clarifications, Sir.

You think 6-7 top pilots in Air Blue dismissed because of their age is "small"? That was the cream of the crop.

Anyway, they are happy now flying elsewhere and getting five times the pay.

I know about restricted zones. I was wondering why the Capt. did not.

I am sorry to hear about the tension between military and civilian pilots in Pakistan. Whatever the merits of the case, the cockpit of an airliner is not the place to carry your resentments into.

Whether the Capt. being harsh with the F/O was also driven by that tension, I do not know. Perhaps it was? And look what it resulted in.

Was the PIA Academy, once the best in Asia as was the airline, shut down because someone decided that the in-take shall be from the forces? No marks for anyone figuring out who would have ordered that in Pakistan!

Finally, I KNOW that reports have always been prepared even in the case of "incidents". I only made the point that given the hyper-active state of the courts and the media, there will be no secrets anymore. This report, whatever its limitations, is a huge breakthrough and marks a very important and significant day for transparency and openness, something that we have been denied for 64 years.

I hope this will extend to other areas as well. There are too many secrets in Pakistan and too much obfuscation and untruths floating about and a profusion of conspiracy theories. The former feeds off the latter.

Yesterday they celebrated the FOURTH death anniversary of Benazir Bhutto. There is still no report on who murdered her so brutally. How astonishing is that?

Of course 80% of the pilots at Shaheen are ex-military. It is run by the military!
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Old 28th Dec 2011, 12:08
  #72 (permalink)  
 
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yes, BOTH, pilots were to blame, maybe the F/O more than the captain
You must be joking! The captain makes a monumental cock-up in almost every aspect of the flight and you say the F/O is maybe more to blame than the idiot of a captain? Methinks you have your wires crossed somewhere.
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Old 28th Dec 2011, 13:21
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Ultimately, the responsibility for the safe conduct of the flight rests with the captain. I know that.

That is why he is paid so well and wears those four gold stripes and a star on his sleeves and has scrambled eggs on his cap.

In this case, I agree the Captain lost it. He did not even know how to use the Heading Selector and may have thought he was flying an analog-style 747 (which he did for almost half his entire career).

However, as someone above said, which made me pause and think, the ONLY one in that cockpit who KNEW what was happening and where they were headed and what would happen if they did not IMMEDIATELY take action, was the co-pilot.

Yet he sat there. Although he warned the Captain several times of impending doom, he did nothing. I don't know what goes into a CRM course but I would assume that it says something to the effect that if the Captain is non-responsive and is headed towards crashing the damn aeroplane, you assume incapacitation and take over.

He did not do that, for all the reasons adduced in the report and here, and got everyone, including himself, killed.

He bears significant responsibility too. But, as we all know, ultimately the responsibility lies with the person in the LHS. But that does not absolve the person in the RHS of blame.

The Captain's son is planning to lodge a protest in the court. I feel his pain. He says his father is not able to defend himself. In CFIT cases, they usually are not.
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Old 28th Dec 2011, 13:23
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Centaurus:

You must be joking! The captain makes a monumental cock-up in almost every aspect of the flight and you say the F/O is maybe more to blame than the idiot of a captain? Methinks you have your wires crossed somewhere.
The F/O knew they were headed for a crash into terrain. The captain apparently did not. So, under the doctrine of "the last clear chance" to avoid an accident, the F/O failed that requirement.

To conclude that makes the F/O more cupable, than a captain who was out of control, is not unreasonable.
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Old 28th Dec 2011, 14:02
  #75 (permalink)  
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Originally Posted by me
in fact the thread title is incorrect as the crash was caused by both pilots, one by commission and the other by omission.
You can cut this both ways.

IF the Captain had not done x,y,z then............

IF the F/O had been decisive and taken control if necessary..................

Let's not confuse the lack of action by the F/O with any notion of 'warm/fluffy CRM'. This is NOT CRM. This is survival. This is acting as the second i/c when the first is patently 'not there'. It was either 'loss of face' by forcing control of the a/c away from the Captain or loss of body and soul along with everyone else by not so doing - what would the 'normal' person choose? At worst, suffer ignominy at the hands of the 'institution' - but live - and perhaps have to find another job OR be driven into the face of a hill at 200mph+?
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Old 28th Dec 2011, 14:21
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Denlopviper,

Thank you for all the clarifications, Sir.

You think 6-7 top pilots in Air Blue dismissed because of their age is "small"? That was the cream of the crop.

Anyway, they are happy now flying elsewhere and getting five times the pay.


i was a flight instructor who was getting twice the pay of Airblue's FOs. big deal. the statement that they were the cream is completely illogical. tens of thousands of hours yes, on something as advanced as an A320, NO. simple fact is they would require the same training on the aircraft a a guy with 200 hours would.

yes they have abundant experience and there is not substitute. but in things like the A320, you dont fly, you manage the systems. and its way more easier to understand those systems for someone whos young. this is a general statement so hold your fire guys

time and again we have seen accident when the crew didnt fully understand how the systems on their aircraft worked.


I am sorry to hear about the tension between military and civilian pilots in Pakistan. Whatever the merits of the case, the cockpit of an airliner is not the place to carry your resentments into.

Whether the Capt. being harsh with the F/O was also driven by that tension, I do not know. Perhaps it was? And look what it resulted in.


this is something which isnt going to go away that easy. this is something that is usually kept outside the cockpit.


Finally, I KNOW that reports have always been prepared even in the case of "incidents". I only made the point that given the hyper-active state of the courts and the media, there will be no secrets anymore. This report, whatever its limitations, is a huge breakthrough and marks a very important and significant day for transparency and openness, something that we have been denied for 64 years.

maybe for you, but since we all already had access to previous reports, its not a big deal.

I hope this will extend to other areas as well. There are too many secrets in Pakistan and too much obfuscation and untruths floating about and a profusion of conspiracy theories. The former feeds off the latter.

Yesterday they celebrated the FOURTH death anniversary of Benazir Bhutto. There is still no report on who murdered her so brutally. How astonishing is that?


the world wouldnt be fun without conspiracy theories. for the BB case, we all think her husband did it, and yes im being serious.


Of course 80% of the pilots at Shaheen are ex-military. It is run by the military!

you been out of the country too long lol. Shaheen got privatized a long time ago. it is a pure civilian airline with no backing or interference from the MoD. yet still they prefer ex mil.

SAPS (shaheen airport services) which is now a separate entity is the one backed by PAF

even if you say that about shaheen, what about the 3 other airlines?


something which i recently found out about the FO.

he resigned his commission because he didnt agree with the operation in the tribal areas saying "i am not going to bomb my own people". so the notion that he didnt have balls is not really justified.
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Old 28th Dec 2011, 14:24
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I was only speculating that CRM would teach that. I have not attended a CRM course to know its contents. But I would imagine you are taught to work together and, most importantly, speak up irrespective of rank in case the other guy/girl is doing something dangerous and if they don't respond despite several interventions, you must assume he/she has "lost it" and take over the controls.
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Old 28th Dec 2011, 14:46
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You are correct, and 'assertiveness' is what is encouraged - and what was missing. In most UK operations, 'three challenges' not heeded is sufficient reason to take control. Whilst it is not 'CRM' it has become bundled together with it.
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Old 28th Dec 2011, 14:56
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It doesn't take a lot of 'system management' to turn the autopilot off and make the plane do what YOU want it to do.

It doesn't take a lot of situation awareness to react to "terrain, terrain" or "PULL UP!" Turning the heading bug is NOT the correct response.

I tell new guys - "automation is your friend, until it isn't."
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Old 28th Dec 2011, 15:16
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yup your right.

"terrain, pull up" is something you react to without thinking.

well the report does mention the 54 degree bank and erratic pitch changes, which tells me he was flying and not the autopilot. at the same time they say the AP was engaged. doesnt the AP disconnect when there is stick input on the A320?

hmm doesnt the A320 come with an "overbank" alert or something like that? 54 degree isnt small. there is no mention of any alerts relating to bank
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