jul-aug2012

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60 FEATURE Air Blue Flight 202 runway centreline, and abeam the threshold of runway 12 on a heading of 352 degrees, the crew turned the aircraft left onto 300 degrees through the autopilot, and the autopilot was reselected to navigation mode. A minute later, when the aircraft was one nm to the south of a prohibited area, the tower controller instructed the crew to turn left in order to avoid entering the no-fly zone. Shortly afterwards, with the aircraft now five nm to the north of the airport, the aircraft’s ground proximity warning system enunciated: ‘TERRAIN AHEAD’! The first officer urged: ‘Sir! Higher ground has been reached! Sir, there is terrain ahead! Sir, turn left’! By this time the captain was displaying frustration, confusion and some anxiety, his speech indicating that he was becoming rattled. At 9.40am, the tower controller asked the crew if they were visual with the airfield. The crew did not respond to the transmission, the first officer asking the captain: ‘What should I tell him, sir?’ At the insistence of the radar controller, the tower controller then asked the crew again if they were visual with the ground. Both the captain and the first officer said they were. Then again the first officer exclaimed: ‘Sir! Terrain ahead is coming!’ The captain replied: ‘Yes, we are turning left.’ But the aircraft was not turning. At the same time, two more ‘TERRAIN AHEAD’ enunciations sounded. In his increasingly flustered state, and trying to turn the aircraft to the left on the autopilot, the captain was moving the heading bug onto reduced headings, but failing to pull out the heading knob to activate change, as required with the autopilot in navigation mode. Forty seconds before impact, the autopilot mode was changed from ‘navigation’ to ‘heading’. At this stage, the aircraft’s heading was 307 degrees, but the captain had reduced the selected heading to 086 degrees. As a result, the aircraft immediately started to turn the shortest way towards this heading, in this case to the right, towards the Margalla Hills. From that time on, more ground proximity warning system callouts, ‘TERRAIN AHEAD, ‘TERRAIN AHEAD, PULL UP!’ began sounding, continuing until impact. Meanwhile, the first officer called out twice in an alarmed voice, ‘Sir turn left! Pull up! Sir, sir, pull up!’ In response, the thrust levers were advanced, the autothrust disengaged, the selected altitude was changed to 3700ft and the aircraft began climbing, still turning right. Seconds later the thrust levers were retarded to the climb detent, the autothrust re-engaged in the climb mode, and the selected altitude reduced to 3100ft. The first officer called out yet again, ‘Sir—pull up, sir!’ and the no. 1 autopilot was disconnected, with the aircraft still rolling 25 degrees to the right. The captain then applied full left stick with some left rudder. The aircraft began turning left at an altitude of 2770ft and increasing. In the last few seconds of the flight, the captain applied more than 50 degrees of bank to increase the turn, also making some nose-down inputs. The aircraft pitched down nearly five degrees. As its speed increased, the auto thrust spooled down the engines, and the aircraft began descending at a high rate. Although the first officer again shouted, ‘Terrain sir’ and the captain started to make pitch-up inputs, the high rate of descent could not be arrested in time. For the last time, the first officer called out: ‘Sir we are going down ... Sir we are going d...’ Seconds after 9.41am, in a slightly nose-down attitude and a steep left bank, the aircraft flew into the Margalla Hills at an elevation of 2858ft. Its rate of descent was more than 3000ft per minute. The aircraft was completely destroyed and all 152 people on board were killed instantly. The weather at Islamabad Airport at the time of the crash was three octas of cumulus cloud at 1000ft, four octas of stratocumulus at 3000ft and seven octas of altostratus at 10,000ft, with a visibility of 3.5km. The wind from 050 degrees was 16kt. The temperature was 24 degrees C and rain was likely. There was also a weather warning, valid to 12 noon, for thunderstorms and rain for 50 miles around, and for south-east to north-east winds at 20 to 40kt, gusting up to 65kt or more. Visibility could reduce to one kilometre or less in precipitation. Moderate to severe turbulence could occur in 1-2 octas of cumulonimbus at 3000ft. Findings The captain’s behaviour towards the first officer was harsh, snobbish and contrary to established norms. This curbed the first officer’s initiative, created a tense environment, and a conspicuous communication barrier. The captain seemed determined to make a right-hand downwind approach to runway 12, despite his knowledge that Islamabad procedures did not permit this, and there was low cloud in the area. Contrary to established procedures for circling to land on runway 12, the captain elected to fly the approach in the navigation mode and asked the first officer to feed unauthorised waypoints into the flight management system. The first officer did not challenge his instructions.
Flight Safety Australia Issue 87 July–August 2012 61 The intention of the captain to fly this type of approach was not known to air traffic control. His violation of established procedure took the aircraft beyond the protected area. The captain exhibited anxiety, confusion and geographical disorientation, particularly after commencing descent. After a delayed break-off from the ILS because of poor visibility, the captain turned right, but did not turn left to parallel the runway. While flying the northerly heading, the captain descended below the MDA to 2300ft. This time the first officer did not challenge him. The captain also failed to maintain visual contact with the airfield. The tower controller could not see the aircraft on downwind or final legs, and sought radar help. The aircraft was identified close to the no-fly zone and was instructed to turn left. When the tower asked the crew if they had contact with the airfield, the first officer’s question to the captain, ‘What should I tell him, sir?’ indicated a possible loss of visual contact, as well as geographical disorientation. the aircraft’s ground proximity warning system enunciated: ‘TERRAIN AHEAD’! The first officer urged: ‘Sir! Higher ground has been reached! Sir, there is terrain ahead! Sir, turn left’! The crew took the aircraft out of the protected area, 7.3nm from the runway 12 threshold. During the last 70 seconds of the flight, despite calls from the tower, the GPWS sounding ‘Terrain ahead’ 21 times, ‘Pull up’ 15 times, and seven warnings from the first officer, the captain did not pull up. The first officer did not assert himself as he watched the captain’s steep banks, continued flight into hilly terrain at low altitude in poor visibility, and failure to pull up. Conclusion The accident was primarily caused by the crew’s violation of all established procedures for a visual approach to runway 12, their disregard of several calls by air traffic controllers, and of 21 GPWS warnings of rising terrain. The official investigation termed the crash ‘a classic CRM failure’. Why this failure occurred is unclear; Captain Chaudhary’s motivation and state of mind remain unknown. The investigation declared: ‘Both the crew members were … medically fit to undertake the flight on 28 July 2010.’ However, unconfirmed reports appearing in Pakistani newspapers in 2011 said that Chaudhary had been treated in hospital for diabetes, hypertension and cardiac problems.
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87 July-August 2012 Unmanned aircra
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CONTENTS Issue 87 | July-August 201
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Flight Safety Australia Issue 87 Ju
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