Analysis of CFIT Accident at Islamabad on 28 July 2010

Analysis by Aviation Safety India of CFIT Accident at Islamabad on 28 July 2010 and Valuable Lessons that can be Learnt.

 The accident happened at Islamabad Airport in adverse weather conditions killing all its occupant’s way back in Jul 2010. Sequence of events as per the accident Investigation Report are covered in subsequent paragraphs.

The aircraft belonging to Air Blue Airline, Pakistan took-off from Karachi at 0241:21,UTC (0741:21 hrs -PST).

During initial climb, the Captain tested the knowledge of FO and used harsh words and snobbish tone, contrary to the company procedures/norms.

The question / answer sessions, lecturing and advises by the mishap Captain continued with intervals for about one hour after takeoff.

After the intermittent humiliating sessions, the FO generally remained quiet, became under confident, submissive, and subsequently did not challenge the

Captain for any of his errors, breaches and violations.

The Captain checked weather enroute, Islamabad, Peshawar and Lahore, through ATS and ATIS, and was fully aware about its gravity / intensity.

The Captain sounded to be apprehensive about weather.

The Captain was heard to be confusing BBIAP Islamabad with JIAP Karachi while planning FMS, and Khanpur Lake (Wah) with Kahuta area during holding pattern.

After learning that ABQ-202 would be required to execute a visual circling approach for RWY-12, in the reduced visibility and low clouds, Captain prepared

himself to fly the visual circling approach on NAV mode.

Accordingly, the Captain asked the FO to feed unauthorized 04 waypoints (PBD 8 to 11) in the FMS. FO did not challenge the Captain for his incorrect actions.

 

While planning for right hand downwind of visual approach RWY-12, at 0357:48 the Captain briefed First Officer (FO), “from abeam RWY-30, 3 to 5 miles abeam CF, then we go to abeam CF and then landing”. This was contrary to established procedures for BBIAP, Islamabad.

During the descent, the Captain’s request for a right hand D/W RWY-12 for a visual approach (the request being contrary to established procedures at BBIAP) was not agreed to by the Radar due to procedural limitations. The Captain became worried about bad weather and low clouds on the left hand Down wind.

  At 0404:20, the Radar Controller informed ABQ-202 to “expect arrival to ILS RWY-30 circle to land RWY-12”.

The FO then requested a “right downwind RWY-12 for the approach”.

The controller responded that “right downwind RWY-12 is not available at the moment because of low clouds”. Captain acknowledged “We understand right downwind is not available, it will be ILS down to minima and then left downwind ok”.

At 0436:20, the crew again asked ATC Tower “how’s the weather right Downwind” The tower controller responded that the right downwind was not

available and that only left downwind for RWY-12 was available.

At 0436:33 the Captain wanted to descend to 2,000 ft, but was reminded by FO of 2,500 ft (MDA), indicating possible intentions of Captain.

At 0437:26, the confirmation by the Tower for the safe landing of PK-356 (aircraft of a competitive airline) in the same weather conditions put the Captain under further pressure to ensure a landing at Islamabad under any circumstances.

At 0437:27, the break-off to the right, after the ILS approach was delayed due to late visual with the airfield caused by poor visibility. ATC also called visual with AB-202 and asked AB-202 to report established left D/W RWY-12.

At 0437:32 as the aircraft was flying over the RN VOR, the crew commanded a right turn through the autopilot.

A few seconds later, the selected altitude was lowered to 2,300 ft and the aircraft started to descend to selected altitude, thus violating the height minima of 2,510 MDA.

After break-off from ILS approach, the Captain ignored the tower controller’s suggestion (at 0437:54) to fly a bad weather circuit by saying “let him say whatever he wants to say”.

 At time 0438:01, although Captain said that he was going for NAV, yet the aircraft kept on flying on HDG mode

At 0439:43, lateral mode was changed to NAV (which continued till 0440:28 hrs.)

At 0439:46 as the aircraft was 01 NM to the south of prohibited area OP (P) – 277, the air traffic controller instructed the crew to turn left in order to avoid a No-Fly Zone (NFZ).

 

At 0439:58, the aircraft was 5 NM to the north of the aerodrome and the first EGPWS predictive “TERRAIN AHEAD” caution was recorded on the CVR.

 FO told the captain “this Sir higher ground has reached, Sir there is a terrain ahead, sir turn left”.

 By now the Captain had become very jittery in his verbal communication and displayed frustration, confusion and anxiety resulting in further deterioration in his behavior.

At 0440:10, tower controller asked the crew if they were visual with the airfield. The crew did not respond to the question, whereas, FO asked the Captain (on cockpit Mic) “Kia batauon Sir ?” (What should I tell him Sir?)

 Immediately at 0440:16 on the insistence of Radar Controller, the Tower Controller asked the crew if they were visual with the ground.

Captain and the FO responded to the controller “Airblue 202 visual with the ground”. FO again asked Captain “Sir Terrain ahead is coming”.

 The Captain replied “Han ji, we are turning left” (Yes, we are turning left). Whereas aircraft was not turning, only the HDG bug was being rotated towards left.

 At the same time, two EGPWS predictive “TERRAIN AHEAD” cautions were recorded on the CVR. The pilots were unsure of their geographical position and did not seek Radar help. The consequent loss of situational awareness caused the aircraft to go astray.

 

In an attempt to turn the aircraft to the left, the Captain was setting the heading bug on reduced headings, but not pulling the HDG knob. 

 Since the aircraft was in the NAV mode, the Captain was not performing the appropriate actions to turn the aircraft to the left.

 At 0440:28, lateral mode was changed from NAV to HDG, 40 Seconds before the impact.

 At this stage, current heading of aircraft was 307 degrees, whereas selected heading had been reduced to 086 degrees, due to which the aircraft started to turn the shortest way to the right towards Margalla hills by default.

From that time onward, several EGPWS predictive “TERRAIN AHEAD PULL UP” warnings were recorded on the CVR until the end of the flight.

The aircraft had ended up in a dangerous situation because of most unprofessional handling by the Captain.

Since the desired initiative of FO had been curbed and a communication barrier had already been created by the Captain, the FO failed to intervene, take over the controls to pull the aircraft out of danger and display required CRM skills.

At 0440:30, FO asked the Captain twice in succession “Sir turn left, Pull Up Sir. Sir pull Up”.

 At 0440:33, the thrust levers were moved forward to the MCT/FLX detent (instead of TOGA position) and the auto-thrust (A/THR) disengaged.

At 0440:35, the selected altitude was changed to 3,700 ft and the aircraft started to climb.

The aircraft was still turning right.

At 0440:39 (within 06 seconds), the thrust levers were moved back to the CLB detent and the A/THR re-engaged in climb mode. The selected altitude was reduced to 3100 ft.

At 0440:41, FO asked the Captain yet another time “Sir Pull Up Sir”.

At 0440:46, autopilot 1 was disconnected.

The roll angle was 25° to the right. The captain applied full left side stick along with a 6° left rudder pedal input and the aircraft started to turn left.

The altitude was 2,770 ft and increasing.

During the last few seconds, the aircraft did climb to 3,090 feet.

The Captain put in 52 degrees of bank to turn the aircraft, and also made some nose down inputs.

Therefore, the aircraft pitched down, speed increased and auto thrust commanded the engines to spooled down to keep airspeed on the target speed.

The aircraft started again to descend at a high rate.

Unfortunately in his panic, until 0440:46 the Captain continued to move the HDG bug without actually looking at it, but failed to pull the knob to activate

When he did activate it, the aircraft turned towards the HDG bug that had been rotated overly to 025 Degrees until end of recording, and at 0440:49, Captain said to FO “left turn kiun naheen ker raha yar?” (Why the aircraft is not turning to left?).

At 0440:52 the Captain started to make pitch down inputs. The roll angle was 30° to the left. The pitch attitude was 15° nose-up and started to decrease.

At 0440:58, the altitude reached 3,110 ft and started to decrease until the end of the flight.

 At 0441:01 an EGPWS reactive “TERRAIN TERRAIN” warning was recorded on the CVR. The roll angle reached its maximum value of 52° to the left.

At 0441:02, FO said “Terrain sir”. The pitch attitude was 4.6° nose-down.

 At 0441:03, the captain started to make pitch-up inputs. The pitch attitude was 3.9° nose-down.

At 0441:05, an EGPWS reactive “PULL UP” warning was recorded on the CVR.

At 0441:06, the FO was heard the last time saying to captain “Sir we are going down, Sir we are going da”.

The high rate of descend at very low altitude could not be arrested and the aircraft flew into the hill and was completely destroyed. All souls on board sustained fatal injuries due to impact forces.

At 0441:08, the aircraft crashed into a hill at an elevation of 2858 ft and FDR and CVR recordings ended.

 

Analyses by ASMSI

This was a typical CFIT accident which was mainly caused due to adverse weather conditions, leading to loss of visual references and poor CRM due to large Power Distance i.e. the difference between the Experience, Age and Status of the Captain and First Officer.

Lack of knowledge, proper flight planning, preparation, briefing, situational awareness, overconfidence, sense of complacency, ignoring SOP’s, ATC instructions, EGPWS warnings and confused state of mind of the Captain under self-inflicted stress conditions, were some of the contributory factors.

The Captain was almost 62 Years old, had 25500 Hrs flying experience with 1060 Hrs on Air Bus A 321, the type of aircraft which crashed and was a very senior pilot in the Company. The First Officer (FO) was 35 Years old, had total 1835 Hrs of flying including 286 Hrs on Air Bus A 321.Thus it can be seen that there was 27 years of age difference and  almost 23600 Hrs flying experience difference between Captain and FO.

The Captain was a very senior Captain, holding a senior position in the Company and the FO was very junior holding much lower status in the Company as compared to the Captain. 286 Hrs of the experience of the FO on A 321 is considered inadequate for him to fully understand the various systems, Nav Aids, FMS and various modes of flying on FMS/Auto Pilot.

It is also apparent from the questioning session of the FO by Captain in the first hour of the flight, where the captain appeared to be harsh on the FO, may be because, the knowledge of the FO was found wanting by the Captain. Possibly, due to large Power Distance between the Captain and FO, humiliation of the FO by Captain, poor knowledge levels of the FO, during the critical phases of the flight, the FO was of no assistance to his Captain and in any case was in no position to advise or assert since he was not knowledgeable about the happenings in the Cockpit.

The Captain appeared to be quite bossy and was instrumental in lowering the self-esteem of the FO by subjecting him to questions and advice in an inappropriate manner (harsh and snobbish) to test his knowledge. This must have resulted in affecting the self-confidence and morale of the FO thus undermining his ability to correct the Captain or be assertive.

It is quite evident that there was a very big power distance between the Captain and FO.

Larger the Power Distance, lesser is the ability of the FO to Speak up, give flight and safety related inputs, make suggestions, convey disagreement related to the decision of the Captain and assert himself or herself to take over controls.

Due to large Power Distance conditions, the FO holds the Captain in very high esteems and is under the impression that being so highly experienced and qualified, his or her Captain can commit no mistakes and will be able to handle any situation, emergencies and adverse weather conditions without any problem. This may not always be true.

The FO may also be afraid of the Captain lest the Captain gets offended and snub him or her for trying to be over smart or showing one up manship. Some FO’s remain quite due to fear of exposure of their lack of knowledge and awareness which may be used by the Captain to pass adverse comments on the knowledge and proficiency of the FO with potential to affect the career progression of the FO. Some FO may not have prepared well for the Flight, lack knowledge and Situational Awareness. So obviously they are in no position to give inputs to the Captain and are mute spectators to the right or wrongdoings of the Captain.

Large Power Distance also can lead to the situation where the Captain in spite of having doubt/not being sure/or not having knowledge, may be reluctant to ask question or clarify doubt from the FO for fear of loss of reputation, ego or what will FO think of the Captain. This situation has led to many accidents.

Some Captains may be quite conceited, arrogant, rude, authoritarian and show scant regards or even ill-treat the FO and keep them subjudicated. There may be some Captain who derive pleasure in humiliating the FO and keeping him or her under pressure and take no steps to groom the FO. Under such cockpit environments, the FO remains passive team member and takes no initiative so as to avoid any possible conflict with the Captain. This is certainly a very hazardous situation since number of serious accidents have been caused due to the adverse consequences of large Power Distance in India as well as other countries around the world.

It is well known fact that owing to sense of complacency, by virtue of  high experience levels ,most of the senior, experienced pilots tend to ignore the important aspect of planning and preparation for the flight, knowledge about the aircraft and its systems, procedures and are found to be overconfident and  complacent. Outwardly, they try to convey a message that they know everything about the aircraft and the flight related knowledge and are competent to handle any emergency or situation. However, it may not be the real fact and they may not be aware of everything which may be essential for the safety of the Flight. This was quite evident in this unfortunate flight.

In the beginning of the Flight itself the Captain displayed his confused state of mind when he got mixed up between Islamabad and Karachi while configuring his FMS. The Captain even asked the FO to feed 4 waypoints which were not authorized since one of the waypoint was in close vicinity of the crash site and outside the protected zone of the airport. The FO did what Captain told him either due to lack of knowledge, faith in the knowledge and ability of the Captain or fear of the rebuke from the Captain.

The Captain was aware of the adverse weather conditions prevailing at Islamabad, and appeared to be worried. He was feeling uncomfortable, confused and under tension to land safely at Islamabad. This was quite evident in the various wrong action taken by the Captain while executing an approach. He did not follow the established procedures for landing, violated SOP’s and kept on requesting for Right Hand Downwind which was not permitted and was against the laid down procedures for landing.

During the approach procedure, the Captain wanted to descend to 2000 ft when the minimum safe altitude was 2500 ft. and at one stage descended to 2300 ft. FO had to remind him about safe altitude. This shows poor situational awareness of the Captain.

When the Captain could not see the runway at break off altitude after the ILS approach, he was advised to fly a bad weather circuit by ATC but the Captain chose to ignore the advice from the ATC.

Although the Captain had declared that he will be flying NAV mode for the circling approach yet he was actually flying on Heading mode. When the FO asked the Captain whether he was visual, the Captain without being visual, told the FO that he was visual.

When the Radar found the aircraft too close to prohibited area, the ATC advised the Captain to turn left immediately. The FO also cautioned the Captain that high terrain is ahead. At this stage, the Captain was so confused, stressed and jittery that in his attempt to turn left, he was rotating the heading knob towards left without pulling it out as per procedure, as a result of which the aircraft was not turning to the left.

When the ATC asked the Pilots if they were visual, they falsely informed ATC that they were visual. During this period number of EGPWS warnings for Terrain and pull up were ignored by the Captain who was in a total state of confusion, nervousness, under tremendous stress and really did not know what was happening.

In the prevailing state of confusion, the Captain changed his lateral mode from Nav to Heading mode when the heading of the aircraft was 307 degree and the selected heading was 086 deg. On auto pilot with heading mode selected, the aircraft obviously turned right through the shortest way to 086 degree thus bringing the aircraft close to the No Fly Zone. The lack of knowledge of the Captain about the terrain, proximity of no fly zone and the operation of the Nav and Heading mode is quite evident.

The Captain failed to respond appropriately to 21 Terrain and 15 pull up warnings from EGPWS, 4 Terrain and 3 pull up warnings from FO and was not fully aware of correct pull up action and use of TOGA switch.

One Chinese aircraft finding very adverse weather conditions had diverted to China. However, another Pakistani aircraft managed to land in the third attempt before the ill-fated flight which crashed. This obviously gave hope to the Captain that may be he will also be able to land and also it must have put pressure on him that being such an experienced pilot, it will be loss of his reputation if he is unable to land.

In spite of the fact that the Captain was in a precarious situation and had lost situational awareness, he did not ask for Radar assistance to come out of the situation, may be due to his self-pride and fear of loss of reputation.

It is surprising that here were no instrument approach procedures formulated for approach on runway 12 and the circling approach was only way to approach. A busy airport like Islamabad with No Flying Zone and hilly terrain in the close proximity, certainly deserved instrument approach procedures for approach and landing at runway 12.

The Radar and the ATC controllers were quite busy due to handling number of aircraft in adverse weather situations and as such failed to monitor the progress of the flight and caution the Captain in time due to their preoccupation.

Under poor visibility and low cloud conditions, the Captain got fully disorientated, lost situational awareness and finally crashed into the hills with very high angle of bank and pitch down attitude.

Lessons Learnt

Number of valuable lessons can be learnt from this accident. Similar accident or near accident situations have occurred in our country as well.

Most important lesson which can be learnt from this accident is the need for proper planning, preparation and briefing for the flight, keeping in mind the weather, terrain and associated hazards, regardless of the experience level of the crew members.

The knowledge of the crew members about the aircraft, its systems, emergencies, procedures, Operation of FMS, Auto Flight Control System, Modes of operations,Radar,GPS,Inertial Nav system, Glass Cockpit displays, Automation, Airport and Apron charts, Spatial Disorientation, Situational Awareness and CFIT etc should be good and the Pilots must continue to refresh their knowledge to remain updated. Remember knowledge and awareness is very essential to ensure safety.

One of the very important lesson from this accident is the need to ensure that the FO is well trained and a competent professional who is fully involved, has good knowledge about the aircraft, its systems, Avionics, prepares and plans well for the flight keeping in mind various aspects of the flight, is alert, vigilant in the cockpit, monitors both happenings outside and inside the cockpit, can speak up with conviction, has the ability to correct the Captain in a polite and respectful manner, asserts if required and is generally a live wire in the cockpit.

FO should be assisting the Captain with flight related inputs, cautions, corrections through proper monitoring to ensure situational awareness rather than being a dummy and leaving it to the Captain to handle the situation alone.

There is a definite need to sensitise the Crew Members about the serious consequences of the Power Distance. There should be open atmosphere in the cockpit where crew members are free to speak and give flight and safety related inputs. In fact the Senior Pilot must make a conscious effort to encourage the FO to remain alert and give him or her freedom to speak up, caution the Captain by giving timely inputs about the flight and safety related threats.

FO’s should also be given freedom by the Captain to correct the Captain if he or she is going wrong or taking a wrong action or making incorrect decision, without any fear of being rebuked from the Captain. The need for FO to assert himself or herself if the safety of the flight is likely to be compromised, should be highlighted during CRM Training and briefing.

The Captain must involve himself/herself to groom the FO so that he/she becomes a valuable team member and an asset in the cockpit, rather than being a dead weight/passenger. The Captain should be careful not to lower the self-esteem of the FO and avoid humiliating or upbraiding them in the Cockpit. The Captain need to understand the importance of the FO,CRM, team work and display maturity and professionalism in handling his crew members with respect and give them due importance.

It is also imperative for the FO to respect his /her Captain, plan, prepare well for the flight, have good knowledge about various aspects of the aircraft and flight, remain fully alert, involved and should closely monitor the progress of the flight. A good knowledgeable and fully involved FO can make difference between life and death particularly during critical phases of the flight.

There may be situation when the Captain lacks knowledge or in a confused state of mind and is not situationally aware. Under such conditions, the Captain should never hesitate to clarify doubts and  take the help of FO if required without standing to ego or self-pride.

A thorough preflight briefing, descent and approach briefing, to cover the weather, terrain, MSA, MDA, approach procedure, runway conditions, risk factors, missed approach procedure and individual duties and responsibilities are of paramount importance and must not be ignored. Be very careful while programming FMS and check, recheck and double check the inputs.

The Captain must appreciate that no amount of experience is enough to fly safely if they have not planned and prepared well for the flight, lack knowledge about the aircraft, systems, avionics, procedures,SOP’s,weather, terrain, display misplaced overconfidence ,complacency and ignore rules ,regulations and established procedures.

The Captain should not get carried away and avoid arrogance, complacency in the interest of the safety of the aircraft. Professionalism and maturity are two essential ingredients which should always be kept uppermost in mind by the crew members.

Notwithstanding the high qualifications, knowledge and experience, any Pilot can get into problems/accident situations, if he or she does not respect the weather, overestimates his or her capability to negotiate any weather conditions and does not make timely decision to return, divert, abort and  carry out missed approach. No one is invulnerable and accidents can happen to anyone any time.

Sop’s, Procedures and rules, regulations have been formulated to ensure safety of the aircraft and must be followed meticulously without taking any short cuts. Tendency of most of the Pilots particularly the senior pilots to ignore SOP’s, rules, regulations and procedures need to be curbed. Most of the Pilots tends to become complacent and overconfident as they become senior and gain experience. This is a serious problem and should be kept under control.

Please remember that when you are stressed, in panic, frustrated and fear the consequences or loss of reputation, the performance of your mental faculties comes down and your chances of making errors are very high.  Further, under such conditions your decision making ability gets degraded and you are likely to get into confused state of mind and make erratic decisions/ actions.

A senior and highly experienced pilot is always under pressure to demonstrate performance of high caliber, especially under very demanding situations, as a result of which they tend to take chances with the weather, to prove themselves. They are more concerned about the loss of their professional reputation and what the others will think of them rather than safety. This pressure has led to number of catastrophic consequences. Hence, it needs to be kept under check.

If some aircraft has landed at the same place just before you, it is likely to put you under pressure and your self-esteem will force you to go out of the way to land. Please don’t succumb to such pressures and make an independent decision after proper risk assessment. Making a missed approach or diversion has no bearing on your performance and no questions will be asked by DGCA, Operator or ATC for missed approach or diversion. (DGCA CAR ON ALL WEATHER OPS).

It should be kept in mind that during adverse weather conditions combined with congested traffic environments, the radar and Air Traffic Controller will be very busy and under extreme pressure to regulate the traffic. Under such conditions, they may not be able to monitor all the aircraft very closely. Hence, the Pilots should be aware of the limitation of the ATC and be extra alert and vigilant to ensure the safety of their own aircraft.

Whenever, ATC gets an impression that an aircraft may be in need of help, they should monitor that aircraft closely and provide necessary guidance and assistance in a timely manner. It is not only Pilots but ATC also are important stakeholder in ensuring the safety of the aircraft. If the weather is below the Aerodrome/Aircraft Minima, than ATC should advise the aircraft to divert or refuse permission to land, under such unsafe conditions, well in advance.

Some Pilots quite often tend to bluff the ATC about their position, visual contact with terrain, and runway etc due to misplaced fear of being reported by the ATC. Both the Pilots and ATC should have good mutual trust and understanding and Pilots should not hesitate to give correct inputs and avoid bluffing ATC. A Just Culture environment need to be fostered to encourage pilots to give correct information and admit their mistake in a professional manner. ATC inputs or instructions should not be ignored and at the same time, do not follow ATC instructions blindly and be situationally aware at all times.

If the Pilots find themselves in difficult or uncertain situation, they should not stand to false sense of ego, pride and should ask for ATC/Radar assistance without any hesitation. ATC is there to provide you all possible assistance since they are quite understanding and competent professionals ever willing to help. Hence, never shy away in seeking help of ATC whenever needed.

Modern Nav, approach, landing and warning aids are quite reliable and of great help to the pilots. However, unless the Pilots have thorough knowledge about these aids, their operation, use and limitations, these aids can be the cause of accident. Moreover, over reliance on the aids can give you a false sense of complacency and one may tend to take chance with weather, terrain and other limitations leading to compromise on safety. Do not ignore the warnings from EGPWS and make use of TOGA switch if finding yourself in state of confusion.

The Airport Regulator and Operator should ensure implementation of Safety Management System, identify the existing, potential hazards and take proper steps to initiate remedial measures with the seriousness it deserves. The Aircraft Operator and Pilots should be fully involved and bring it to the notice of the Regulator and Airport Operator if they find any safety threats to operations or improvements required in the safety environments. Reporting culture is sadly missing and must be given due importance.

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