PIA A320 Crash Karachi
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
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
Bottom line is simple. KAL was a 
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.
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 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.
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Would SOP’s have really helped?
Below are two quotes from a post above:
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.
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.
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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/scienc...58361222001111
Reference here: https://www.sciencedirect.com/scienc...58361222001111
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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.
......
......
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.
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.
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.
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Crash Report PIA A320 Karachi
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'll avoid flying in any airline of that country, simply because of safety concerns. PIA are statistically the worst.
de minimus non curat lex
I think it took 4 years to publish the AF447 report - and I 'm sure soem others have taken longer
Report is out!
Simon has managed to obtain the Final Report that was released today:
http://avherald.com/files/(PUBLIC%20...3%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."
http://avherald.com/files/(PUBLIC%20...3%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."
Last edited by andrasz; 26th Feb 2024 at 07:28.
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.