Air Blue crash was caused by Captain
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Air Blue crash was caused by Captain
Some new information released, actual report was to be made public a few days back but hasnt come out yet.
Airblue inquiry finds captain uneasy, confused | Provinces | DAWN.COM
Airblue inquiry finds captain uneasy, confused | Provinces | DAWN.COM
DAWN, December 22, 2011
Headlines: Airblue inquiry finds captain uneasy, confusedWaseem Ahmad Shah | Peshawar | From the Newspaper (14 hours ago) Today
PESHAWAR, Dec 21: Inquiry into the last year’s Airblue plane crash into the Margalla Hills of Islamabad has said the captain showed signs of anxiety, preoccupation, confusion and geographical disorientation in various phases of the flight, especially after commencement of descent.
All 152 passengers and crew on board died in the July 28, 2010 incident.
The 38 pages inquiry report submitted to the Peshawar High Court by a team headed by Air Commodore Khwaja A Majeed a day ago said deteriorated weather conditions were a factor in the causation of the crash and that no evidence of any internal or external sabotage, incapacitation of aircraft systems, in-flight fire, bird strike or structural fatigue had been found.
According to the report, Airblue crash has been finalised as a case of Controlled Flight into Terrain (CFIT) in which aircrew failed to display superior judgment and professional skills in a self created unsafe environment.
“In their pursuit to land in inclement weather, they committed serious violations of procedures and breaches of flying discipline, which put the aircraft in an unsafe condition over dangerous terrain at low altitude.
“Captain Pervez Iqbal Chaudhry’s behaviour towards the flying officer was harsh, snobbish and contrary to establish norms. This undesired activity of the captain curbed the initiative of the first officer (FO), created a tense and undesirable environment, and a very conspicuous communication barrier in the cockpit, portraying a classic CRM (Crew Resource Management) failure.”
The report said the captain had prior knowledge of the decision by two captains flying ahead of him.
“While the captain of PK-356 managed to land in the third attempt, the captain of China Southern decided to divert back to Urumchi (China). The captain of the mishap flight opted to follow PK-356 but with non-standard approach procedure.”
The report said though aircrew captain was fit to undertake the flight on the mishap day, his portrayed behaviour and efficiency was observed to have deteriorated with the inclement weather at the Benazir Bhutto International Airport (BBIAP).
It further said the chain of events leading to the accident began with the commencement of the flight where the captain was heard to be confusing BBIAP, Islamabad, with HIAP (Jinnah International Airport), Karachi, while planning FMS (Flight Management System) and Khanpur Lake (Wah) with Kahuta area during holding pattern.
“This state continued when the captain of the mishap flight violated the prescribed Circling approach Procedure for RWY-12 by descending below Minimum Descent Allowed (i.e 2,300 feet instead of maintaining 2,510 feet) losing visual contact with the airfield, etc,” it said.
About the sequence of events, the report said during initial climb, the captain tested the knowledge of the FO and used harsh words and snobbish tone, contrary to the company procedure/norms.
“The question/answer sessions, lecturing and advices by the mishap, the captain continued with intervals for about one hour after takeoff. After the intermittent humiliating sessions, the FO generally remained quiet, became under confidence, submissive and subsequently did not challenge the captain for any of his errors, breaches and violations.”
It said the plane had ended up in a dangerous situation due to most unprofessional handling by the captain, adding that since the desired initiative of the FO had been curbed and a communication barrier had already been created by the captain the FO failed to intervene, take over the controls to pull the plane out of danger and display the required CRM skills.
“At 0441:08 hours, the FO was heard the last time saying to the captain ‘Sir we are going down, sir we are going da….’ The high rate of descend at very low altitude could not be arrested and the aircraft flew into the hill and was completely destroyed. All souls on board sustained fatal injuries due to impact force.”
The report said at 0439:58 (70 seconds before the impact), first Enhanced Ground Proximity Warning System (EGPWS) warning of ‘terrain ahead’ started sounding meaning that the EGPWS worked exactly in the manner for which it was designed. It is added that the aircrew ignored several calls by the ATS (Air Traffic Services) controllers and EGPWS system warnings (21 times) related to approaching terrain and pull up.
It further said flight recorders contained the complete flight data and cockpit voice recording for the entire flight duration from the takeoff to the crash.
Headlines: Airblue inquiry finds captain uneasy, confusedWaseem Ahmad Shah | Peshawar | From the Newspaper (14 hours ago) Today
PESHAWAR, Dec 21: Inquiry into the last year’s Airblue plane crash into the Margalla Hills of Islamabad has said the captain showed signs of anxiety, preoccupation, confusion and geographical disorientation in various phases of the flight, especially after commencement of descent.
All 152 passengers and crew on board died in the July 28, 2010 incident.
The 38 pages inquiry report submitted to the Peshawar High Court by a team headed by Air Commodore Khwaja A Majeed a day ago said deteriorated weather conditions were a factor in the causation of the crash and that no evidence of any internal or external sabotage, incapacitation of aircraft systems, in-flight fire, bird strike or structural fatigue had been found.
According to the report, Airblue crash has been finalised as a case of Controlled Flight into Terrain (CFIT) in which aircrew failed to display superior judgment and professional skills in a self created unsafe environment.
“In their pursuit to land in inclement weather, they committed serious violations of procedures and breaches of flying discipline, which put the aircraft in an unsafe condition over dangerous terrain at low altitude.
“Captain Pervez Iqbal Chaudhry’s behaviour towards the flying officer was harsh, snobbish and contrary to establish norms. This undesired activity of the captain curbed the initiative of the first officer (FO), created a tense and undesirable environment, and a very conspicuous communication barrier in the cockpit, portraying a classic CRM (Crew Resource Management) failure.”
The report said the captain had prior knowledge of the decision by two captains flying ahead of him.
“While the captain of PK-356 managed to land in the third attempt, the captain of China Southern decided to divert back to Urumchi (China). The captain of the mishap flight opted to follow PK-356 but with non-standard approach procedure.”
The report said though aircrew captain was fit to undertake the flight on the mishap day, his portrayed behaviour and efficiency was observed to have deteriorated with the inclement weather at the Benazir Bhutto International Airport (BBIAP).
It further said the chain of events leading to the accident began with the commencement of the flight where the captain was heard to be confusing BBIAP, Islamabad, with HIAP (Jinnah International Airport), Karachi, while planning FMS (Flight Management System) and Khanpur Lake (Wah) with Kahuta area during holding pattern.
“This state continued when the captain of the mishap flight violated the prescribed Circling approach Procedure for RWY-12 by descending below Minimum Descent Allowed (i.e 2,300 feet instead of maintaining 2,510 feet) losing visual contact with the airfield, etc,” it said.
About the sequence of events, the report said during initial climb, the captain tested the knowledge of the FO and used harsh words and snobbish tone, contrary to the company procedure/norms.
“The question/answer sessions, lecturing and advices by the mishap, the captain continued with intervals for about one hour after takeoff. After the intermittent humiliating sessions, the FO generally remained quiet, became under confidence, submissive and subsequently did not challenge the captain for any of his errors, breaches and violations.”
It said the plane had ended up in a dangerous situation due to most unprofessional handling by the captain, adding that since the desired initiative of the FO had been curbed and a communication barrier had already been created by the captain the FO failed to intervene, take over the controls to pull the plane out of danger and display the required CRM skills.
“At 0441:08 hours, the FO was heard the last time saying to the captain ‘Sir we are going down, sir we are going da….’ The high rate of descend at very low altitude could not be arrested and the aircraft flew into the hill and was completely destroyed. All souls on board sustained fatal injuries due to impact force.”
The report said at 0439:58 (70 seconds before the impact), first Enhanced Ground Proximity Warning System (EGPWS) warning of ‘terrain ahead’ started sounding meaning that the EGPWS worked exactly in the manner for which it was designed. It is added that the aircrew ignored several calls by the ATS (Air Traffic Services) controllers and EGPWS system warnings (21 times) related to approaching terrain and pull up.
It further said flight recorders contained the complete flight data and cockpit voice recording for the entire flight duration from the takeoff to the crash.
Last edited by newscaster; 22nd Dec 2011 at 18:01.
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Hard stuff.
" It is added that the aircrew ignored several calls by the ATS (Air Traffic Services) controllers and EGPWS system warnings (21 times) related to approaching terrain and pull up."
Almost unbelievable.
And the most frightening about this story is that there are hundreds or even thousands of captains out there with this kind of attitude...
" It is added that the aircrew ignored several calls by the ATS (Air Traffic Services) controllers and EGPWS system warnings (21 times) related to approaching terrain and pull up."
Almost unbelievable.
And the most frightening about this story is that there are hundreds or even thousands of captains out there with this kind of attitude...
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The F/O was an ex F16 pilot (wikipedia), rank of sqn ldr even, and he was intimidated (severely I might add) by the captain, who others consider to be a amiable man. HF nightmare!
Yes..times are a changing BB but it takes time.....
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The F/O was an ex F16 pilot (wikipedia), rank of sqn ldr
All it takes a captain with an insecure personality and the natural reaction will be to "put the FO in his place".
This was a surefire recipe for conflict and disaster.
They should never have been together.
I suspect that I'm the usual mix of hubris, arrogance, humility, respect, competence, incompetence. We are not supermen; just selected and trained humans.
I flew, as a B747 captain, with ex RAF Harrier and Red Arrows first officers including a Reds Leader. As an ex RAF truckie I was pretty impressed by these guy's history. They'd have been (and I hope now are) great captains to fly with; competent and confident and, therefore, relaxed.
However! There is only one captain and let's hope he runs a flight deck in which his FO may speak up and the old man (sailor's term for captain) is sensitive to concerns so voiced.
That's all a general comment - I've no idea what happened on that ill-fated flight deck.
p.s. Just in from pub - usual disclaimers
I flew, as a B747 captain, with ex RAF Harrier and Red Arrows first officers including a Reds Leader. As an ex RAF truckie I was pretty impressed by these guy's history. They'd have been (and I hope now are) great captains to fly with; competent and confident and, therefore, relaxed.
However! There is only one captain and let's hope he runs a flight deck in which his FO may speak up and the old man (sailor's term for captain) is sensitive to concerns so voiced.
That's all a general comment - I've no idea what happened on that ill-fated flight deck.
p.s. Just in from pub - usual disclaimers
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There was quite a bit of discussion here shortly after that crash happened. I constructed the generous PANS-OPS circle-to-land area for Runway 12. It should have been a "piece of cake" for the captain unless he ran into obscurations and showers. Then, a missed approach would have been very easy compared to many airports.
Instead of turning toward the airport within the generous circle-to-land area they continued northwest for approximately 3 miles beyond the boundaries before they were in real trouble. And, with the first EPGWS warning, had the captain pulled full aft on his side stick, they would have almost certainly out-climbed the terrain.
Instead of turning toward the airport within the generous circle-to-land area they continued northwest for approximately 3 miles beyond the boundaries before they were in real trouble. And, with the first EPGWS warning, had the captain pulled full aft on his side stick, they would have almost certainly out-climbed the terrain.
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I find it strange that an F/O with his reported 'background' would be so 'intimidated' as to allow him to be killed. Either the quality of PAF pilots is suspect OR something does not ring true. I cannot envisage any situation where whatever the sullen silence/anger/despair/whatever he was experiencing would allow this. The one thing being on your own in a high performance aircraft teaches you is an instinct for self-preservation.
I am also confused by the reference to "The high rate of descend at very low altitude could not be arrested and the aircraft flew into the hill and was completely destroyed." for dawn.com as I thought it had been established that they were more or less level at impact. I assume Dawn means terrain closure rate - or do we have a new aspect to this crash?
I am also confused by the reference to "The high rate of descend at very low altitude could not be arrested and the aircraft flew into the hill and was completely destroyed." for dawn.com as I thought it had been established that they were more or less level at impact. I assume Dawn means terrain closure rate - or do we have a new aspect to this crash?
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I find it strange that an F/O with his reported 'background' would be so 'intimidated' as to allow him to be killed.
In these countries the boss is always right.
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CRM
Hats off to the Peshawar authorities for a transparent report.
Sadly the CRM issue is a common one.....here a bullying,insecure captain and an able but relatively new first officer combined to crash a serviceable aircraft. Had the FO been allowed to speak up, and an accident then been avoided, the FO would have probably damaged his career prospects or even lost his job. A bad CRM culture stems from the Flight Director and Chief Pilot, who are the people in a position to change things.
In many cultures, CRM is not seen as an important or relevant issue, and the results of this bone-headedness are all to clear to see. (E.G. KAL's spate of crashes in the recent past)
Sadly the CRM issue is a common one.....here a bullying,insecure captain and an able but relatively new first officer combined to crash a serviceable aircraft. Had the FO been allowed to speak up, and an accident then been avoided, the FO would have probably damaged his career prospects or even lost his job. A bad CRM culture stems from the Flight Director and Chief Pilot, who are the people in a position to change things.
In many cultures, CRM is not seen as an important or relevant issue, and the results of this bone-headedness are all to clear to see. (E.G. KAL's spate of crashes in the recent past)
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As JH says, there is no 'report' for us and I suspect we will not see it. It appears to be 38 pages long. It was submitted to the government on 20/12.
There is not much from the History of PIA forum to add to the 'Dawn' item: note the number of GPWS warnings
That's one every 3 seconds. Anyone explain a 'PBD based approach'?
"The report said the captain of the unfortunate flight violated the prescribed Circling Approach procedure for RWY-12 by descending below Minimum Descent Altitude (MDA) (i.e. 2,300 ft instead of maintaining 2,510 ft), losing visual contact with the airfield and instead resorting to fly the non-standard self-created PBD-based approach, thus transgressing out of the protected airspace of maximum of 4.3 NM into Margalla and finally colliding with the hills.
“The aircrew captain not only clearly violated the prescribed procedures for circling approach, but also did not at all adhere to Flight Crew Operating Manual (FCOM) procedures of displaying reaction and response to timely and continuous terrain and pull up warnings (21 times in 70 seconds)."
There is not much from the History of PIA forum to add to the 'Dawn' item: note the number of GPWS warnings
That's one every 3 seconds. Anyone explain a 'PBD based approach'?"The report said the captain of the unfortunate flight violated the prescribed Circling Approach procedure for RWY-12 by descending below Minimum Descent Altitude (MDA) (i.e. 2,300 ft instead of maintaining 2,510 ft), losing visual contact with the airfield and instead resorting to fly the non-standard self-created PBD-based approach, thus transgressing out of the protected airspace of maximum of 4.3 NM into Margalla and finally colliding with the hills.
“The aircrew captain not only clearly violated the prescribed procedures for circling approach, but also did not at all adhere to Flight Crew Operating Manual (FCOM) procedures of displaying reaction and response to timely and continuous terrain and pull up warnings (21 times in 70 seconds)."
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PBD is for sure Place/Bearing/Distance - an Airbus terminology for constructed way point (not in FMGS database) referenced to database way point. It means (to my understanding) circling approach was not conducted by timing as prescribed but in NAV mode.
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About the sequence of events, the report said during initial climb, the captain tested the knowledge of the FO and used harsh words and snobbish tone, contrary to the company procedure/norms.
“The question/answer sessions, lecturing and advices by the mishap, the captain continued with intervals for about one hour after takeoff. After the intermittent humiliating sessions, the FO generally remained quiet, became under confidence, submissive and subsequently did not challenge the captain for any of his errors, breaches and violations.”
“The question/answer sessions, lecturing and advices by the mishap, the captain continued with intervals for about one hour after takeoff. After the intermittent humiliating sessions, the FO generally remained quiet, became under confidence, submissive and subsequently did not challenge the captain for any of his errors, breaches and violations.”
what a wonderful world..
(CW, of course)
Had the FO been allowed to speak up, and an accident then been avoided,
Captain as PF descending at night into a South Pacific airport and set the altitude alerter to descend below the sector MSA when the rules stated stay at Sector MSA until inside a specific DME distance from the VOR.
F/O suggested correctly that Sector MSA was inviolate. Captain snarled at him telling him to shut up and continued to descend. F/O warned him once more and when the captain pressed on regardless, the F/O grabbed the cockpit crash axe and threatened to brain the captain unless he stopped the descent.
The captain wisely then took the F/O advice. The original concept of CRM I am sure did not envisage the crash axe as a cockpit resource. But it certainly worked, though. The so called "macho culture" exhibited by some pilots is sometimes an ethnic thing and sometimes a dreadful cultural affliction known as Loss of Face. To those types CRM is a meaningless term.
