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 Ilyushin II-76TD in Karachi: 11 killed

Date & Time: Nov 28, 2010 at 0145 LT
Type of aircraft:
Operator:
Registration:
4L-GNI
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Karachi - Khartoum - Douala
MSN:
43452546
YOM:
1982
Flight number:
MGC4412
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
11
Captain / Total flying hours:
7272
Captain / Total hours on type:
5502.00
Copilot / Total flying hours:
2220
Aircraft flight hours:
8357
Aircraft flight cycles:
3373
Circumstances:
On 27th November, 2010 the operating crew of mishap aircraft flew from Fujairah (UAE) to JIAP, Karachi (Pakistan) at 1000 UTC. The load onboard was weighing 9 tons (Packaged Boeing
747 engine). The aircraft had flown to Fujairah airport from Kandahar. According to the provided information on the 27-11-2010 the crew comprising Aircraft Commander, Second Pilot, Navigator, Flight Engineer, Flight Radio Operator, and Flight Operator flew from Fujairah (UAE) to JIAP Karachi. After landing the crew members were shifted to “Regent Plaza” hotel in Karachi. The stay of crew in the hotel was not less than 8 hours. The aircraft was refuelled at JIAP, Karachi and total fuel onboard was 74 tons. A cargo load of 30.5 tons was also loaded after refuelling the aircraft. The aircraft mass was 197 tons with its CG at 30% Mean Aerodynamic Chord (MAC) before undertaking the mishap flight. The aircraft was scheduled for departure from JIAP, Karachi at 2025 UTC 28th November, 2010) on route “Karachi – Khartoum – Douala, Cameroon to deliver humanitarian aid (tents). The crew arrived at airport around 1900 UTC. The weather conditions were satisfactory. The weather details are mentioned in this report at Para 1.7. After starting engines the crew taxied the plane to Runway 25L and reported to the air traffic controller that the plane would take off in 3 minutes and the aircraft took off at 2048 UTC. According to the radar data the aircraft ascended to 600 feet, started descending and then disappeared from the radar screen. The air traffic controller did not receive any information from the crew members about emergency conditions onboard. The aircraft crashed at about 2050 UTC on a bearing of 070 degree and approximately 02 NM from JIAP, Karachi at geographical location N24°53.651’, E 067°06.406’.
Probable cause:
The cause of the occurrence was uncontained failure of the 2nd stage disk of LP compressor of Engine # 4 due to fatigue fracture which resulted in in-flight fire and damage to adjacent areas of right wing / flaps to an extent that flight could not be sustained.
The use of mishap engine beyond its manufacturer’s assigned life without assessment and life enhancement by the manufacturer was the cause of its uncontained fatigue failure.
Final Report:

Crash of a Beechcraft 1900C-1 in Karachi: 21 killed

Date & Time: Nov 5, 2010 at 0706 LT
Type of aircraft:
Operator:
Registration:
AP-BJD
Flight Phase:
Survivors:
No
Schedule:
Karachi - Bhit Shah
MSN:
UC-157
YOM:
1991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
21
Captain / Total flying hours:
8114
Captain / Total hours on type:
1820.00
Copilot / Total flying hours:
1746
Copilot / Total hours on type:
1338
Aircraft flight hours:
18545
Aircraft flight cycles:
24990
Circumstances:
0C-1 aircraft Reg # AP-BJD was scheduled to fly chartered flight from Jinnah International Airport (JIAP), Karachi to Bhit Shah Oil Fields to convey 17 employees of M/s Eni company including one foreign national from Italy. The flight crew included two cockpit crew ie Captain and First Officer (FO), one JS (Air) ground crew (technician) and one Airport Security Force staff. The Mishap Aircraft (MA) took off from JIAP, Karachi at 02:04:31 UTC. The reported weather was fit for the conduct of ill-fated flight to Bhit Shah Oil Fields. After takeoff aircraft experienced Engine No 2 abnormal operation and cockpit crew decided to land back at JIAP Karachi after calling right hand downwind for runway 25R. While joining for right hand downwind for 25R the mishap aircraft could not sustain flight and crashed at a distance of around 1 nm from runway 07R beginning JIAP, Karachi. All souls (21) onboard got fatally injured as a result of aircraft ground impact and extensive post impact ground fire.
Probable cause:
Detailed investigation and analyses of the examinable evidence confirmed that the aircraft had developed some problem with its Engine No.2 (Right) immediately after takeoff which was observed by the cockpit crew as propeller feathering on its own. No concrete evidence could be found which would have led to the engine’s propeller malfunction as observed. The only probable cause of propeller feathering on its own could be the wear & tear of the beta valve leading to beta system malfunction. However, this anomaly at the most could have led to the non availability of one engine and making a safe landing with a single engine since the aircraft was capable of landing with a single engine operation. Some of the actions by the cockpit crew before takeoff and subsequent to the observed anomaly in the Engine No.2 were not according to the QRH / FCOM which aggravated the situation and resulted into the catastrophic accident.
The following factors contributed 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 cause of accident includes, inappropriate skill level of Captain to handle abnormal operation of engine No 2 just after takeoff, failure of cockpit crew to raise the landing gears after experiencing the engine anomaly, execution of remedial actions by FO before the attainment of minimum safe altitude of 400 ft AGL resulted in non conformance and non compliance of cockpit crew to OEM recommended procedures to handle such situations.
The lack of situational awareness and CRM failure directly contributed towards ineffective management of the flight deck by the cockpit crew.
The contributory factors include inadequate cockpit crew simulator training monitoring mechanism both at operator and CAA Pakistan levels in respect of correlation of previous / current performance and skill level of cockpit crew during the simulator training sessions along with absence of conduct of recurrent / refresher simulator training between two annual simulator checks in accordance with ICAO Annex-6 guidelines and CAA Pakistan (applicable ANOs) requirements for specific type of aircraft in a year.
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 in Multan: 45 killed

Date & Time: Jul 10, 2006 at 1205 LT
Type of aircraft:
Operator:
Registration:
AP-BAL
Flight Phase:
Survivors:
No
Schedule:
Multan - Lahore
MSN:
10243
YOM:
1964
Flight number:
PK688
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
41
Pax fatalities:
Other fatalities:
Total fatalities:
45
Captain / Total flying hours:
9320
Captain / Total hours on type:
138.00
Copilot / Total flying hours:
520
Copilot / Total hours on type:
303
Aircraft flight hours:
73591
Aircraft flight cycles:
83485
Circumstances:
On 10 July 2006, F-27 Fokker registration No AP-BAL, belonging to Pakistan International Airline was scheduled to fly from Multan to Lahore. The aircraft had 45 souls on board including four crew members. The Captain of the aircraft was Captain Hamid Qureshi. The aircraft took off for Lahore at 1205 hours Pakistan Standard Time (PST) from Multan Runway 36. Soon after takeoff, the aircraft was observed by the ATC and other eyewitnesses to be maintaining very low altitude and drifting right in a bank. ATC Control tower tried to establish contact with aircraft, but no contact was established. Subsequently a call from the local resident was received stating that an aircraft had crashed at about 2 km, NE of the Runway. All souls on board the aircraft sustained fatal injuries and the aircraft was completely burned.
Probable cause:
Accidents and losses are part of aviation business, but avoidable accidents hurt us the most. PIA or any other company can ill afford such losses. In this accident, while the aircraft had developed a problem in its right engine turbine, resulting in the engine failure, yet a professional handling by the aircrew could have saved 45 precious lives and a valuable aircraft. It is also felt that this accident may not be viewed as an isolated case of a pilot’s failure to handle the emergency. The problems were observed to be complex and deep routed and reflect towards the organization and her culture. The occurrence (right engine failure) took place due to improper assembly during overhaul. Quality Control system of PIA Engineering appears to be ineffective in detecting the weaknesses. The accident took place due to improper handling of the emergency by the air crew which reflected towards in adequacies of PIA Training/Assessment and Scheduling System. The CAA Airworthiness, too, can not be absolved of their responsibilities of regulating and monitoring the quality control system at PIAC Engineering.
Final Report:

Crash of a Fokker F27 Friendship 200 in Chitral

Date & Time: Jun 16, 2004
Type of aircraft:
Operator:
Registration:
AP-AUR
Survivors:
Yes
Schedule:
Peshawar - Chitral
MSN:
10307
YOM:
1966
Flight number:
PK660
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
36
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 02 at Chitral Airport, the aircraft was unable to stop within the remaining distance. It overran, lost its undercarriage and came to rest in a grassy and sandy area. All 40 occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of a Cessna 402B off Karachi: 8 killed

Date & Time: Feb 24, 2003
Type of aircraft:
Operator:
Registration:
AP-BFG
Flight Phase:
Survivors:
No
Schedule:
Karachi - Kabul
MSN:
402B-1304
YOM:
1977
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Aircraft flight hours:
6793
Circumstances:
The aircraft was chartered by the Afghan Government to carry a delegation from Karachi to Kabul. After takeoff from Karachi-Quaid-e-Azam Airport, the twin engine aircraft continued to climb to an altitude of 9,000 feet when it entered an uncontrolled descent. At an altitude of 2,500 feet, the aircraft disappeared from radar screens then crashed in the Arabian Sea few km offshore. The stabilizers and the tail were found few hundred metres from the main wreckage. All eight occupants were killed, among them Juma Mohammad Mohammadi, Afghan Minister of Industry and four members of his cabinet as well as one Chinese businessman.
Probable cause:
The Pakistan board of investigations determined that the probable cause of this accident was a structural failure due to overload. The aircraft weight was 7,183 lbs at the time of the accident as the maximum load as mentioned in the operational manual is 6,300 lbs, which means 883 pounds above max gross weight. It is believed that during climbout, the tail and stabilizers detached due to overload conditions.

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.

Ground accident of a Dornier DO228-201 in Karachi

Date & Time: Feb 19, 2003
Type of aircraft:
Operator:
Registration:
AP-BGF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Karachi - Karachi
MSN:
8016
YOM:
1983
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful training flight at Karachi-Quaid-e-Azam Airport, the crew was taxiing to his parking place when control was lost. The aircraft rolled across the apron and eventually collided with a concrete wall. Both pilots escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Lockheed KC-130R Hercules at Shamsi AFB: 7 killed

Date & Time: Jan 9, 2002
Type of aircraft:
Operator:
Registration:
160021
Flight Type:
Survivors:
No
Site:
Schedule:
Jacobabad – Shamsi
MSN:
4702
YOM:
1976
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
Following an uneventful flight from Jacobabad, the crew started a night approach to Shamsi AFB. While descending in limited visibility at the altitude of 3,200 feet, the four engine aircraft struck the slope of a mountain located few km from the airfield. All seven occupants were killed.
Probable cause:
It is believed that the crew lost his orientation while approaching Shamsi AFB by night and without any visual references on ground.