PIA A320 Crash Karachi
Also in the report, a nod to the captain's apparently gung-ho approach to flying: "After the accident, flights of Captain for last 12 months were analysed which indicated, 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." Again, there are no such comments against the FO.
It's not dangerous to perform a maneuver that's under control. What's dangerous is to be in an unexpected, unwanted position, unintentionally. In this case it shows that the pilot does not control the flight path.
Unstable approaches are forbidden, so when they happen, it's a sign that the pilot is behind the aircraft, or that he voluntarily disregards the rule.
The latter case is not necessarily dangerous. At least, in my opinion, less than the first case. Again, do you think airbus test pilots fly stabilized approaches ? They disregard this safety rule, yet they're not dangerous.
To claim the captain was incompetent, it would require to prove that all these violations of usual rules were unintentional. You proved that he was either incompetent, or disregarding voluntarily the rules.
In my opinion it's not clear which is true, however the F/O really didn't help him in this case. There is a clear disregard for the rule, but the fact that the CPT could say "they're gonna be amazed we did it" when indeed his flight path was consistent with a landing (assuming the gear was let down...) pleads, in this case, for the second part.
Constant disregard of the rule giving him some proficiency in this kind of situations (high energy approaches). Not enough obviously...
Do you think airbus test pilots fly stabilized approaches ? What do you think about aerobatics, spins, barrels.. ?
It's not dangerous to perform a maneuver that's under control.
....
To claim the captain was incompetent, it would require to prove that all these violations of usual rules were unintentionnal.
It's not dangerous to perform a maneuver that's under control.
....
To claim the captain was incompetent, it would require to prove that all these violations of usual rules were unintentionnal.
1) Aerobatics (in particular, barrel rolls), spins and test flying are hazardous activities where risk is controlled through application of mitigations in respect of pilot qualifications, experience, supervision, geographic location, etc - and perhaps most importantly in this context, numbers of commercial passengers: ie none.
2) Any captain of a commercial passenger flight who intentionally violates rules in the absence of extenuating circumstances is, by any reasonable definition, incompetent in their role. So I don't think any consideration of intent is necessary.
Yes I am sure they do, whenever they land after a test flight if the landing is not part of the evaluation. I am also sure that they perform all sorts of non-nominal approaches - if those are part of their test plan - with full ground backup and cleared airspace if necessary.
I think those manoeuvres - along with Airbus test pilots - constitute whataboutery and are irrelevant to the PIA incident which was not a test flight and which went south because of an abject failure to operate the aircraft properly... on the part of both pilots (I do agree with you there!)
I think those manoeuvres - along with Airbus test pilots - constitute whataboutery and are irrelevant to the PIA incident which was not a test flight and which went south because of an abject failure to operate the aircraft properly... on the part of both pilots (I do agree with you there!)
Unstable approaches are forbidden, so when they happen, it's a sign that the pilot is behind the aircraft, or that he voluntarily disregards the rule. The latter case is not necessarily dangerous. At least, in my opinion, less than the first case. Again, do you think airbus test pilots fly stabilized approaches ? They disregard this safety rule, yet they're not dangerous.
I would think that test pilots fly stabilised approaches, just like everyone else, unless they are doing something that has been pre-briefed as non-standard and a safety case made for it. Airbus lost a jet and four test pilots in one go at Toulouse, due to an unplanned/unbriefed engine shut down on a perfectly serviceable aeroplane, when one of them decided to show how good the automatics were in this scenario but hadn’t thought it through fully, or involved the other crew members in the decision. I would expect that test pilots are in reality pretty cautious as a group (certainly the ones I know, the older, less bold ones), as I would be if operating much closer to the edge of the flight envelope than in normal ops.
It has been well established that the captain on the PIA flight was more akin to a crash test dummy than a test pilot, and would be a perfect example of the Dunning-Kruger Effect. He was disregarding the rules in some part because he was incompetent; it seems he got away with it up until then because PIAs FOQA was almost non-existent and/or serious issues were flagged but nothing done about them, breeding Normalization of Deviance.
There is a clear disregard for the rule, but the fact that the CPT could say "they're gonna be amazed we did it" when indeed his flight path was consistent with a landing (assuming the gear was let down...) pleads, in this case, for the second part.
Also in the report, a nod to the captain's apparently gung-ho approach to flying: "After the accident, flights of Captain for last 12 months were analysed which indicated, 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." Again, there are no such comments against the FO.
Your claim is way too broad.
You should restrict it to rules which have a direct impact on safety.
Furthermore, the approach is to be stabilized by 500ft (VMC).
Hence, it's perfectly by the book to fly a high energy approach where you descend at an angle of negative 10° of flight path angle, then join the glide path and configure for landing and lift your thrust levers at 540ft AGL and reach VAPP+13kt (my airline allows +15) with some thrust by 500ft AGL. Sometimes it's even part of recurrent training to do this sort of thing.
The PIA8303 was, give or take, close to this sort of profile.
The moment where landing became less likely was when the F/O pulled the gear up.
Had he not done that, the landing would have been nominal. I can't guarantee the approach would have been stabilized (Vapp+15 could have been reached below 500ft, so unstable), but it's 99% sure the captain would have landed and stopped without any passenger noticing anything wrong. Like he did all the time before.
It's easy to notice and compensate for one's own mistakes. It's much more difficult when someone like this guy does completely unexpected things.
Yes I am sure they do, whenever they land after a test flight if the landing is not part of the evaluation.
I didn't have to look for very long to find a sidestep performed below 500ft and finished at 300ft AGL, on flightradar.
For example when they need to gather data about braking or flaring, they will make very short circuits.
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Do you respect the entirety of your tens of thousands of pages of OM A-B-C-.. ? I doubt it. Or, your manuals are much smaller than they could be.
Your claim is way too broad.
You should restrict it to rules which have a direct impact on safety.
Furthermore, the approach is to be stabilized by 500ft (VMC).
Hence, it's perfectly by the book to fly a high energy approach where you descend at an angle of negative 10° of flight path angle, then join the glide path and configure for landing and lift your thrust levers at 540ft AGL and reach VAPP+13kt (my airline allows +15) with some thrust by 500ft AGL. Sometimes it's even part of recurrent training to do this sort of thing.
The PIA8303 was, give or take, close to this sort of profile.
The moment where landing became less likely was when the F/O pulled the gear up.
Had he not done that, the landing would have been nominal. I can't guarantee the approach would have been stabilized (Vapp+15 could have been reached below 500ft, so unstable), but it's 99% sure the captain would have landed and stopped without any passenger noticing anything wrong. Like he did all the time before.
It's easy to notice and compensate for one's own mistakes. It's much more difficult when someone like this guy does completely unexpected things.
If you lived in Toulouse, you would regularly see, during weekdays, white and blue jetliners turning to final lower than 500ft AGL.
I didn't have to look for very long to find a sidestep performed below 500ft and finished at 300ft AGL, on flightradar.
For example when they need to gather data about braking or flaring, they will make very short circuits.
Your claim is way too broad.
You should restrict it to rules which have a direct impact on safety.
Furthermore, the approach is to be stabilized by 500ft (VMC).
Hence, it's perfectly by the book to fly a high energy approach where you descend at an angle of negative 10° of flight path angle, then join the glide path and configure for landing and lift your thrust levers at 540ft AGL and reach VAPP+13kt (my airline allows +15) with some thrust by 500ft AGL. Sometimes it's even part of recurrent training to do this sort of thing.
The PIA8303 was, give or take, close to this sort of profile.
The moment where landing became less likely was when the F/O pulled the gear up.
Had he not done that, the landing would have been nominal. I can't guarantee the approach would have been stabilized (Vapp+15 could have been reached below 500ft, so unstable), but it's 99% sure the captain would have landed and stopped without any passenger noticing anything wrong. Like he did all the time before.
It's easy to notice and compensate for one's own mistakes. It's much more difficult when someone like this guy does completely unexpected things.
If you lived in Toulouse, you would regularly see, during weekdays, white and blue jetliners turning to final lower than 500ft AGL.
I didn't have to look for very long to find a sidestep performed below 500ft and finished at 300ft AGL, on flightradar.
For example when they need to gather data about braking or flaring, they will make very short circuits.
I don’t know why You are mentioning Airbus test pilots but anyway those guys have a very specific job to do and they are also highly trained for that, their margins are different from a standard line flight crew, regardless of the crew experience, for many different reasons already mentioned above.
Here is a possible scenario:
The Captain - who we have learned was generally difficult and autocratic and did not fly by the book - is for some reason, (maybe hunger), in a particularly bad and unapproachable mood that day. Due to his impatience, he decides to accept an approach that is too close, too high and too fast, instead of simply asking for more track miles or even a 360°
He barks orders to his F/O who is either brand new or timid or both. This shouting and the extreme approach puts the F/O behind the aircraft trying to keep up with the orders and checklists and seating the cabin crew and radio calls, so he has no time to think except to do what the Captain is ordering. Captain barks "Gear down" 30 nm out and the F/O complies, his mind paralysed. As they get to short finals the Captain - who has forgotten the gear is already down - barks "Gear Down" and the F/O moves the lever, but because the gear was already down he actually raises the gear. As they flare; the F/O realises what has happened and miserably, finally manages to speak up and calls go-around to avoid a crash landing.
The Captain at last realises that he has severely f****d up and hasn't got away with it this time, so he obeys the go-around call, hoping he can rescue the situation and be able to explain the disastrous approach away somehow. But then the engine accessory gearboxes and oil pumps are badly damaged and the subsequent fatal accident is inevitable.
This is the sort of thing that F/Os need to be able to deal with, (and all Captains need to be aware of), but in years of CRM courses, I have never seen it properly addressed. Cabin crew are given specific training and role playing about how to deal with angry or unreasonable passengers but I have never seen F/Os trained to deal with angry or unreasonable Captains.
The Captain - who we have learned was generally difficult and autocratic and did not fly by the book - is for some reason, (maybe hunger), in a particularly bad and unapproachable mood that day. Due to his impatience, he decides to accept an approach that is too close, too high and too fast, instead of simply asking for more track miles or even a 360°
He barks orders to his F/O who is either brand new or timid or both. This shouting and the extreme approach puts the F/O behind the aircraft trying to keep up with the orders and checklists and seating the cabin crew and radio calls, so he has no time to think except to do what the Captain is ordering. Captain barks "Gear down" 30 nm out and the F/O complies, his mind paralysed. As they get to short finals the Captain - who has forgotten the gear is already down - barks "Gear Down" and the F/O moves the lever, but because the gear was already down he actually raises the gear. As they flare; the F/O realises what has happened and miserably, finally manages to speak up and calls go-around to avoid a crash landing.
The Captain at last realises that he has severely f****d up and hasn't got away with it this time, so he obeys the go-around call, hoping he can rescue the situation and be able to explain the disastrous approach away somehow. But then the engine accessory gearboxes and oil pumps are badly damaged and the subsequent fatal accident is inevitable.
This is the sort of thing that F/Os need to be able to deal with, (and all Captains need to be aware of), but in years of CRM courses, I have never seen it properly addressed. Cabin crew are given specific training and role playing about how to deal with angry or unreasonable passengers but I have never seen F/Os trained to deal with angry or unreasonable Captains.
That's more like it tho my own take is that the whole cockpit environment was a bit more insidious and places a little bit more blame on the FO but maybe helps explain why the FO acted as he did. As follows:-
Autocratic but laid-back Capt sets the scene of "lets wing this flight as usual" right from the Departure Gate and the FO sort of goes along with it as the Capts reputation of bawling out FOs is well known - maybe these 2 have flown on previous occasions - and so "non-standard" is the accepted norm. Indeed, the Capt appears quite amicable on the day as they are reported to be chatting about this and that - but his reputation is there as someone who can "turn"........
The FO, while seemingly playing along with the "lets wing this flight as usual" gets more and more concerned during the approach and finally starts to suggest the hold is the solution to get back on profile - but here the Capt gets annoyed and rejects the hold suggestion from both the FO and ATC and then just takes over.
The FO, by now, is very unhappy and increasingly stressed both at the lack of a hold to sort things out - something he's wanting to do and hence the gear coming up - but, wait, now he's just had control whipped from him....... The Capt has consistently rejected buying time and seems intent on seeing "Plan A" through to it's conclusion and has now made that abundantly clear. After all, he's even said that he'll show ATC what he can do as a skilled aviator!!!! But, because of the way the whole flight has been conducted so far, the Capts not really on top of the aircraft anymore .... hence the gear......
At that point the FO seems to simply enter into a sort of "sod it" mode and what rational thinking he was doing now seems to leave him (certainly WRT remembering the status of the gear). The rest is as we see until the Capt finally realises that it's all gone South as you say.
WRT to the comment that this is the sort of situation FOs need to be able to deal with, I was on a Training Course with several guys from Pakistan - all really nice guys. But, when it came to working scenarios (moving aircraft about on the ground) when we all role-played, there was in their group a "No 1". The guys would consistently turn to this guy for direction even if he was playing a "minion". Whenever the guy who was managing the move issued an instruction - Brit or one of their team - they would immediately look to this guy for his approval. It drove the Instructor nuts as they refused to do otherwise - their No 1 had the final say on everything - end of! That was "the way" and, had I not seen it myself, I'd never have believed it. CRM would have a tough time in breaking down such thinking. But, as I said, a nicer bunch of guys you couldn't find!
Anyway, a thought...... FWIW!
Autocratic but laid-back Capt sets the scene of "lets wing this flight as usual" right from the Departure Gate and the FO sort of goes along with it as the Capts reputation of bawling out FOs is well known - maybe these 2 have flown on previous occasions - and so "non-standard" is the accepted norm. Indeed, the Capt appears quite amicable on the day as they are reported to be chatting about this and that - but his reputation is there as someone who can "turn"........
The FO, while seemingly playing along with the "lets wing this flight as usual" gets more and more concerned during the approach and finally starts to suggest the hold is the solution to get back on profile - but here the Capt gets annoyed and rejects the hold suggestion from both the FO and ATC and then just takes over.
The FO, by now, is very unhappy and increasingly stressed both at the lack of a hold to sort things out - something he's wanting to do and hence the gear coming up - but, wait, now he's just had control whipped from him....... The Capt has consistently rejected buying time and seems intent on seeing "Plan A" through to it's conclusion and has now made that abundantly clear. After all, he's even said that he'll show ATC what he can do as a skilled aviator!!!! But, because of the way the whole flight has been conducted so far, the Capts not really on top of the aircraft anymore .... hence the gear......
At that point the FO seems to simply enter into a sort of "sod it" mode and what rational thinking he was doing now seems to leave him (certainly WRT remembering the status of the gear). The rest is as we see until the Capt finally realises that it's all gone South as you say.
WRT to the comment that this is the sort of situation FOs need to be able to deal with, I was on a Training Course with several guys from Pakistan - all really nice guys. But, when it came to working scenarios (moving aircraft about on the ground) when we all role-played, there was in their group a "No 1". The guys would consistently turn to this guy for direction even if he was playing a "minion". Whenever the guy who was managing the move issued an instruction - Brit or one of their team - they would immediately look to this guy for his approval. It drove the Instructor nuts as they refused to do otherwise - their No 1 had the final say on everything - end of! That was "the way" and, had I not seen it myself, I'd never have believed it. CRM would have a tough time in breaking down such thinking. But, as I said, a nicer bunch of guys you couldn't find!
Anyway, a thought...... FWIW!
Last edited by Hot 'n' High; 25th Apr 2024 at 11:22.
This is the sort of thing that F/Os need to be able to deal with, (and all Captains need to be aware of), but in years of CRM courses, I have never seen it properly addressed. Cabin crew are given specific training and role playing about how to deal with angry or unreasonable passengers but I have never seen F/Os trained to deal with angry or unreasonable Captains.
However your last point is more than valid.
At my airline we received some guidance to help us deal with overwhelmed captains. And some advice about what to do with this type of behavior. Not a huge training but definitely some guidance.
It does not resemble in any way or form to manipulating important controls in the back of the captain and trying to take decisions in his back. On the contrary, in the end you have to work as a team until the airplane is landed. Then, once safely at the gate, not one minute before that, you will make as many reports as you need and call management to explain why you don't want to fly with the guy anymore.
I know first hand accounts from friends, of pilots using this type of method in very exceptional cases.
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Furthermore, the approach is to be stabilized by 500ft (VMC).
I don't buy your scenario, the F/O voluntarily retracted the gear because he wanted to go around, but didn't anything about either going around nor retracting the gear.
3.1.3.22 After AP disconnection, “OVERSPEED” VFE triggered Master Warning along with CRC Aural Alert. Flight crew selected FLAPS without monitoring speed
and did not verbalize acknowledgement of the Master Warning.
3.1.3.23 Two Sequence of GPWS Alerts were triggered before the R/W contact. During 04 GPWS Warnings of “PULL UP”, flight crew did not perform an immediate Terrain Avoidance / Escape Manoeuvre. On 02 “SINK RATE” and 10 “TOO LOW TERRAIN” Amber Cautions, flight crew did not call out GPWS Caution.
3.1.3.24 At 1,600 ft baro altitude, 5 NM from R/W 25L, Landing Gears were selected UP, and Speed Brakes were retracted. Retraction of Landing Gears and Speed
Brakes were not verbalized. 3.1.3.25 At 1,100 ft baro altitude and CAS 227 kts, FO was heard saying “Should we do the Orbit?” (in Urdu) to which Captain replied “No-No”, followed by “Leave it” (both in Urdu). This communication indicates FO has intention for an Orbit. Most probably Landing Gear and Speed Brakes were retracted by FO.
3.1.3.26 Captain took over controls and change of controls was not verbalized by either of the flight crew.
and did not verbalize acknowledgement of the Master Warning.
3.1.3.23 Two Sequence of GPWS Alerts were triggered before the R/W contact. During 04 GPWS Warnings of “PULL UP”, flight crew did not perform an immediate Terrain Avoidance / Escape Manoeuvre. On 02 “SINK RATE” and 10 “TOO LOW TERRAIN” Amber Cautions, flight crew did not call out GPWS Caution.
3.1.3.24 At 1,600 ft baro altitude, 5 NM from R/W 25L, Landing Gears were selected UP, and Speed Brakes were retracted. Retraction of Landing Gears and Speed
Brakes were not verbalized. 3.1.3.25 At 1,100 ft baro altitude and CAS 227 kts, FO was heard saying “Should we do the Orbit?” (in Urdu) to which Captain replied “No-No”, followed by “Leave it” (both in Urdu). This communication indicates FO has intention for an Orbit. Most probably Landing Gear and Speed Brakes were retracted by FO.
3.1.3.26 Captain took over controls and change of controls was not verbalized by either of the flight crew.
This was a maximally dysfunctional team. Either one by themselves would likely have landed safely, but the failures of basic communication became overwhelming and the Captain, who was monitoring, didn't seem to monitor in spite of warnings from the plane and from the ATC.
I am unsure if the Captain at any time was aware of just how badly this approach was going. I am unsure if fasting can carry the full blame as the report indicates the Captain had a number of unstabilized approaches that he continued with, but fasting could certainly have made realizing how bad the situation was unlikely.
The entire thing leaves me sad.
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This is the sort of thing that F/Os need to be able to deal with, (and all Captains need to be aware of), but in years of CRM courses, I have never seen it properly addressed. Cabin crew are given specific training and role playing about how to deal with angry or unreasonable passengers but I have never seen F/Os trained to deal with angry or unreasonable Captains.
Over this last part I would like to emphasize the fact that when operating within the boundaries of proper Aviation Safety Agencies and proper NAA, there should be no place for any Operator to have highly unsuitable crew members at the controls.
Generally speaking we do not expect pilots to reach those kind of extreme behaviors (even though I remember some time ago a couple of pilots from a National Airline fighting in the cockpit but luckily that was on the ground…). Problematic Captains should be stopped by Flt Ops at the very first signs that something is going out of the loop.
A general word For all the FOs, especially the youngest ones: remember that the Captain is there also for YOUR safety. If you don’t feel safe with someone go ahead and fill up reports. Always be factual, never give Your opinions, so that will work even if some guys “have connections”.
Remember that the Legal implications of seating up front, especially in the LHS, are HUGE. Always do Your best to keep everyone safe.
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Last edited by vilas; 26th Apr 2024 at 08:20.
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Yes, it is correct ;-) VFR/IFR, as you mentioned, has nothing to do with IMC/VMC.
It is up the Operator to define which gates must be complied with.
Generally speaking most operators require the landing configuration to be achieved by 1000 ft AAL in all conditions regardless of IMC/VMC. Other parameters such as speed and thrust can be achieved by 500 ft AAL under specific conditions as You mention, which could be an ATC speed restriction for example. For example at my Operator, we are allowed to achieve all the parameters (including landing conf) by 500 ft AAL if VMC conditions are present.
Of course it is strongly recommended to be stable by 1000 ft AAL in all conditions and to have landing Conf achieved by 1000 ft AAL, but again it’s not a violation.
The circling approach is another “beast”. It can be flown in wx conditions lower than VMC (I.e. 5km visibility) and specific stabilization criteria apply.
Trying as a lot of us are to make some sense of the sequence of events as described in the report. We are hampered by having only some extracts from the CVR and FDR data. What does strike me very strongly is lack of coherence between the pilots as to who was “in charge” of the flight, and responsible for starting a chain of events which then became catastrophic, with an almost unimaginable failure to adhere to the proper way to operate a modern aircraft. Much of what follows is speculative but here goes anyway….
Typically SOPs are written down with a basic assumption that Captain (rank) = Pilot in charge (role) = Pilot flying (function). This results in a single Rank authority (Captain) determining the aircraft trajectory. The F/O (rank) as PM (role) is supposed to assist in achieving this trajectory (functions), BUT also somehow over-ride if he/she detects the trajectory to be flawed. So far, in theory, so good.
Then, most operators and indeed manufacturers like to encourage distribution of experience and skills between pilots with “leg and leg” flying with varying restrictions on how and when it is done. These restrictions transfer varying amounts of authority to the F/O, while notionally transferring ALL of the roles and functions, including responsibility for initiating things. It may work perfectly with crew members who can be considered as equally qualified in all senses, and adequately the vast majority of the time. But flaws in this concept look to me like one of the “holes in the Swiss cheese” in this appalling event. They are underlying system failures which meant that when put to the test, both pilots completely failed to meet their responsibilities, with a Captain in particular who was truly unfit to occupy that position.
On this flight the F/O seems to have been NOMINALLY “in charge” (as PF) to start with, and expecting eventually to make the landing - certainly from before the start of the descent, although the report isn’t explicit about this. But not only did he lack the Captain’s FORMAL authority (RANK), it appears that the Captain’s personality further diminished the F/O’s “in charge” capability to determine the aircraft’s actual flight path.
The Captain’s rank as “Aircraft Commander” meant he still retained his overall ability to determine what the crew collectively prioritised and how things were done. Only a Captain (in this case twice the age of his F/O and with 8 times the experience) can create or allow the atmosphere of “conducive and cordial” chat about “various topics not related to aircraft operations”, continuing even below 10,000ft. In my opinion this must have been a major factor in the failure to conduct any kind of briefing and hence get mentally prepared with a mutually understood plan. That was the starting point for this particular tragedy.
So it’s quite hard to determine who was actually “in charge” as things started going wrong. ATC communications are normally a PM function, yet prior to descent at 09:15:00 it’s specifically stated that the F/O made the request for descent to ATC. After getting clearance and starting descent they then seemed to have changed radio frequency without being asked to do so, mistuning the approach frequency in the process (probably by the Captain?) and losing ATC contact for about 8 minutes, chatting about “various non-operational topics”. Meanwhile the autopilot was doing its own thing, with no announced monitoring of its modes, resulting in the high profile with the extra miles of the hold in the FMS horizontal track.
It's at 09:30:35 that a call from ATC seems to have triggered an initial concern, although it’s unclear which pilot responded to ATC with “affirm”. The CAPTAIN then instructs the F/O to take the hold out and “tell Karachi established on localiser” – implying that the F/O was now in the role of PM and doing the radio.
At 09:30:44 and 15 miles out the aircraft was at 9200’ and 245kt, and someone extended the speedbrakes. Subsequent communications don’t show which pilot was doing them (normally PM function) or who told ATC “no problem sir”, but the use of the subordinate’s term “sir” might imply it was the F/O rather than the Captain, who was known to have a more arrogant and dominant personality and perhaps less likely to call ATC “sir”.
About a minute later the gear was extended: while the gear was in transit, ATC asked if they wanted to orbit. The Captain’s response is “say it’s OK” and after a significant (6 second) gap the F/O transmits “Negative Sir we are comfortable, we can make it, Insha-Allah”. To me this suggests he was already unhappy about it, and the final phrase “Insha-Allah” – “if God wills it”? - might indicate a recognition that events were not entirely in the control of the crew – certainly not himself. But that of course is pure speculation on my part.
These and subsequent calls indicate to me that the Captain had now effectively assumed the PF role and functions, without saying so. My suspicion is also that as the autopilot was still manipulating the physical controls, it would have been the Captain who actually leaned across and extended the gear, which would normally be an action by the PM – his nominal role.
The F/O had now been cut out of the control loop. The Captain had used his command authority, amplified by his personal attitudes and possibly exacerbated by local cultural factors (respect for age and experience etc) to take complete charge, and was now carrying out functions that should have been split between PF and PM, with the F/O theoretically PF but in reality reduced to being an increasingly concerned subordinate to the Captain.
At 5.5 miles and 2730ft, the autopilot tripped out due to excessive nose down pitch attitude, with a descent rate of 7400 fpm. The F/O reacted with 2/3 full stick back for 10 seconds, but didn’t change the thrust. During that period the sequence of overspeed and GPWS alerts started and the gear and then speedbrakes were retracted starting at 09:32:57 – the report says, probably by the F/O - and overall he reduced the pitch to 0 and ROD to 2000 fpm. This was not the initiation of an actual go-around but would make sense if he wanted to reduce the extremely high descent rate, especially if the gear had been put down by the Captain, interfering earlier to increase the descent rate.
Manual control remained with the F/O (presumably, since there’s no comment about dual inputs for a further 50 seconds), during which the flaps were extended to conf 2, and then conf 3. The F/O suggested making an orbit but had it rejected by the Captain and the descent continued in compliance with the Captain’s evident intention as aircraft commander to proceed to landing.
The Captain pressed his sidestick button at 09:33.37 (about 1050ft,) and there were conflicting inputs for about 4 seconds, which the report classifies as the Captain “taking control”. My recall of the A320 system is very hazy but since the autopilot was already disconnected, what practical effect on control inputs would this PB press have had (as it did not seem to be a 40 second “deactivate other sidestick” push)? However since there’s no subsequent mention of dual inputs it appears that the F/O must have stopped trying to influence the flight path directly through the sidestick. Since there’s no record of instructions here it’s my conjecture then is that the Captain had made the flap selections himself and the F/O simply recognised that with the runway clearly visible at 1000ft the Captain was determined to try complete the landing.
It seems likely to me that the Captain’s thought processes had gone from being blithely overconfident and casual to being completely dominated by his own plan continuation bias to land at all costs, and he was operating as a “one man band”. He knew he had put the gear down himself, but forgotten or not registered that the F/O had retracted it when the autopilot disconnected. His landing determination was so strong it drowned out all other inputs including the multiple GPWS and gear alerts, and would done the same to any gate parameter exceedances even if the F/O had called them, which he did not appear to have done. I suspect that the F/O had become like the proverbial “rabbit in headlights”, frozen by conflicting inputs. “We can see the runway, the Captain’s taken over and to do the landing now (“things are OK”) but there are these instrument readings and warnings saying “it’s not OK”; he was effectively frozen by events that had spiralled out of control.
The Captain’s continuation bias was so extreme that once over the runway, a long way down but still airborne, he selected full reverse thrust, and applied maximum brake pedal inputs as the engines nacelles hit the runway.
The crew then had conflicting reactions to the ground contact and made diametrically opposed inputs, with the F/O’s desire to go-around even so belatedly (“takeoff, Sir, takeoff”) eventually winning out after several seconds of Engine 2 Fire alerts.
Ironically, had the Captain stuck with his original determination to stop it might possibly have saved a few lives in the subsequent over-run. As it was they took an unflyable aircraft back into the air and killed everyone.
I have my own views on how the chances of this sort of thing can be reduced, but the above is my opinion on how this particular disaster came abouit, for what it's worth.
Steve
Edit: there's no reference in the report to checklists being called for or actioned, and configuration changes are said "not to have been verbalised by either pilot " hence my suggestions that e.g. they were not made as a result of both pilots being involved.
Typically SOPs are written down with a basic assumption that Captain (rank) = Pilot in charge (role) = Pilot flying (function). This results in a single Rank authority (Captain) determining the aircraft trajectory. The F/O (rank) as PM (role) is supposed to assist in achieving this trajectory (functions), BUT also somehow over-ride if he/she detects the trajectory to be flawed. So far, in theory, so good.
Then, most operators and indeed manufacturers like to encourage distribution of experience and skills between pilots with “leg and leg” flying with varying restrictions on how and when it is done. These restrictions transfer varying amounts of authority to the F/O, while notionally transferring ALL of the roles and functions, including responsibility for initiating things. It may work perfectly with crew members who can be considered as equally qualified in all senses, and adequately the vast majority of the time. But flaws in this concept look to me like one of the “holes in the Swiss cheese” in this appalling event. They are underlying system failures which meant that when put to the test, both pilots completely failed to meet their responsibilities, with a Captain in particular who was truly unfit to occupy that position.
On this flight the F/O seems to have been NOMINALLY “in charge” (as PF) to start with, and expecting eventually to make the landing - certainly from before the start of the descent, although the report isn’t explicit about this. But not only did he lack the Captain’s FORMAL authority (RANK), it appears that the Captain’s personality further diminished the F/O’s “in charge” capability to determine the aircraft’s actual flight path.
The Captain’s rank as “Aircraft Commander” meant he still retained his overall ability to determine what the crew collectively prioritised and how things were done. Only a Captain (in this case twice the age of his F/O and with 8 times the experience) can create or allow the atmosphere of “conducive and cordial” chat about “various topics not related to aircraft operations”, continuing even below 10,000ft. In my opinion this must have been a major factor in the failure to conduct any kind of briefing and hence get mentally prepared with a mutually understood plan. That was the starting point for this particular tragedy.
So it’s quite hard to determine who was actually “in charge” as things started going wrong. ATC communications are normally a PM function, yet prior to descent at 09:15:00 it’s specifically stated that the F/O made the request for descent to ATC. After getting clearance and starting descent they then seemed to have changed radio frequency without being asked to do so, mistuning the approach frequency in the process (probably by the Captain?) and losing ATC contact for about 8 minutes, chatting about “various non-operational topics”. Meanwhile the autopilot was doing its own thing, with no announced monitoring of its modes, resulting in the high profile with the extra miles of the hold in the FMS horizontal track.
It's at 09:30:35 that a call from ATC seems to have triggered an initial concern, although it’s unclear which pilot responded to ATC with “affirm”. The CAPTAIN then instructs the F/O to take the hold out and “tell Karachi established on localiser” – implying that the F/O was now in the role of PM and doing the radio.
At 09:30:44 and 15 miles out the aircraft was at 9200’ and 245kt, and someone extended the speedbrakes. Subsequent communications don’t show which pilot was doing them (normally PM function) or who told ATC “no problem sir”, but the use of the subordinate’s term “sir” might imply it was the F/O rather than the Captain, who was known to have a more arrogant and dominant personality and perhaps less likely to call ATC “sir”.
About a minute later the gear was extended: while the gear was in transit, ATC asked if they wanted to orbit. The Captain’s response is “say it’s OK” and after a significant (6 second) gap the F/O transmits “Negative Sir we are comfortable, we can make it, Insha-Allah”. To me this suggests he was already unhappy about it, and the final phrase “Insha-Allah” – “if God wills it”? - might indicate a recognition that events were not entirely in the control of the crew – certainly not himself. But that of course is pure speculation on my part.
These and subsequent calls indicate to me that the Captain had now effectively assumed the PF role and functions, without saying so. My suspicion is also that as the autopilot was still manipulating the physical controls, it would have been the Captain who actually leaned across and extended the gear, which would normally be an action by the PM – his nominal role.
The F/O had now been cut out of the control loop. The Captain had used his command authority, amplified by his personal attitudes and possibly exacerbated by local cultural factors (respect for age and experience etc) to take complete charge, and was now carrying out functions that should have been split between PF and PM, with the F/O theoretically PF but in reality reduced to being an increasingly concerned subordinate to the Captain.
At 5.5 miles and 2730ft, the autopilot tripped out due to excessive nose down pitch attitude, with a descent rate of 7400 fpm. The F/O reacted with 2/3 full stick back for 10 seconds, but didn’t change the thrust. During that period the sequence of overspeed and GPWS alerts started and the gear and then speedbrakes were retracted starting at 09:32:57 – the report says, probably by the F/O - and overall he reduced the pitch to 0 and ROD to 2000 fpm. This was not the initiation of an actual go-around but would make sense if he wanted to reduce the extremely high descent rate, especially if the gear had been put down by the Captain, interfering earlier to increase the descent rate.
Manual control remained with the F/O (presumably, since there’s no comment about dual inputs for a further 50 seconds), during which the flaps were extended to conf 2, and then conf 3. The F/O suggested making an orbit but had it rejected by the Captain and the descent continued in compliance with the Captain’s evident intention as aircraft commander to proceed to landing.
The Captain pressed his sidestick button at 09:33.37 (about 1050ft,) and there were conflicting inputs for about 4 seconds, which the report classifies as the Captain “taking control”. My recall of the A320 system is very hazy but since the autopilot was already disconnected, what practical effect on control inputs would this PB press have had (as it did not seem to be a 40 second “deactivate other sidestick” push)? However since there’s no subsequent mention of dual inputs it appears that the F/O must have stopped trying to influence the flight path directly through the sidestick. Since there’s no record of instructions here it’s my conjecture then is that the Captain had made the flap selections himself and the F/O simply recognised that with the runway clearly visible at 1000ft the Captain was determined to try complete the landing.
It seems likely to me that the Captain’s thought processes had gone from being blithely overconfident and casual to being completely dominated by his own plan continuation bias to land at all costs, and he was operating as a “one man band”. He knew he had put the gear down himself, but forgotten or not registered that the F/O had retracted it when the autopilot disconnected. His landing determination was so strong it drowned out all other inputs including the multiple GPWS and gear alerts, and would done the same to any gate parameter exceedances even if the F/O had called them, which he did not appear to have done. I suspect that the F/O had become like the proverbial “rabbit in headlights”, frozen by conflicting inputs. “We can see the runway, the Captain’s taken over and to do the landing now (“things are OK”) but there are these instrument readings and warnings saying “it’s not OK”; he was effectively frozen by events that had spiralled out of control.
The Captain’s continuation bias was so extreme that once over the runway, a long way down but still airborne, he selected full reverse thrust, and applied maximum brake pedal inputs as the engines nacelles hit the runway.
The crew then had conflicting reactions to the ground contact and made diametrically opposed inputs, with the F/O’s desire to go-around even so belatedly (“takeoff, Sir, takeoff”) eventually winning out after several seconds of Engine 2 Fire alerts.
Ironically, had the Captain stuck with his original determination to stop it might possibly have saved a few lives in the subsequent over-run. As it was they took an unflyable aircraft back into the air and killed everyone.
I have my own views on how the chances of this sort of thing can be reduced, but the above is my opinion on how this particular disaster came abouit, for what it's worth.
Steve
Edit: there's no reference in the report to checklists being called for or actioned, and configuration changes are said "not to have been verbalised by either pilot " hence my suggestions that e.g. they were not made as a result of both pilots being involved.
Last edited by slast; 26th Apr 2024 at 13:44.
Per the report analysis, before the FO could start the go-around the Captain took controls from the FO.
I haven't backed up enough to see how coming in too high and too fast originated, but the FO was generally in charge of the controls until the Captain decided to grab them. Had the Captain not done so, the FO had clearly prepped to go around, having retracted the gear, the speed brakes, and seemed to be prepping to follow through on the PULL UP, SINK RATE, and TOO LOW TERRAIN warnings.
This was a maximally dysfunctional team. Either one by themselves would likely have landed safely, but the failures of basic communication became overwhelming and the Captain, who was monitoring, didn't seem to monitor in spite of warnings from the plane and from the ATC.
I am unsure if the Captain at any time was aware of just how badly this approach was going. I am unsure if fasting can carry the full blame as the report indicates the Captain had a number of unstabilized approaches that he continued with, but fasting could certainly have made realizing how bad the situation was unlikely.
The entire thing leaves me sad.
I haven't backed up enough to see how coming in too high and too fast originated, but the FO was generally in charge of the controls until the Captain decided to grab them. Had the Captain not done so, the FO had clearly prepped to go around, having retracted the gear, the speed brakes, and seemed to be prepping to follow through on the PULL UP, SINK RATE, and TOO LOW TERRAIN warnings.
This was a maximally dysfunctional team. Either one by themselves would likely have landed safely, but the failures of basic communication became overwhelming and the Captain, who was monitoring, didn't seem to monitor in spite of warnings from the plane and from the ATC.
I am unsure if the Captain at any time was aware of just how badly this approach was going. I am unsure if fasting can carry the full blame as the report indicates the Captain had a number of unstabilized approaches that he continued with, but fasting could certainly have made realizing how bad the situation was unlikely.
The entire thing leaves me sad.
FYI, the hot n high situation arose from the F/O's failure to identify that his FMS computed descent profile wasn't in accordance with the intentions of the crew (ie, not doing the pattern)
You gave the following parameters at the time of gear retraction : 1500ft AGL, 5 nm from touchdown. This gives us exactly on the profile, 3° slope, but too fast. Maybe around 210-220kt ?
With gear down and flaps, you lose approximately 10kt per 100ft, on the 3° profile. That doesn't account for spoilers. So, with gear down, whatever flaps they had, full spoilers, they would have lost at least 15kt per 100ft. So by 1000ft they would have been at 150-160kt. They would have extended more steps of flaps, and there's even a good chance they would have been stabilized by the book at 500ft.
Also, the captain had a good technique consisting of diving at high speed, where the drag is the worst. Diving at high speed with all drags out then reducing speed with a shallow path is a very efficient technique for reducing speed and meeting the stabilization criteria.
So, that was a hot n high approach but it could have been stabilized, by the book, by 500ft AGL.
Many airlines allow approaches to be stabilized at 500ft VMC according to Airbus's criteria.
I've never read this fact (I think it is a fact, it would take a performance study to know for sure, but it's very likely) anywhere.
On the other hand, on many incident occurrences, the report will point out that the crew could have done differently without problems. For example, for the British 350 tailstrike following go around, the AAIB points out that disregarding the touchdown zone rule would have not led to a runway excursion. Hence, implying in a soft manner than it's sometimes better to disregard rules ?
How come such scenarios are sometimes pointed out, sometimes not ?
Does this fact change your view on the crew performance on this flight ?
The approach was not unrealistic at all. It was a bit further than the limits because they tried to extend flaps at too high speeds. But nothing deserving to die for.
The F/O failed to imagine that he could be wrong about thinking the approach was not feasible. It was.
As a young F/O, my first months were a bit uncomfortable because I was aware that I lacked experience. So I had two choices : learning from the captain when they put themselves in "risky" situations. Or refusing to do anything I wasn't comfortable with, and learning nothing.
The drawback in the second case is never developing my knowledge, experience and skills. The drawback in the first case is that I wasn't able to know what really was too much. So I just expressed my doubts. But of course, without ever digging our tomb by doing idiotic things in the captain's back.
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Full disclaimer - not a pilot, just an aviation enthusiast.
Post from CVivid read quite concerning if taken on face value. Not that I'd ever know but I'd hope the people at the front don't make a habit of putting themselves in "risky" situations.
Post from CVivid read quite concerning if taken on face value. Not that I'd ever know but I'd hope the people at the front don't make a habit of putting themselves in "risky" situations.
