Crash of a Beechcraft 350i Super King Air in Islamabad: 19 killed

Date & Time: Jul 30, 2019 at 1400 LT
Operator:
Registration:
766
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Chaklala - Chaklala
MSN:
FL-766
YOM:
2011
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
19
Circumstances:
The twin engine airplane departed Chaklala-Nur Khan AFB with five crew members on board for a local training flight. In flight, it went out of control and crashed onto several houses located in the suburb of Mora Kalu, about 10 km south of Chaklala-Nur Khan AFB, Islamabad, bursting into flames. The aircraft and several houses were destroyed. All five crew members as well as 14 people on the ground were killed.

Crash of an ATR42-500 in Gilgit

Date & Time: Jul 20, 2019 at 0815 LT
Type of aircraft:
Operator:
Registration:
AP-BHP
Survivors:
Yes
Schedule:
Islamabad – Gilgit
MSN:
665
YOM:
2007
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
48
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Islamabad, the crew was cleared to land on runway 25 at Gilgit Airport. After touchdown, the crew initiated the braking procedure but the aircraft was unable to stop within the remaining distance. It overran, lost its right main gear and came to rest 12 metres further in a grassy area. All 53 occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of an ATR42-500 near Havelian: 47 killed

Date & Time: Dec 7, 2016 at 1620 LT
Type of aircraft:
Operator:
Registration:
AP-BHO
Flight Phase:
Survivors:
No
Site:
Schedule:
Chitral – Islamabad
MSN:
663
YOM:
2007
Flight number:
PK661
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
42
Pax fatalities:
Other fatalities:
Total fatalities:
47
Captain / Total flying hours:
11265
Captain / Total hours on type:
1216.00
Copilot / Total flying hours:
570
Copilot / Total hours on type:
369
Aircraft flight hours:
18739
Circumstances:
On 07 December 2016 morning, after a routine daily inspection at Benazir Bhutto International Airport (BBIAP) Islamabad, Pakistan International Airlines (PIA) aircraft ATR42-500 Reg No AP-BHO operated 05 flights (ie Islamabad to Gilgit and back, Islamabad to Chitral, Chitral to Peshawar and back). As 6th and last flight of that day, it took off from Chitral at time 10:38:50 UTC (15:38:50 PST) with 42 passengers (including 01 engineer) and 05 crew members (03 pilots and 02 cabin crew) aboard for Islamabad. It crashed after 42 minutes of flight at 11:20:38 UTC (16:20:38 PST) about 3.5 Nautical Miles (NM) SSE of Havelian, and 24 NM North of BBIAP Islamabad. All 47 souls aboard were fatally injured. The aircraft remained in air for about 42 minutes before crash (all timings in UTC). These 42 minutes have been split into three stages of flight, described hereunder:

(a) Initial Stage: From 10:38 to 11:04 (~26 minutes) degraded speed governing accuracy of the port propeller was evident in the DFDR data, but was apparently not observed by the cockpit crew. The flight stabilized at an altitude 13,500 feet AMSL and a cruising speed of 186 knots IAS (instead of expected 230 knots IAS). There were two latent pre-existing technical anomalies in the aircraft (a Fractured / dislodged PT-1 blade due to a known quality issue and a fractured pin inside the OSG), and one probable latent pre-existing condition (external contamination) inside the PVM of No 1 Engine. Digital Flight Data Recorder (DFDR) analysis indicates that No 1 Engine was degraded.

(b) Middle Stage (Series of Technical Malfunctions): From 11:04 to 11:13 (~09 minutes), a series of warnings and technical malfunctions occurred to No 1 Engine (left side) and its related propeller control system. These included Propeller Electronic Control (PEC) fault indications, followed by No 1 Engine power loss, and uncontrolled variation of its propeller speed / blade pitch angle abnormal system operation). The propeller speed which was initially at 82% (cruise setting) decreased gradually to 62% and later at the time of engine power loss it increased to 102% (and stayed at that value for about 15 to 18 seconds). It then reduced down to Non Computed Data (NCD) as per DFDR. At this point, (based on simulation results) the blade pitch angle increased (possibly close to feather position). Later, the propeller speed increased to 120% to 125% (probably caused due to unusual technical malfunctions) and stayed around that value for about 40 to 45 seconds. It finally showed an abrupt drop down to NCD again. At this point, (based on simulation results) the blade pitch angle may have settled at a value, different from the expected feathered propeller. During this unusual variation of propeller speed, there were drastic variations in the aircraft aerodynamic behaviour and sounds. The directional control was maintained initially by the Auto-Pilot. A relatively delayed advancement of power (of No 2 Engine) post No 1 Engine power loss, reduction of power (of No 2 Engine) for about 15 seconds during the timeframe when left propeller rpm was in the range of 120% to 125%, and once again a reduction of power towards the end of this part of flight, were incorrect pilot actions, and contributed in the IAS depletion. Auto-Pilot got disengaged. Towards the end of this part of flight, the aircraft was flying close to stall condition. No 1 Engine was already shutdown and No 2 Engine (right side) was operating normal. At this time, IAS was around 120 knots; aircraft started to roll / turn left and descend. Stick shaker and stick pusher activated. Calculated drag on the left side of the aircraft peaked when the recorded propeller speed was in the range of 120% to 125%. During transition of propeller speed to NCD, the additional component of the drag (possibly caused due to abnormal behaviour of left propeller) suddenly reduced. The advancement of power of No 2 Engine was coupled with excessive right rudder input (to counter the asymmetric condition). This coincided with last abrupt drop in the propeller speed. As a combined effect of resultant aerodynamic forces aircraft entered into a stalled / uncontrolled flight condition, went inverted and lost 5,100 feet AMSL altitude (ie from ~13,450 feet to 8,350 feet AMSL).

(c) Final Stage: The final stage of flight from 11:13 to 11:20 (~07 minutes) started with the aircraft recovering from the uncontrolled flight. Although blade pitch position was not recorded (in the DFDR – by design), and it was not possible to directly calculate that from the available data, a complex series of simulations and assumptions estimated that the blade pitch of left propeller may have settled at an angle around low pitch in flight while rotating at an estimated speed of 5%. Aircraft simulations indicated that stable additional drag forces were present on the left side of the aircraft at this time and during the remaining part of flight. Aircraft had an unexpected (high) drag from the left side (almost constant in this last phase); the aircraft behavior was different from that of a typical single engine In Flight Shutdown (IFSD) situation. In this degraded condition it was not possible for the aircraft to maintain a level flight. However, that level of drag did not preclude the lateral control of the aircraft, if a controlled descent was initiated. The aircraft performance was outside the identified performance envelope. It was exceptionally difficult for the pilots to understand the situation and hence possibly control the aircraft. Figure hereunder shows different stages of flight.
Probable cause:
The following factors were reported:
Probable Primary Factors:
(a) The dislodging / fracture of one PT-1 blade of No 1 Engine triggered a chain of events. Unusual combination of fractured / dislodged PT-1 blade with two latent factors caused off design performance of the aircraft and resulted into the accident.
(b) The dislodging / fracture of PT-1 blade of No 1 Engine occurred after omission from the EMM (Non-Compliance of SB-21878) by PIA Engineering during an unscheduled maintenance performed on the engine in November 2016, in which the PT-1 blades had fulfilled the criteria for replacement, but were not replaced.
(c) Fracture / dislodging of PT-1 blade in No 1 Engine, after accumulating a flying time slightly more than the soft life of 10,000 hrs (ie at about 10004.1 + 93 hrs) due to a known quality issue. This aspect has already been addressed by re-designing of PT-1 blades by P&WC.
Probable Contributory Factors:
(a) A fractured pin (and contamination inside the OSG), contributed to a complex combination of technical malfunctions. The pin fractured because of improper re-assembly during some unauthorized / un-documented maintenance activity. It was not possible to ascertain exact time and place when and where this improper re-assembly may have occurred.
(b) Contamination / debris found in overspeed line of PVM of No 1 Engine probably introduced when the propeller system LRU"s were not installed on the gearbox, contributed to un-feathering of the propeller. It was not possible to ascertain exact time and place when and where this contamination was introduced.
Final Report:

Crash of an ATR42-500 in Lahore

Date & Time: Aug 31, 2012 at 1510 LT
Type of aircraft:
Operator:
Registration:
AP-BHJ
Survivors:
Yes
Schedule:
Islamabad - Lahore
MSN:
657
YOM:
2006
Flight number:
PK653
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
42
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Islamabad, the crew started the descent to runway 36R in marginal weather conditions. Upon touchdown on a wet runway, the right main gear collapsed. The aircraft slid for about 1,700 feet before exiting the runway to the right and coming to rest 60 feet further on. All 46 occupants were unhurt while the aircraft was considered as damaged beyond repair. Five minutes after the accident, the weather briefing was as follow: OPLA 311015Z 16009KT 3000 RA BKN040 OVC100 29/24 Q1003. But ten minutes prior to the crash, the weather briefing was as follow: OPLA 311000Z 33008KT 4000 -RA SCT040 BKN100 32/24 Q1002 TEMPO 31030KT 2000 TSRA FEW030CB. Thus, the conditions were considered as marginal with turbulences, wind to 30 knots and CB's at 3,000 feet. On 11SEP2012, the French BEA reported that the aircraft touched down just at the beginning of the paved surface (undershoot area) to the right of the extended runway 36R centerline, causing the right main gear to collapse. It was reported that the aircraft was unstable on short final and that the crew failed to initiate a go-around procedure while the aircraft was too low on the glide.

Crash of a Boeing 737-236 in Islamabad: 127 killed

Date & Time: Apr 20, 2012 at 1840 LT
Type of aircraft:
Operator:
Registration:
AP-BKC
Survivors:
No
Schedule:
Karachi - Islamabad
MSN:
23167/1074
YOM:
1984
Flight number:
BHO213
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
121
Pax fatalities:
Other fatalities:
Total fatalities:
127
Captain / Total flying hours:
10158
Captain / Total hours on type:
2027.00
Copilot / Total flying hours:
2832
Copilot / Total hours on type:
750
Aircraft flight hours:
46933
Aircraft flight cycles:
37824
Circumstances:
On 20th April, 2012, M/s Bhoja Air Boeing 737-236A Reg # AP-BKC was scheduled to fly domestic Flight BHO-213 from Jinnah International Airport (JIAP) Karachi to Benazir Bhutto International Airport (BBIAP) Islamabad. The aircraft had 127 souls onboard including 06 flight crew members. The Mishap Aircraft (MA) took off for Islamabad at 1705 hrs Pakistan Standard Time (PST) from Karachi. The reported weather at Islamabad was thunderstorm with gusty winds. During approach for landing at BBIAP, Islamabad (OPRN), Flight BHO-213 was cleared by Islamabad Approach Radar for an Instrument Landing System (ILS) approach for Runway 30. The MA, while established on ILS (aligned with Runway 30 at prescribed altitude), at 6 miles to touchdown was asked by the Approach Radar to change over to Air Traffic Control (ATC) Tower frequency for final landing clearance. The cockpit crew came on ATC Tower frequency and flight was cleared to land at BBIAP, Islamabad, but the cockpit crew did not respond to the landing clearance call. The ATC Tower repeated the clearance but there was no response. After a few minutes, a call from a local resident was received in ATC Tower, stating that an aircraft had crashed close to Hussain Abad (A population around 4 nm short of runway 30 BBIAP, Islamabad). It was later confirmed that Flight BHO-213 had crashed and all 127 souls onboard (121 passengers + 6 flight crew) had sustained fatal injuries along with complete destruction of aircraft.
Probable cause:
Factors Leading to the Accident:
- The aircraft accident took place as a result of combination of various factors which directly and indirectly contributed towards the causation of accident. The primary causes of accident include, ineffective management of the basic flight parameters such as airspeed, altitude, descent rate attitude, as well as thrust management. The contributory factors include the crew’s decision to continue the flight through significant changing winds associated with the prevailing weather conditions and the lack of experience of the crew to the airplane’s automated flight deck.
- The reasons of ineffective management of the automated flight deck also include Bhoja Air’s incorrect induction of cockpit crew having experience of semi automated aircraft, inadequate cockpit crew simulator training and absence of organizational cockpit crew professional competence and monitoring system.
- The incorrect decision to continue for the destination and not diverting to the alternate aerodrome despite the presence of squall line and very small gaps observed by the Captain between the active weather cells is also considered a contributory factor in causation of the accident.
- The operator’s Ops Manual (CAA Pakistan approved) clearly states to avoid active weather cells by 5 to 10 nm which was violated by the cockpit crew is also considered a contributory factor in causation of the accident.
- FO possessed average professional competence level and was due for his six monthly recurrent simulator training for Boeing 737-200 aircraft (equipped with a semi-automated flight deck). Bhoja Air requested an extension for his recurrent simulator training on 07th March, 2012. As per the existing laid down procedures of CAA Pakistan, two months extension was granted for recurrent simulator training on 09th March, 2012. The extension was granted for Boeing 737-200 aircraft, whereas the newly inducted Boeing 737-236A aircraft was equipped with automated flight deck. It is important to note that Bhoja Air did not know this vital piece of information till their cockpit crew went for simulator training to South Africa. This critical information regarding automation of the newly inducted Boeing 737-236A was not available with Flight Standard Directorate CAA, Pakistan as the information was not provided by the Bhoja Air Management.
- Therefore it is observed that due to the ignorance of Bhoja Air Management and CAA Pakistan, the said extension in respect of FO for simulator training was initially requested by former and subsequently approved by the latter. This resulted in absence of variance type training conformance of FO because of which he did not contribute positively in recovering the aircraft out of unsafe set of conditions primarily due to lack of automation knowledge, proper training and relying on captain to take remedial actions. This is also considered as one of the contributory factors in causation of accident.
- The Captain’s airline flying experience on semi automated flight deck aircraft and his selection for automated aircraft without subsequent training and monitoring to enhance his professional competence and skill, is one of the factors in causation of the accident.
- None of the cockpit crew member challenged the decision of each other to continue for the destination despite violation of Ops Manual instructions which is against the essence of CRM training.
- After experiencing the extremely adverse weather conditions, the cockpit crew neither knew nor carried out the Boeing recommended QRH and FCOM / Ops Manual procedures to handle the abnormal set of conditions / situations due to non availability of customized Boeing documents for Boeing 737-236A (advanced version of Boeing 737-200 series).

Finalization:
- The ineffective automated flight deck management in extreme adverse weather conditions by cockpit crew caused the accident. The ineffective automated flight deck management was due to various factors including; incorrect selection of cockpit crew on account of their inadequate flying experience, training and competence level for Boeing 737-236A (advanced version of Boeing 737-200 series), absence of formal simulator training in respect of FO for handling an automated flight deck, non-existence of cockpit crew professional competence / skill level monitoring system at operator level (Bhoja Air).
- The cockpit crew incorrect decision to continue the flight for destination and non- adherence to Boeing recommended QRH and FCOM remedial actions / procedures due to non-availability of customized aircraft documents (at Bhoja Air) for Boeing 737-236A (advanced version of Boeing 737-200 series) contributed towards the causation of accident. The inability of CAA Pakistan to ensure automated flight deck variance type training and monitoring requirements primarily due to incorrect information provided by the Bhoja Air Management was also a contributory factor in causation of the accident.
Final Report:

Crash of an Airbus A321-231 in Islamabad: 152 killed

Date & Time: Jul 28, 2010 at 0941 LT
Type of aircraft:
Operator:
Registration:
AP-BJB
Survivors:
No
Site:
Schedule:
Karachi - Islamabad
MSN:
1218
YOM:
2000
Flight number:
ABQ202
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
146
Pax fatalities:
Other fatalities:
Total fatalities:
152
Captain / Total flying hours:
25497
Captain / Total hours on type:
1060.00
Copilot / Total flying hours:
1837
Copilot / Total hours on type:
286
Aircraft flight hours:
34018
Aircraft flight cycles:
13566
Circumstances:
Flight ABQ202, operated by Airblue, was scheduled to fly a domestic flight sector Karachi - Islamabad. The aircraft had 152 persons on board, including six crew members. The Captain of aircraft was Captain Pervez Iqbal Chaudhary. Mishap aircraft 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. The aircraft was completely destroyed and all souls on board the aircraft, sustained fatal injuries.
Probable cause:
- Weather conditions indicated rain, poor visibility and low clouds in and around the airport. The information regarding prevalent weather and the required type of approach on arrival was in the knowledge of aircrew.
- 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.
- 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.
- 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).
- F/O 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 Captain’s behavior in the flight.
- At the crucial juncture both the ATC and the Radar controllers were preoccupied with bad weather and the traffic; the air traffic controller having lost visual contact with the aircraft got worried and sought Radar help on the land line (the ATC does not have a Radar scope); the radar controller having cleared aircraft to change frequency to ATC, got busy with the following traffic. Having been alerted by the ATC, the Radar controller shifted focus to the mishap aircraft – seeing the aircraft very close to NFZ he asked the ATCO (on land line) to ask the aircraft to immediately turn left, which was transmitted. Sensing the gravity of the situation and on seeing the aircraft still heading towards the hills, the Radar controller asked the ATCO on land line “Confirm he has visual contact with the ground. If not, then ask him to immediately climb, and make him execute missed approach”. The ATCO in quick succession asked the Captain if he had contact with the
airfield – on receiving no reply from aircrew the ATCO on Radars prompting asked if he had contact with the ground. Aircrew announced visual contact with the ground which put ATS at ease.
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.
- 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.
Final Report:

Crash of a Fokker F27 Friendship 200 near Kohat: 17 killed

Date & Time: Feb 20, 2003 at 0915 LT
Type of aircraft:
Operator:
Registration:
10254
Flight Type:
Survivors:
No
Site:
Schedule:
Islamabad - Kohat
MSN:
10254
YOM:
1964
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
17
Circumstances:
The aircraft departed Islamabad on a flight to Kohat, carrying nine passengers and eight crew members. While descending to Kohat, the crew encountered poor visibility when, at an altitude of 3,000 feet, the aircraft struck the slope of a mountain located 27 km from the airport. The aircraft disintegrated on impact and all 17 occupants were killed, among them Mushaf Ali Mir, Chief of Staff of the Pakistan Air Force and his wife. He was flying to Kohat with a delegation to perform the annual inspection of the airbase.
Probable cause:
Controlled flight into terrain after the crew initiated the descent prematurely, causing the aircraft to descend below the minimum safe altitude until it impacted ground. Poor weather conditions were considered as a contributing factor.

Crash of a Fokker F27 Friendship 200 near Bunji: 54 killed

Date & Time: Aug 25, 1989 at 0745 LT
Type of aircraft:
Operator:
Registration:
AP-BBF
Flight Phase:
Survivors:
No
Site:
Schedule:
Gilgit - Islamabad
MSN:
10207
YOM:
1962
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
49
Pax fatalities:
Other fatalities:
Total fatalities:
54
Aircraft flight hours:
44524
Aircraft flight cycles:
41685
Circumstances:
Nine minutes after takeoff from Gilgit Airport, while flying in poor weather conditions, the aircraft struck the slope of a mountain located near Bunji, about 40 km southeast of Gilgit. The wreckage was found in an isolated area few hours later and all 54 occupants were killed.
Probable cause:
For unknown reasons, the crew failed to follow the correct route after departure and the aircraft's altitude was insufficient.

Crash of a Lockheed C-130B Hercules in Bahawalpur: 30 killed

Date & Time: Aug 17, 1988 at 1630 LT
Type of aircraft:
Operator:
Registration:
23494
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bahawalpur - Islamabad
MSN:
3708
YOM:
1962
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
30
Circumstances:
Shortly after takeoff from Bahawalpur Airport, while in initial climb, the four engine aircraft went out of control and crashed 7 km from the airport. All 30 occupants were killed, among them Muhammad Zia Ul-Haq, President of the Republic of Pakistan, chairman Joint Chiefs of Staff Committee General Akhtar Abdur Rahman, Brigadier Siddique Salik, several high ranking officers of the Pakistan Army and also the American Ambassador to Pakistan Arnold Lewis Raphel. They were returning to Islamabad following a US M1 Abrams tank demonstration in Bahawalpur.
Probable cause:
Due to the presence of officials on board, it was believed that the accident was the consequence of sabotage but this could not be proven. About 20 years later, in 2008, the British newspaper 'The Times' reported that, back in 1988, an analysis conducted by a US laboratory found 'extensive contamination' by brass and aluminium particles in the elevator booster package. This may have caused sluggish controls leading to overcontrol. This in turn may have led to the pilots losing control at low altitude soon after takeoff. Nevertheless, the exact cause of the accident remains unclear.

Crash of a Vickers 815 Viscount in Islamabad

Date & Time: May 18, 1959
Type of aircraft:
Operator:
Registration:
AP-AJC
Survivors:
Yes
MSN:
335
YOM:
1958
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
39
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown on a wet runway due to monsoon, the airplane skidded, veered off runway and lost successively its undercarriage and its right wing before coming to rest in a drainage ditch. All 43 occupants were evacuated safely while the aircraft was written off. Brand new, it was delivered four month ago.