airblue Flight ABQ-202 Crash Report

airblue Flight ABQ-202 Crash Report2014Daniyal AliBAT113622/12/2014

Department of Engineering and Technology

Appropriate Task: Air blue Flight APQ-202 Crash ReportA research on Air blue Flight APQ-202 crash. What are the main factors in the behind the crash and what are the solutions for these factors.Prepared By:Daniyal Ali (BAT11362)Submitted To:Prof. W/C Imran KhanDiscipline:BS-Aviation TechnologySubmission Date:13-02-2014

airblue Flight ABQ-202Flight Details:Airblue Flight 202was a scheduled domestic passenger flight which crashed on 28 July 2010 nearIslamabad, the capital ofPakistan, killing all 146 passengers and six crew on board. It is thedeadliest air accidentto occur in Pakistan to date.The Captain of aircraft was Captain Pervez Iqbal Chaudhary. Mishap aircraft, an AirblueoperatedAirbus A321-231narrow-bodyjet airliner, crashed in theMargalla Hillsnorth of Islamabad during a flight fromKarachi's Jinnah International AirporttoBenazir Bhutto International Airport, took-off from Karachi at 0241 UTC (0741 PST) for Islamabad. At time 0441:08, while executing a circling approach for RWY-12 at Islamabad, it flew into Margalla Hills, and crashed at a distance of 9.6 NM, on a radial 334 from Islamabad VOR. Air traffic controllers reportedly lost contact with the flight crew during its attempt to land in dense fog and heavy monsoon rain. The aircraft was completely destroyed and all souls on board the aircraft, sustained fatal injuries. May Allah bless their souls.Pilot Details:The sixty-two-year-old captain of Flight 202, Pervez Iqbal Chaudhry, had 35 years and more than 25,000 hours of flying experience, with an unblemished flight safety record and rating of A-319/320/321.The comparatively junior first officer (Sqn Ldr) Muntajib Ahmed, a former F-16Pakistan Air Forcefighter pilot, had logged one year of experience on the Airbus A321 aircraft.Aircraft Information:The aircraft that crashed was an Airbus A321-231, registered AP-BJB,manufacturer's serial number 1218, which was built in 2000. This was the first fatal crash for the A321, and the second hull-loss of the type.The aircraft had originally been delivered toAero Lloydand used byAero Flightbefore being taken up by Airblue in 2006.It had accumulated approximately 34,000 flight hours in some 13,500 flights.Passengers:Early reports in the morning had stated that there were over 40 injured survivors, later revised at around midday to around five to six people having been rescued, before Interior MinisterRehman Malikconfirmed in the afternoon that there were in fact no survivors.Pakistani footballer Misha Dawood, 19, of Diya Football Club, Karachi,and former national athlete Zafar Saleem, who was director-general of the Sindh Workers Welfare Board, were killed in the crash. Of the passengers, 110 were men, 29 were women, 5 were children, and 2 were infants.Six members of theYouth Parliament of Pakistanwere on boardas were three off duty air hostesses,and four foreign nationals.

Accident:The flight left Karachi at 07:50local time(01:50UTC).Initial reports suggested that flight controllers at Benazir Bhutto International Airport lost contact with the aircraft at 09:43 local time (03:43 UTC)after they delayed its landing 13 minutes earlier.It was reported that the poor weather had forced controllers to divert another aircraft attempting to land 30 minutes before the crash. The aircraft approached Islamabad from the southeast, following a procedure that required it to fly toward the airport until making visual contact. It was then to have flown around the airport to the east and north, keeping within a distance of 5nmi (9.3km), until lining up with runway 12, which faces toward the southeast. The aircraft crashed in the mountains outside the 5nmi (9.3km) radius, approximately 8nmi (15km) north of the airport, facing almost due west, before it could line up with runway 12 for final approach. While the BBC reported that officials stated that "there was nothing in conversations between the pilot and the Islamabad control tower that suggests anything was wrong",The New York Timesgave an account of communications between the aircraft and the ground that indicated otherwise. The newspaper claimed that the pilots were warned that they were flying away from the runway, to which the pilot responded I can see.The controller then told the flight crew to immediately turn left, Margalla [Hills] are ahead, before the pilot again replied we can see it.MultipleEGPWS"TERRAIN AHEAD" warnings were recorded on theCockpit Voice Recorderstarting 40 seconds before the crash. The first officer was also heard requesting to the captain "Sir turn left, Pull Up Sir. Sir pull Up." This was the firstcontrolled flight into terrainaccident since 2002, when all planes with more than six passengers became required to have an advanced terrain awareness warning system. An airline official stated that the pilots did not send any emergency signals prior to the crash.Resources stated that the plane was at 2,600 feet (790m) as it approached Islamabad but went back up to 3,000 feet (910m) before eventually crashing.The altitude of 2,600 feet (790m) was above the safe minimum descent altitude (2,510 feet (770m) above sea level, or 852 feet (260m) above ground level) had the aircraft remained within the 5nmi (9.3km) radius of the airport. One witness on the ground, who was out walking, stated that "the plane had lost balance, and then we saw it going down".Others described the plane as being lower than it should have been. "I wondered why the plane wasn't flying higher as it was flying towards the hill", one stated. "Then within three or four minutes I heard a loud explosion". Another said that "it was raining. I saw the plane flying very low from the window of my office".Imran Abbasi toldThe New York Timesthat he "could tell it was trouble because it stayed so low even though the mountains were up ahead". He stated that the jet was "flying as low as a four-story building".It was reported that Mr. Abbasi said that "as the aircraft started to turn, the right side of its front banged into the highest mountain, emitting an instant billow of blue fire and black smoke".The plane was found nearDaman-e-Kohviewing point in the Margalla Hills outside Islamabad. TheLos Angeles Timesreported that "television footage of the crash site showed smoke and burning debris strewn in a swath cutting through the forest. Rescue helicopters hovered overhead. Fire was visible, and smoke was blowing up from the scene." The weather conditions before the accident, as detailed by the 03:00 UTCMETAR(aviation routine weather observation message) report for Benazir Bhutto International Airport, were as follows: Wind from 50 (approximately north east) at 16 knots (30km/h). Visibility 2 kilometres (1.2mi), rain,few cloudsat 1,500 feet (460m), few clouds at 3,000 feet (910m) withtowering cumulus. Scattered clouds at 4,000 feet (1,200m), broken clouds at 10,000 feet (3,000m). Temperature 24C, dewpoint 23C.QNH1006.5hPa.Investigation:TheCivil Aviation Authorityimmediately launched an investigation into the accident.Airbusstated that they would provide full technical assistance to Pakistani authorities.A six member Airbus team, headed by Nicolas Bardou, the company's director of flight safety, arrived in Islamabad on 29 July 2010. The recorders were located on 31 July,when Junaid Ameen, the director-general of the Pakistan Civil Aviation Authority, told the Associated Free Press that "the investigating committee found the black box from the Margalla Hills this morning ... the black box was found from the bulk of the wreckage of the crashed plane." He stated that the box would be examined by "foreign experts" in Germany or France as Pakistan does not possess the equipment to decode the flight recorders. He also stated that the process of extracting information may take six months to a year.The Pakistani authorities decided to send theCVRandFDRto theBureau d'Enqutes et d'Analyses pour la Scurit de l'Aviation Civile(BEA) in France.Findings:1) The weather conditions especially at the destination were marginal and these Deteriorated weather conditions were found to be a factor in the causation of this accident.2) The Captains behavior towards the FO was harsh, snobbish and contrary to establish norms. This undesired activity of the Captain curbed the initiative of the FO, created a tense and undesirable environment, and a very conspicuous communication barrier in the cockpit, portraying a classic CRM failure.3) Contrary to ATS briefing and established procedures of Circle to Land RWY-12, the Captain opted to fly approach on Nav mode and asked the FO to feed 04 way points. FO did not challenge the captain for his incorrect actions.4) This intention of Captain to fly PBD based approach was not known to the ATS at any stage of flight. Due to this violation of established procedure, the FMS created positions were way out of the protected airspace lying into Margalla hills. Unfortunately, PBD-11 happened to be in the near vicinity of the crash point.5) The Captain had a very strong fixation for landing through RH D/W for RWY-12. This despite the fact that with his vast experience of flying, he knew RH D/W for RWY-12 is not allowed by procedures; and this time even low clouds were reported in the area.6) The Captain showed signs of anxiety, preoccupation, confusion and geographical disorientation in various phases of flight especially after commencement of descent.7) During the descent, the Captains request for RH D/W for RWY-12 for a visual approach was not agreed to by Radar.8) During ILS approach, the Captains second request for RH D/W for RWY-12 was also declined by ATC Tower due to procedural limitations (RH D/W for RWY-12 is not allowed).9) After delayed break-off from ILS at minima due to poor visibility, the Captain turned right to about 352 degrees and then contrary to the published procedure, did not turn left to parallel the course of the runway.10) While flying the northerly heading, abeam downwind, the Captain descended below the MDA (2,510ft) to 2,300ft. FO remained reliant on the Captains actions and did not challenge the deviation from procedures.11) The Captain failed to maintain visual contact with the airfield, in violation of the published procedures.12) While aircraft was flying in the general direction of 352 degrees, it went very close to the NFZ (01 km) in the North.13) When the ATC Controller did not find the aircraft on Downwind / final approach, he sought Radar help on landline. The aircraft was re-identified by the Radar close to NFZ. As advised by Radar controller, ATC instructed ABQ-202 to turn left to avoid No Flying Zone. However, the Captain had already initiated the left turn onto 300 degrees using HDG mode.14) At 0439:58 hrs (70 seconds before the impact), the first EGPWS warning of terrain ahead started sounding meaning that the EGPWS worked exactly in the manner for which it was designed.15) ABQ-202 was asked by ATS if they had contact with the airfield. No reply was given by either of aircrew, but FO asked the Captain in the cockpit Kia batauon Sir (what should I tell him Sir), indicating possible loss of visual contact with airfield as well as geographical disorientation.16) The protected circling airspace to fly at MDA was available till 4.3 NM. Contrary to the recommended procedures, the mishap aircrew took the aircraft out of the protected area to 7.3 NM from RWY-12 threshold.17) In the ensuing self created emergency situation, the Captain unknowingly failed to do even the simple things such as engaging the HDG knob by pulling it to activate the desired mode.18) During last 70 seconds from crash, despite calls from ATS and the EGPWS sounding 21 times as Terrain ahead including 15 times for pull up (extract of sound and alarms chronology is attached at Appendix-C), the Captain continued to take the aircraft on its fatal journey. The FO also informed the Captain 4 times about the terrain / Terrain Warning and asked him at least 3 times to pull up. But the Captain did not pull up, nor did he apply the TOGA (Take Off Go Around) thrust, contrary to the established SOPs.19) FO kept watching the Captains failures, and unsafe actions such as inducing steep banks; and continuous flight into hilly terrain at low altitude in poor visibility; and failure to apply power and pull up. Unfortunately, FO remained impassive and failed to assert himself due to non congenial environment in the cockpit.20) While the FO sensing imminent and acute danger did shout twice in the most disappointed / frustrated manner to inform the Captain that the aircraft was going down, but unfortunately still failed to takeover / override.21) The aircraft was fully airworthy and its power plants, control surfaces, Enhanced Ground Proximity Warning System (EGPWS) and associated systems were functioning normal till its impact with the hill.22) No evidence was found for any internal or external sabotage, incapacitation of the aircraft systems, in-flight fire, bird strike or structural fatigue.23) BBIAP Islamabad being a busy international airport of the country, instrument approach procedure was not established for RWY-12, because of which Circle to land on RWY-12 was in use.

Conclusion:1) A lack of professionalism in the cockpit crew along with poor weather as primary factors in the crash.2) 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.3) The accident was primarily caused by the aircrew who violated all established procedures for a visual approach for RWY-12 and ignored several calls by ATS Controllers and EGPWS system warnings (21) related to approaching rising terrain and PULL UP.4) FO simply remained a passive bystander in the cockpit and did not participate as an effective team member failing to supplement / compliment or to correct the errors of his captain assertively in line with the teachings of CRM due to Captains behavior in the flight.5) Aircrew Captain not only clearly violated the prescribed procedures for circling approach but also did not at all adhere to FCOM procedures of displaying reaction / response to timely and continuous terrain and pull up warnings (21 times in 70 seconds) despite these very loud, continuous and executive commands, the Captain failed to register the urgency of the situation and did not respond in kind (break off / pull off).6) Captain was fit to undertake the flight on the mishap day, yet his portrayed behavior and efficiency was observed to have deteriorated with the inclement weather at BBIAP Islamabad.7) The chain of events leading to the accident in fact started with the commencement of flight, where Captain was heard to be confusing BBIAP Islamabad with JIAP Karachi while planning FMS, and Khanpur Lake (Wah) with Kahuta area during holding pattern. This state continued when Captain of the mishap flight violated the prescribed Circling Approach procedure for RWY-12; by descending below 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 protected airspace of maximum of 4.3 NM into Margallas and finally collided with the hills.

References:1) http://www.dawn.com/news/713312/caa-releases-airblue-crash-reports2) http://en.wikipedia.org/wiki/Airblue_Flight_2023) INVESTIGATION REPORT issued by CAA Pakistan, AIR BLUE FLIGHT ABQ-202 A-321 REG AP-BJB PAKISTAN CRASHED ON 28 JULY 2010 AT MARGALLA HILLS, ISLAMABAD2