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December 22, 2011

Report alleges lack of judgment, professionalism


December 22, 2011

PESHAWAR: In the inquiry report, the probe committee has declared the Airblue plane crash in the Margalla Hills in Islamabad a case of Controlled Flight into Terrain (CFIT) in which the aircrew failed to display superior judgment and professional skills in a self-created unsafe environment and in their pursuit to land in inclement weather.
It said in the process the crew committed serious violations of procedures and breaches of flying disciplines, which put the aircraft in an unsafe state over dangerous terrain at low altitude.
In the 38-page comprehensive report of the Civil Aviation Authority (CAA) made available to The News, the inquiry committee said the chain of events leading to the incident, in fact, started with the commencement of flight when Captain Pervez Iqbal Chaudhry was heard confusing the Benazir Bhutto International Airport Islamabad with Jinnah International Airport Karachi while planning Flight Management System (FMS) and Khanpur Lake with Kahuta area during the holding pattern.
The report said the captain of the unfortunate flight violated the proscribed 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 full 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 and full off),” said the inquiry report.
It stated in

the inquiry that the First Officer simply remained a passive bystander in the cockpit and did not participate as an effective team member failing to supplement and compliment or to correct the errors of his captain assertively in line with the teachings of the Crew Resource Management (CRM) due to the captain’s behaviour in the flight.
“At the crucial juncture, both the Air Traffic Control (ATC) and the radar controllers were preoccupied with bad weather and the traffic; the air controller having lost visual contact with the aircraft got worried and sought radar help on the landline (the ATC does not have radar scope); the radar controller having cleared aircraft to change frequency to ATC, got busy with following traffic. Having been alerted by the ATC, the radar controller shifted focus to the aircraft — seeing the aircraft very close to ‘No Fly Zone’, he asked the ATC Officer (on landline) to ask the aircraft to immediately turn left, which was transmitted,” said the inquiry report, adding that sensing the aircraft still heading towards the hills, the radar controller asked the ATCO on landline to confirm he has visual contact with the ground and if not, then asked him to immediately climb, and make him execute missed approach.
The report said the ATCO in quick succession asked the captain whether or not he had contact with the airfield and on receiving no reply from aircrew, the ATCO on radars promptly asked if he had contact with the ground.
“The aircrew announced visual contact with the ground, which put ATS at ease. Ensuing discussion and mutual situational update (on landline) continued and, in fact, the ATC call ‘message from radar immediately turn left’ was though transmitted, but by the time the call got transmitted, the aircraft had crashed at the same time,” said the inquiry report.
The inquiry committee concluded that the accident was primarily caused by the aircrew that violated all established procedures for a visual approach for RWY-12 and ignored several calls by ATS controllers and Enhanced Ground Proximity Warning System (EGPWS) system warnings (21) related to approaching rising terrain and pull up.
The findings revealed that the captain and the first officer possessed the requisite qualifications and ratings and were medically fit to undertake this flight. It said the captain was scheduled for the flight only a night before, yet the aircrew were well rested and the prescribed rest period violation did not take place. It said the weather conditions, especially at the destination, were marginal and these deteriorated weather conditions were found to be a factor in the causation of the accident.
It was also revealed that the captain’s behaviour towards the first officer was harsh, snobbish and contrary to the established norms. “The captain had prior knowledge of the decision by two captains flying ahead of him. While the captain of PK-365 managed to land in the third attempt, the captain of China Southern decided to divert back to Urumchi (China). The captain of the Airblue flight opted to follow PK-356, but with non-standard approach procedure,” said the report.
The ABQ-202, on July 28, 2010, being operated by Airblue was scheduled to fly a domestic flight sector from Karachi to Islamabad. All the 146 passengers and six crewmembers were killed in the crash.
The investigation was ordered by the government of Pakistan and the inquiry report was completed by an eight-member investigation team headed by Air Commodore Khawaja A Majeed, who is chairman Safety Investigation of the Civil Aviation Authority (CAA). It was submitted to the CAA director general on March 7, 2011.
Other committee members were Group Captain (R) Mujahid Islam Khan as operations member, Group Captain Sardar Muhammad Ilyas as technical member, M Afzal Boghio as medical officer, Amanullah Alvi as ATS member, Engineer Tahir Abbas as airworthiness member, Captain Sohail Sarwar as Airblue member and Air Commodore Salamat Ali as PAF member.

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