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Airblue 202 Crash

Vikram Surana

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FirstRemember
The sole objective of the investigation of an accident
or incident shall be the prevention of accidents and
incidents. It is not the purpose of this activity to
apportion blame or liability
Annex 13, Chapter 3
BUT

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Summary

Airblue Airbus A321(AP-BJB)

Flying from Karachi to Islamabad (Domestic)
152 TOB including 6 Crew
Flew into Margalla mountains while executing a
circle to land approach for Rwy 12 at 04:41 UTC

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A closer Look
on the
approach Plate

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Airport Surroundings

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Factual
Information 1
History of Flight (Crash)
Injuries to persons (All Perished)
Damage to Aircraft (Destroyed)
Other Damages (Greenery / Forest)
Flight Crew information (Experienced & Fit to Fly)
Aircraft Information (Was Airworthy)
Meteorological Information (3500m Visibility / Clouds)
Aids to Navigation (ILS, VOR
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Factual Information 2
Aerodrome Information (Types of approaches & numbers)
Flight Data Recorders (Contained full flight information)
Wreckage & impact information
Fire (No Fire Fighting, but rain)
Survival Aspects (No ELT mentioned)

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What does the Procedures Say ?

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Factual Information Deficiencies

Extra A320 explanations (FMS / EGPWSetc.)
ICAO recommended sequencing was not followed
Medical and Pathological information was not up to
expectations
Communications part was not clear (whos responsible?)
Organizational and management Information
No consideration of Pilots activities prior to the flight.

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Critical Analysis - 1
Report concludes the following to be responsible for the
disaster:
a. Poor CRM
b. Pilot Error
c. Marginal Weather
d. Loss of Situational Awareness and control.
Although the facts presented in the report strongly points
towards the above mentioned reasons however I strongly feel
there are few facts which are shadowed behind these facts and
it becomes immensely important to try and understand such
hidden facts which in turn might help us to understand few
more probable reasons for the accident
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Critical Analysis - 2
In the factual information on page 14 no. 5.8.5, it says:
The Flight Recorders contained the complete flight
data as well as cockpit voice recording for the entire
flight duration from take off to crash.
If the voice recording was available than why is the
initial cockpit voice recording not shown in the report
and never made public, as this conversation is
described to be offensive, absurd and absolutely
unacceptable and the investigation report believes
that this is the reason why the FO became
submissive.

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Critical Analysis - 3
The Capt. might have taken it on his personal ego
that a PIA aircraft had just landed before them and
given the fact he was an ex air force and ex PIA
Capt.
The military culture still existed between the two
crew members as both were from air force.

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Critical Analysis - 4
The body of the first officer was taken away by the
Air Blue staff and handed over to his family for burial
even before the investigation team arrived as a
result no autopsy/ postmortem was carried out for
the first officers body and the Captains body was
already shattered and burnt so there was no
possibility to do that.

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Critical Analysis - 5
Findings 10.2 on page 29 states that the Captain
was scheduled only the night before but there is no
information as to when the Capt. was informed to
conduct the flight and how much rest he had before
flight. There is a possibility that he was fatigued
which in the report is briefly mentioned on page 32
at 11.4 where it says that the chain of events started
at commencement of the flight where the captain
confused BBIAP (Islamabad) with JIAP (Karachi)
while planning FMS and Khanpur lake with Khatua
Area during holding pattern. Unfortunately the report
never investigated on these lines which reveals
there was on organizational failure and the report is
trying to protect the organization.
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Critical Analysis - 6
The Capt. was a religious guy as revealed from his company
and colleagues and was probably fasting and praying for the
whole night prior to the accident as 27th of July in 2010 was the
15th of Shaban which is considered holy in the religion and
people like to fast and pray contrary to what the factual
information which states in 10.3 that they were not fasting at
first place why do you need to put that point there.
The role of ATC is not clearly stated in the facts however it
reveals that the Capt. disregarded the ATC instruction to fly a
bad weather circuit and decided to fly managed approach on a
preselected PBD unbeknown to ATC
At the same time ATC was unable to follow the traffic and give
the crew the information about terrain in a timely manner.

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Critical Analysis - 7
As per the article in Published in The Express Tribune,
March 29th, 2013:
Airblue
crash re-investigation: ATC staff failed to navigate plane t
o safety, reveals CAA report
http://tribune.com.pk/story/528123/airblue-crash-re-invest
igation-atc-staff-failed-to-navigate-plane-to-safety-revea
ls-caa-report
/

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Critical Analysis - 8
As per the article posted on the internet by Geo News
on the 24th of April 2012, one of the leading news
channel in the country:
Captain of crashed Air Blue flight ignored Air Traffic
Controller: CAA
http://
www.geo.tv/article-45972-Captain-of-crashed-Air-Blue-fligh
t-ignored-Air-Traffic-Controller-CAA

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Conclusions as per CAA

1. AC is airworthy
2. Poor weather condition
3. Though aircrew 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.
4. The chain of event started when Captain confused Islamabad with Karachi. This state
continued when Captain ignored the circling approach
5. Aircrew captain not only clearly violated 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. 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.
7. Description of ATS Radar and Air crew actions, in poor visibility conditions
8. Ensuing discussion and mutual situational update (on land line) 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
9. 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
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PULL UP

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Cause of the accident and

contributing factor

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Probable Cause:
Poor CRM and no situational awareness made Aircrew fail to operate
in the adequate manner.

Contributing Factors
o Air Traffic Control and AC had failure to communicate in time effective
manner once the AC lost sight of the runway:
o Poor weather condition
o Failure to establish standard operating procedure of ATS and Radar
o Failure to react on EGPWS alarm in proper and timely effective manner by
the Captain and First Officer

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Safety Recommendations as per the

Report - Part 1
1. All aircrew be re-briefed on CFIT avoidance and Circling Approach
procedures and a strict implementation of this procedure be ensured
through an intensive monitoring system.
2. Aircrew scheduling and pairing being a critical subject be preferably
handled / supervised by Flight Operations.
3. The implementation of an effective CRM program be ensured and the
syllabus of CRM training be reviewed in line with international
standards.
4. Existing aircrew training methodology be catered for standardization
and harmonization of procedures.
5. Human factor / personality profiling program for aircrew be introduced
to predict their behavior under crises.
6. Instrument landing procedure for RWY-12 be established, if possible.
7. Safety Management System be implemented in ATS as per the spirit of
the ICAO document (doc. 4444).
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Safety Recommendations as per

the Report Part 2
8. New Islamabad International Airport (NIIA) be completed and made functional
on priority.
9. Visual augment system (Approach Radar Scope) be installed in control tower to
monitor the positions and progress of aircraft flying in the circuit.
10. Review of the existing Regulations for the compensation and their expeditious
award to the legal heirs of the victims be ensured.
11. Adequacy of SIB resources comprising qualified human resource and equipment
be reviewed.
12. Information to public on the progress of the investigation process through the
media by trained / qualified investigators of SIB be ensured on regular
intervals.
13. NDMA be tasked to acquire in-country airlift capability for removal of wreckage
from difficult terrain like Margalla etc. As an interim arrangement, some
foreign sources be earmarked for making such an arrangements on as and when
required basis.
14. Civil Police Department be tasked to work out and ensure effective cordoning
and onsite security arrangements of crashed aircraft wreckage at all the places
specially remote / difficult hilly locations.
15. Environment Control Department be directed to recover the ill effects of
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deterioration / damages caused to Marghalla hill due to the crash.

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What Should Have Been there

RADAR vectoring procedures shall be established for all
runways especially in the marginal weather conditions.
The wreckage and human bodies should not be touched
until investigation team arrives.

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Any Questions ?

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