2014

Daniyal Ali
BAT11362
2/12/2014
airblue Flight ABQ-202 Crash Report

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Department of Engineering and
Technology

Appropriate Task:
Air blue Flight APQ-202 Crash Report
A research on Air blue Flight APQ-202 crash. What are the main factors in the behind the crash
and what are the solutions for these factors.
Prepared By:
Daniyal Ali (BAT11362)
Submitted To:
Prof. W/C Imran Khan
Discipline:
BS-Aviation Technology
Submission Date:
13-02-2014


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airblue Flight ABQ-202
Flight Details:
Airblue Flight 202 was a scheduled domestic passenger flight which crashed on 28 July
2010 near Islamabad, the capital of Pakistan, killing all 146 passengers and six crew on
board. It is the deadliest air accident to occur in Pakistan to date. The Captain of aircraft
was Captain Pervez Iqbal Chaudhary. Mishap aircraft, an Airblue operated Airbus A321-
231 narrow-body jet airliner, crashed in the Margalla Hills north of Islamabad during a
flight from Karachi's Jinnah International Airport to Benazir Bhutto International Airport,
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. Air traffic
controllers reportedly lost contact with the flight crew during its attempt to land in dense
fog and heavy monsoon rain. The aircraft was completely destroyed and all souls on
board the aircraft, sustained fatal injuries. May Allah bless their souls.
Pilot Details:
The sixty-two-year-old captain of Flight 202, Pervez Iqbal Chaudhry, had 35 years and
more than 25,000 hours of flying experience, with an unblemished flight safety record
and rating of A-319/320/321. The comparatively junior first officer (Sqn Ldr) Muntajib
Ahmed, a former F-16 Pakistan Air Force fighter pilot, had logged one year of
experience on the Airbus A321 aircraft.
Aircraft Information:
The aircraft that crashed was an Airbus A321-231, registered AP-BJB, manufacturer's
serial number 1218, which was built in 2000. This was the first fatal crash for the A321,
and the second hull-loss of the type. The aircraft had originally been delivered to Aero
Lloydand used by Aero Flight before being taken up by Airblue in 2006. It had
accumulated approximately 34,000 flight hours in some 13,500 flights.
Passengers:
Early reports in the morning had stated that there were over 40 injured survivors, later
revised at around midday to around five to six people having been rescued, before
Interior Minister Rehman Malik confirmed in the afternoon that there were in fact no
survivors. Pakistani footballer Misha Dawood, 19, of Diya Football Club, Karachi, and
former national athlete Zafar Saleem, who was director-general of the Sindh Workers
Welfare Board, were killed in the crash.
Of the passengers, 110 were men, 29 were women, 5 were children, and 2 were
infants. Six members of the Youth Parliament of Pakistan were on board as were three
off duty air hostesses, and four foreign nationals.


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Accident:
The flight left Karachi at 07:50 local time (01:50 UTC). Initial reports suggested that
flight controllers at Benazir Bhutto International Airport lost contact with the aircraft at
09:43 local time (03:43 UTC) after they delayed its landing 13 minutes earlier. It was
reported that the poor weather had forced controllers to divert another aircraft
attempting to land 30 minutes before the crash.
The aircraft approached Islamabad from the southeast, following a procedure that
required it to fly toward the airport until making visual contact. It was then to have flown
around the airport to the east and north, keeping within a distance of 5 nmi (9.3 km),
until lining up with runway 12, which faces toward the southeast. The aircraft crashed in
the mountains outside the 5 nmi (9.3 km) radius, approximately 8 nmi (15 km) north of
the airport, facing almost due west, before it could line up with runway 12 for final
approach.
While the BBC reported that officials stated that "there was nothing in conversations
between the pilot and the Islamabad control tower that suggests anything was
wrong", The New York Times gave an account of communications between the aircraft
and the ground that indicated otherwise. The newspaper claimed that the pilots were
warned that they were flying away from the runway, to which the pilot responded I can
see. The controller then told the flight crew to immediately turn left, Margalla [Hills] are
ahead, before the pilot again replied we can see it. Multiple EGPWS "TERRAIN
AHEAD" warnings were recorded on the Cockpit Voice Recorder starting 40 seconds
before the crash. The first officer was also heard requesting to the captain "Sir turn left,
Pull Up Sir. Sir pull Up." This was the first controlled flight into terrain accident since
2002, when all planes with more than six passengers became required to have an
advanced terrain awareness warning system.
An airline official stated that the pilots did not send any emergency signals prior to the
crash. Resources stated that the plane was at 2,600 feet (790 m) as it approached
Islamabad but went back up to 3,000 feet (910 m) before eventually crashing. The
altitude of 2,600 feet (790 m) was above the safe minimum descent altitude (2,510 feet
(770 m) above sea level, or 852 feet (260 m) above ground level) had the aircraft
remained within the 5 nmi (9.3 km) radius of the airport.
One witness on the ground, who was out walking, stated that "the plane had lost
balance, and then we saw it going down". Others described the plane as being lower
than it should have been. "I wondered why the plane wasn't flying higher as it was flying
towards the hill", one stated. "Then within three or four minutes I heard a loud
explosion". Another said that "it was raining. I saw the plane flying very low from the
window of my office". Imran Abbasi told The New York Times that he "could tell it was
trouble because it stayed so low even though the mountains were up ahead". He stated

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that the jet was "flying as low as a four-story building". It was reported that Mr. Abbasi
said that "as the aircraft started to turn, the right side of its front banged into the highest
mountain, emitting an instant billow of blue fire and black smoke".
The plane was found near Daman-e-Koh viewing point in the Margalla Hills outside
Islamabad. The Los Angeles Times reported that "television footage of the crash site
showed smoke and burning debris strewn in a swath cutting through the forest. Rescue
helicopters hovered overhead. Fire was visible, and smoke was blowing up from the
scene."
The weather conditions before the accident, as detailed by the 03:00
UTC METAR (aviation routine weather observation message) report for Benazir Bhutto
International Airport, were as follows: Wind from 50 (approximately north east) at 16
knots (30 km/h). Visibility 2 kilometres (1.2 mi), rain, few clouds at 1,500 feet (460 m),
few clouds at 3,000 feet (910 m) with towering cumulus. Scattered clouds at 4,000 feet
(1,200 m), broken clouds at 10,000 feet (3,000 m). Temperature 24C, dewpoint
23C. QNH 1006.5 hPa.
Investigation:
The Civil Aviation Authority immediately launched an investigation into the
accident. Airbus stated that they would provide full technical assistance to Pakistani
authorities. A six member Airbus team, headed by Nicolas Bardou, the company's
director of flight safety, arrived in Islamabad on 29 July 2010.
The recorders were located on 31 July, when Junaid Ameen, the director-general of the
Pakistan Civil Aviation Authority, told the Associated Free Press that "the investigating
committee found the black box from the Margalla Hills this morning ... the black box was
found from the bulk of the wreckage of the crashed plane." He stated that the box would
be examined by "foreign experts" in Germany or France as Pakistan does not possess
the equipment to decode the flight recorders. He also stated that the process of
extracting information may take six months to a year. The Pakistani authorities decided
to send the CVR and FDR to the Bureau d'Enqutes et d'Analyses pour la Scurit de
l'Aviation Civile (BEA) in France.
Findings:
1) The weather conditions especially at the destination were marginal and these
Deteriorated weather conditions were found to be a factor in the causation of this
accident.
2) The Captains behavior towards the FO was harsh, snobbish and contrary to
establish norms. This undesired activity of the Captain curbed the initiative of the
FO, created a tense and undesirable environment, and a very conspicuous
communication barrier in the cockpit, portraying a classic CRM failure.

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3) Contrary to ATS briefing and established procedures of Circle to Land RWY-12,
the Captain opted to fly approach on Nav mode and asked the FO to feed 04 way
points. FO did not challenge the captain for his incorrect actions.
4) This intention of Captain to fly PBD based approach was not known to the ATS at
any stage of flight. Due to this violation of established procedure, the FMS
created positions were way out of the protected airspace lying into Margalla hills.
Unfortunately, PBD-11 happened to be in the near vicinity of the crash point.
5) The Captain had a very strong fixation for landing through RH D/W for RWY-12.
This despite the fact that with his vast experience of flying, he knew RH D/W for
RWY-12 is not allowed by procedures; and this time even low clouds were
reported in the area.
6) The Captain showed signs of anxiety, preoccupation, confusion and geographical
disorientation in various phases of flight especially after commencement of
descent.
7) During the descent, the Captains request for RH D/W for RWY-12 for a visual
approach was not agreed to by Radar.
8) During ILS approach, the Captains second request for RH D/W for RWY-12 was
also declined by ATC Tower due to procedural limitations (RH D/W for RWY-12
is not allowed).
9) After delayed break-off from ILS at minima due to poor visibility, the Captain
turned right to about 352 degrees and then contrary to the published procedure,
did not turn left to parallel the course of the runway.
10) While flying the northerly heading, abeam downwind, the Captain descended
below the MDA (2,510ft) to 2,300ft. FO remained reliant on the Captains actions
and did not challenge the deviation from procedures.
11) The Captain failed to maintain visual contact with the airfield, in violation of the
published procedures.
12) While aircraft was flying in the general direction of 352 degrees, it went very
close to the NFZ (01 km) in the North.
13) When the ATC Controller did not find the aircraft on Downwind / final approach,
he sought Radar help on landline. The aircraft was re-identified by the Radar
close to NFZ. As advised by Radar controller, ATC instructed ABQ-202 to turn
left to avoid No Flying Zone. However, the Captain had already initiated the left
turn onto 300 degrees using HDG mode.
14) At 0439:58 hrs (70 seconds before the impact), the first EGPWS warning of
terrain ahead started sounding meaning that the EGPWS worked exactly in the
manner for which it was designed.
15) ABQ-202 was asked by ATS if they had contact with the airfield. No reply was
given by either of aircrew, but FO asked the Captain in the cockpit Kia batauon
Sir (what should I tell him Sir), indicating possible loss of visual contact with
airfield as well as geographical disorientation.
16) The protected circling airspace to fly at MDA was available till 4.3 NM. Contrary
to the recommended procedures, the mishap aircrew took the aircraft out of the
protected area to 7.3 NM from RWY-12 threshold.

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17) In the ensuing self created emergency situation, the Captain unknowingly failed
to do even the simple things such as engaging the HDG knob by pulling it to
activate the desired mode.
18) During last 70 seconds from crash, despite calls from ATS and the EGPWS
sounding 21 times as Terrain ahead including 15 times for pull up (extract of
sound and alarms chronology is attached at Appendix-C), the Captain continued
to take the aircraft on its fatal journey. The FO also informed the Captain 4 times
about the terrain / Terrain Warning and asked him at least 3 times to pull up. But
the Captain did not pull up, nor did he apply the TOGA (Take Off Go Around)
thrust, contrary to the established SOPs.
19) FO kept watching the Captains failures, and unsafe actions such as inducing
steep banks; and continuous flight into hilly terrain at low altitude in poor visibility;
and failure to apply power and pull up. Unfortunately, FO remained impassive
and failed to assert himself due to non congenial environment in the cockpit.
20) While the FO sensing imminent and acute danger did shout twice in the most
disappointed / frustrated manner to inform the Captain that the aircraft was going
down, but unfortunately still failed to takeover / override.
21) The aircraft was fully airworthy and its power plants, control surfaces, Enhanced
Ground Proximity Warning System (EGPWS) and associated systems were
functioning normal till its impact with the hill.
22) No evidence was found for any internal or external sabotage, incapacitation of
the aircraft systems, in-flight fire, bird strike or structural fatigue.
23) BBIAP Islamabad being a busy international airport of the country, instrument
approach procedure was not established for RWY-12, because of which Circle to
land on RWY-12 was in use.

Conclusion:
1) A lack of professionalism in the cockpit crew along with poor weather as primary
factors in the crash.
2) Controlled Flight into Terrain (CFIT), in which aircrew failed to display superior
judgment and professional skills in a self-created unsafe environment. In their
pursuit to land in inclement weather, they committed serious violations of
procedures and breaches of flying discipline, which put the aircraft in an unsafe
condition over dangerous terrain at low altitude.
3) 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.
4) 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.
5) 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

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commands, the Captain failed to register the urgency of the situation and did not
respond in kind (break off / pull off).
6) 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.
7) 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.

References:
1) http://www.dawn.com/news/713312/caa-releases-airblue-crash-reports
2) http://en.wikipedia.org/wiki/Airblue_Flight_202
3) INVESTIGATION REPORT issued by CAA Pakistan, AIR BLUE FLIGHT ABQ-
202 A-321 REG AP-BJB PAKISTAN CRASHED ON 28 JULY 2010 AT
MARGALLA HILLS, ISLAMABAD