Crash of a Dornier DO228-202 in Kathmandu: 19 killed

Date & Time: Sep 28, 2012 at 0618 LT
Type of aircraft:
Operator:
Registration:
9N-AHA
Flight Phase:
Survivors:
No
Schedule:
Kathmandu - Lukla
MSN:
8123
YOM:
1987
Flight number:
SIT601
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
19
Captain / Total flying hours:
8308
Captain / Total hours on type:
7112.00
Copilot / Total flying hours:
772
Copilot / Total hours on type:
519
Circumstances:
A Dornier 228 aircraft, registration 9N-AHA, was planned to operate a flight from Tribhuvan International Airport (TIA), Kathmandu, to Tensing/Hillary Airport, Lukla with 16 passengers and 3 crews. The Commander was the Pilot Flying (PF) which was in accordance with common practice for flight crews operating this route. The 0020Z METAR for TIA reported calm wind, 3,000 m visibility in mist, scattered cloud at 2,000 ft AAL, broken cloud at 10,000 ft AAL, a temperature of 19° C and a QNH of 1017 HPa. ATC broadcast a change in the QNH to 1018 HPa at 0029 hrs. At 0028 hrs (0613 am), the Co-pilot asked ATC for taxi clearance and 9N-AHA taxied towards Intersection 2 for Runway 20. While taxiing towards the runway the flight crew carried out the before takeoff checklist during which the Commander confirmed that Flaps 1 was set and all four booster pumps were ON. There was no emergency brief or discussion about the reference speeds to be used during the takeoff. The flight crew changed frequency and contacted the tower controller who gave them clearance to enter Runway 20 from the intersection and wait for clearance to takeoff. The Commander asked for the line-up checks to be completed during which the Speed Lever was selected to HIGH. After lining up, the Commander said "THERE IS A BIRD" and, three seconds later "I WILL TAKE FLAPS TWO" which was acknowledged by the co-pilot. The aircraft was cleared for departure and began its takeoff run at 0032 hrs. Two seconds after beginning the takeoff roll, the Commander said "WATCH OUT THE BIRD". The Co-pilot called "50 KNOTS " as the aircraft approached 50 kt and the Commander replied "CHECK". Two seconds later, the co-pilot called "BIRD CLEAR SIR" as the aircraft accelerated through 58 kt. Approaching 70 kt, approximately 13 kt below V1 and Vr , the first officer called "VEE ONE ROTATE". The aircraft began to rotate but did not lift off the ground and the nose was briefly lowered again. As the aircraft reached 86 kt, it lifted off the ground and the landing gear was raised immediately. As the aircraft began to climb, it accelerated to 89 kt over approximately 2 seconds. It continued to climb to 100 ft above the runway over the next 11 seconds but, during this time, the speed decreased to 77 kt. The aircraft then flew level for 14 seconds during which time the following occurred: the speed decreased to 69 kt; the air traffic controller asked "ANY TECHNICAL?" to which the pilot replied "[uncertain]….DUE BIRD HIT"; it's heading changed slowly from 200 °M to approximately 173 °M; and the stall warning was triggered for three seconds as the aircraft decelerated through 71 kt. Two seconds after the stall warning ended, it was triggered again for approximately six seconds with the airspeed at 69 kt. The aircraft began a gentle descent at 69 kt with the stall warning sounding and the rate of turn to the left increased rapidly. It departed controlled flight, most probably left wing low, and crashed into a small open area 420 m south-east of the end of Runway 20. A runway inspection found the remains of a bird, identified as a "Black Kite", at a position 408 m from Intersection 2. No bird strike was reported in relation to any other departure.
Probable cause:
Causal Factors:
The investigation identified the following causal factors:
1. During level flight phase of the aircraft, the drag on the aircraft was greater than the power available and the aircraft decelerated. That resulted in excessive drag in such critical phase of ascent lowering the required thrust. The investigation was unable to determine the reason for the reduced thrust.
2. The flight crew did not maintain the airspeed above the stall speed and there was insufficient height available to recover when the aircraft departed controlled flight.
Contributory Factors:
The investigation identified the following contributory factors:
1. The flight crew did not maintain V2 during the climb and so the power required to maintain the level flight was greater than it would otherwise have been.
2. The flight crew did not maintain the runway centreline which removed the option of landing the aircraft on the runway remaining.
Final Report:

Crash of a PZL-Mielec AN-28 in Palana: 10 killed

Date & Time: Sep 12, 2012 at 1220 LT
Type of aircraft:
Operator:
Registration:
RA-28715
Survivors:
Yes
Schedule:
Petropavlovsk-Kamchatsky - Palana
MSN:
1AJ006-25
YOM:
1989
Flight number:
PTK251
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
8955
Captain / Total hours on type:
7732.00
Copilot / Total flying hours:
6543
Copilot / Total hours on type:
6347
Aircraft flight hours:
11947
Aircraft flight cycles:
8891
Circumstances:
Following an uneventful flight from Petropavlovsk-Kamchatsky, the crew started the descent to Palana Airport Runway 11 from the south. In marginal weather conditions, the twin engine aircraft descended too low, impacted trees and crashed in a wooded area located on Mt Pyatibratka. The wreckage was found at a height of 216 meters some 10 km south of the airport. Both pilots and 8 passengers were killed while four other passengers were seriously injured. Thea aircraft was destroyed by impact forces.
Probable cause:
The fatal accident with An-28 RA-28715 aircraft was caused by violation of specified approach pattern in Palan Airport resulted in outbound track and premature descending up to unauthorized low altitude performing flight in mountainous terrain in weather conditions excluding sustained visual reference with ground references resulted in aircraft collision with mountain slope, its destruction and crew and passengers fatality. Alcohol was detected in blood of both crew members.
Contributing factors were:
- Low level of discipline of personnel in Petropavlovsk-Kamchatsky Air Enterprise and inadequate flight methodical work in enterprises in a part of crew preflight training and approach patterns monitoring.
- Crew inaction when the radio altimeter altitude alert was actuated.
- Ground Proximity Warning System at An-28 aircraft could probably prevent the accident.
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 Let L-410UVP-E9 in Ngerende: 4 killed

Date & Time: Aug 22, 2012 at 1220 LT
Type of aircraft:
Operator:
Registration:
5Y-UVP
Flight Phase:
Survivors:
Yes
Schedule:
Amboseli – Ngerende – Mara North – Ukunda – Mombasa
MSN:
91 26 27
YOM:
1991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7480
Captain / Total hours on type:
1150.00
Copilot / Total flying hours:
312
Circumstances:
This was a commercial non scheduled flight which was being operated for air transport for local flights. The operator is based in Mombasa and mostly executes passenger flights to the Masai Mara and other game parks and reserves within the Republic of Kenya. On 22nd Aug 2012, the aircraft was scheduled to carry out a flight to the Masai Mara, do several sectors to pick and drop passengers and return to Moi international Airport via Ukunda Airport. The call sign was 5Y-UVP. The last point of departure was Ngerende Airstrip in the Masai Mara at 0917 with intention of onward flight to Mara North airstrip in the Masai Mara. The flight had earlier left Amboseli Airstrip with two crew, and 17 passengers for Ngerende Airstrip. 6 passengers had disembarked at Ngerende and the remaining 11 passengers were continuing to other destinations. No additional passengers or cargo was picked up from Ngerende airstrip. No refueling was done at the airstrip. The airfield is an unmanned airfield, with crew executing unmanned airfield communication procedures to execute approach and landings and also during takeoff. There is however a ground time keeper and a fueling bay at the airfield. Due to terrain and prevailing winds at the time of the flight, Runway 28 was in use. The crew was using unmanned airfield procedures and after the drop-off of 6 passengers, the aircraft lined up runway 28 and proceeded with the take off run. Ground staff at the airstrip reported a normal takeoff run and rotation. During the initial climb, the ground staff still had the aircraft in sight and reported to have seen the aircraft veer sharply to the left and then disappear behind terrain. Shortly afterwards, a loud sound was heard followed by dust in the air. Emergency SAR was initiated with the airport and hotel staff rushing to the accident site. The location of the accident was about 310 meters from the threshold of Runway 10, offset 30° to the left of the extended center line Runway 28. GPS coordinates (figure 1.2) 01.084189° S, 35.1781127° E, Ngerende airstrip. The accident occurred at 0917 UTC on 22nd Aug 2012, during daytime.
Probable cause:
The following findings were identified:
- The left engine was most probably not developing power at the time of impact,
- The left engine propeller was most probably in feather at the time of impact,
- Both CVR and FDR were unserviceable at the time of the accident,
- AAID was unable to determine origin of contaminant found in the left engine Fuel Control Unit,
- Sufficient oversight was not exercised over the Operator,
- High turnover of the Operator’s staff.
Final Report:

Crash of an ATR42-320 in Jersey

Date & Time: Jun 16, 2012 at 0823 LT
Type of aircraft:
Operator:
Registration:
G-DRFC
Survivors:
Yes
Schedule:
Guernsey - Jersey
MSN:
007
YOM:
1986
Flight number:
BCI308
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
40
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6106
Captain / Total hours on type:
1255.00
Circumstances:
The crew, comprising a commander, co-pilot and cabin crewmember, reported for duty at 0620 hrs at Guernsey Airport. The commander was conducting line training of the co-pilot, a first officer who had recently joined the companyThe first sector was to be from Guernsey to Jersey. No problems were identified during the pre-flight preparation and the aircraft departed on time at 0705 hrs, with the commander acting as handling pilot. The short flight was without incident and the weather for landing was reported as good, with the wind from 210° at 16 kt, FEW cloud at 2,000 ft and visibility in excess of 10 km. The commander elected to carry out a visual approach to Runway 27 at Jersey, using a planned approach speed of 107 kt and flap 30 selected for landing. During the approach, the gear was selected down and the flight crew confirmed the three green ‘gear safe’ indication lights were illuminated, indicating that the gear was locked in the down position. The commander reported that both the approach and touchdown seemed normal, with the crosswind from the left resulting in the left main gear touching first. Just after touchdown both pilots heard a noise and the commander stated the aircraft appeared to settle slightly differently from usual. This made him believe that a tyre had burst. The cabin crew member also heard a noise after touchdown which she too thought was from a tyre bursting. The commander selected ground idle and partial reverse pitch and, as the aircraft decelerated through 70 kt, the co-pilot took over control of the ailerons, as per standard procedures, to allow the commander to take control of the steering tiller. The co-pilot reported that despite applying corrective inputs the aircraft continued rolling to the left. A member of ground operations staff, situated at Holding Point E, reported to the tower controller that the left landing gear leg of the aircraft did not appear to be down properly as it passed him. The aircraft continued to quickly roll to the left until the left wingtip and propeller contacted the runway. The aircraft remained on the runway, rapidly coming to a halt to the left of the centreline, approximately abeam Holding Point D. Both propellers continued to rotate and the commander selected the condition levers to the fuel shutoff position and pulled the fire handles to shut both engines down. The tower controller, seeing the incident, pressed the crash alarm and airfield emergency services were quickly in attendance.
Probable cause:
The recorded data indicates that the rate of descent during the final approach phase was not excessive and remained low through the period of the touchdown. Although the registered vertical acceleration at ground contact was high, this is not consistent with the recorded descent rate and is believed to have been the effect of the close physical proximity of the accelerometer to the location of the fractured side brace. It is reasonable to assume that the release of strain energy during the fracturing process produced an instant shock load recorded as a 3 g spike.The general nature of the failure mechanism precipitating the collapse of the landing gear is clear. A fatigue crack propagated through most of the cross-section of one side of an attachment lug of the left main landing gear side brace upper arm. This continued as a final region of ductile cracking until complete failure occurred. The increased loading, during normal operation, on other elements of the twin lugs, once the initial crack was large or had passed completely through the section, led to overloading in the other section of the forward lug and both sections of the aft lug. This caused rapid onset of three small areas of fatigue damage followed by ductile overload failure of both lugs. The failure rendered the side brace ineffective and the unrestrained main trunnion continued to translate outboard leading to the collapse of the gear. The aluminium was found to be within the specifications to which it was made. The initial fatigue crack emanated from a feature which was inter-granular and high in titanium content, which was probably a TiB2 particle introduced during grain refining. This was surrounded by an area consistent with static loading before propagating a crack in fatigue. Given that there was not a measurable effect on the fatigue life of the material with the feature, and that an area of static overload was evident immediately surrounding the TiB2 particle, it is therefore concluded that at some time during the life of the side brace component it probably suffered a single loading event sufficient to exploit the presence of the origin, initiating a crack that remained undetectable until failure.
Final Report:

Crash of a McDonnell Douglas MD-83 in Lagos: 159 killed

Date & Time: Jun 3, 2012 at 1545 LT
Type of aircraft:
Operator:
Registration:
5N-RAM
Survivors:
No
Site:
Schedule:
Abuja - Lagos
MSN:
53019/1783
YOM:
1990
Flight number:
DAV992
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
147
Pax fatalities:
Other fatalities:
Total fatalities:
159
Captain / Total flying hours:
18116
Captain / Total hours on type:
7466.00
Copilot / Total flying hours:
1143
Copilot / Total hours on type:
808
Aircraft flight hours:
60850
Aircraft flight cycles:
35220
Circumstances:
On 3rd June, 2012 at about 1545:00hrs, 5N-RAM, a Boeing MD-83, a domestic scheduled commercial flight, operated by Dana Airlines (Nig.) Limited as flight 0992 (DANACO 0992), crashed into a densely populated area of Iju-Ishaga, a suburb of Lagos, following engine number 1 loss of power seventeen minutes into the flight and engine number 2 loss of power while on final approach to Murtala Muhammed Airport Lagos, Nigeria. Visual Meteorological Conditions prevailed at the time and the airplane was on an instrument flight plan. All 153 persons onboard the airplane, including the six crew were fatally injured. There were also six confirmed ground fatalities. The airplane was destroyed. There was post impact fire. The flight originated at Abuja (ABV) and the destination was Lagos (LOS). The airplane was on the fourth flight segment of the day, consisting of two round-trips between Lagos and Abuja. The accident occurred during the return leg of the second trip. DANACO 0992 was on final approach to runway 18R at LOS when the crew declared a Mayday call “Dual Engine Failure – negative response from the throttles.” According to records, the flight arrived ABV as Dana Air flight 0993 at about 1350:00hrs and routine turn-around activities were carried out. DANACO 0992 initiated engine start up at 1436:00hrs. Abuja Control Tower cleared the aircraft to taxi to the holding point of runway 04. En-route ATC clearance was passed on to DANACO 0992 on approaching holding point of runway 04. According to the ATC ground recorder transcript, the aircraft was cleared to line-up on runway 04 and wait, but the crew requested for some time before lining-up. DANACO 0992 was airborne at 1458:00hrs after reporting a fuel endurance of 3 hours 30 minutes. The aircraft made contact with Lagos Area Control Centre at 1518:00hrs and reported 1545:00hrs as the estimated time of arrival at LOS at cruising altitude of 26,000 ft. The Cockpit Voice Recorder (CVR) retained about 30 minutes 53 seconds of the flight and started recording at 1513:44hrs by which time the Captain and First Officer (F/O) were in a discussion of a non-normal condition regarding the correlation between the engine throttle setting and an engine power indication. However, they did not voice concerns then that the condition would affect the continuation of the flight. The flight crew continued to monitor the condition and became increasingly concerned as the flight transitioned through the initial descent from cruise altitude at 1522:00hrs and the subsequent approach phase. DANACO 0992 reported passing 18,100ft and 7,700ft, at 1530:00hrs and 1540:00hrs respectively. After receiving radar vectors in heading and altitude from the Controller, the aircraft was issued the final heading to intercept the final approach course for runway 18R. According to CVR transcript, at 1527:30hrs the F/O advised the Captain to use runway 18R for landing and the request was made at 1531:49hrs and subsequently approved by the Radar Controller. The crew accordingly changed the decision height to correspond with runway 18R. At 1531:12hrs, the crew confirmed that there was no throttle response on the left engine and subsequently the Captain took over control as Pilot Flying (PF) at 1531:27hrs. The flight was however continued towards Lagos with no declaration of any distress message. With the confirmation of throttle response on the right engine, the engine anti-ice, ignition and bleed-air were all switched off. At 1532:05hrs, the crew observed the loss of thrust in No.1 Engine of the aircraft. During the period between 1537:00hrs and 1541:00hrs, the flight crew engaged in prelanding tasks including deployment of the slats, and extension of the flaps and landing gears. At 1541:46hrs the First Officer inquired, "both engines coming up?" and the Captain replied “negative” at 1541:48hrs. The flight crew subsequently discussed and agreed to declare an emergency. At 1542:10hrs, DANACO 0992 radioed an emergency distress call indicating "dual engine failure . . . negative response from throttle." At 1542:35hrs, the flight crew lowered the flaps further and continued with the approach and discussed landing alternatively on runway 18L. At 1542:45hrs, the Captain reported the runway in sight and instructed the F/O to retract the flaps and four seconds later to retract the landing gears. At 1543:27hrs, the Captain informed the F/O, "we just lost everything, we lost an engine. I lost both engines". During the next 25 seconds until the end of the CVR recording, the flight crew attempted to recover engine power without reference to any Checklist. The airplane crashed into a densely populated residential area about 5.8 miles north of LOS. The airplane wreckage was approximately on the extended centreline of runway 18R, with the main wreckage concentrated at N 06o 40.310’ E 003o 18.837' coordinates, with elevation of 177ft. During the impact sequence, the airplane struck an uncompleted building, two trees and three other buildings. The wreckage was confined in a small area, with the separated tail section and engines located at the beginning of the debris trail. The airplane was mostly consumed by post crash fire. The tail section, both engines and portions of both wings representing only about 15% of the airplane, were recovered from the accident site for further examination.
Probable cause:
Probable Causal Factors:
1. Engine number 1 lost power seventeen minutes into the flight, and thereafter on final approach, Engine number 2 lost power and failed to respond to throttle movement on demand for increased power to sustain the aircraft in its flight configuration.
2. The inappropriate omission of the use of the Checklist, and the crew’s inability to appreciate the severity of the power-related problem, and their subsequent failure to land at the nearest suitable airfield.
3. Lack of situation awareness, inappropriate decision making, and poor airmanship.

Tear down of the engines showed that the no.1 engine was overhauled in the U.S in August 2011 and was not in compliance with Service Bulletin SB 6452. Both engines had primary and secondary fuel manifold assemblies fractured, cracked, bent, twisted or pinched which led to fuel leaks, fuel discharge to bypass duct, loss of engine thrust and obvious failure of engine responding to
throttle movement. This condition was similar to the no.1 engine of a different Dana Air MD-80, 5N-SAI, that was involved in an incident in October 2013 when the aircraft returned to the departure airport with the engine not responding th throttle movements. This engine also was not in compliance with Service Bulletin SB 6452. This bulletin was issued in 2003 and called for the installation of new secondary fuel manifold assemblies, incorporating tubes fabricated from new material which has a fatigue life that was approximately 2 times greater than the previous tube material.
Final Report:

Crash of a Boeing 737-4Y0 in Pontianak

Date & Time: Jun 1, 2012 at 1235 LT
Type of aircraft:
Operator:
Registration:
PK-CJV
Survivors:
Yes
Schedule:
Jakarta - Pontianak
MSN:
24689/1883
YOM:
1990
Flight number:
SJY188
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
155
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25000
Circumstances:
The approach to Pontianak was unstable and really difficult due to turbulence and poor weather conditions (heavy rain falls). The aircraft landed on wet runway 15 and skidded. It eventually veered off runway to the left and went through a muddy field. The nose gear was torn off while both main gears sank, leaving both engines on the ground. While all 163 occupants were evacuated safely, the aircraft was damaged beyond repair. At the time of the accident, weather conditions were as follow: wind from 230 at 22 knots, visibility 600 metres, few clouds at 900 feet, broken at 700 feet, CB's above the terrain and turbulences.

Crash of a Dornier DO228-212 in Jomsom: 15 killed

Date & Time: May 14, 2012 at 0945 LT
Type of aircraft:
Operator:
Registration:
9N-AIG
Survivors:
Yes
Schedule:
Pokhara - Jomsom
MSN:
8216
YOM:
1997
Flight number:
AG-CHT
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
15
Captain / Total flying hours:
5776
Captain / Total hours on type:
596.00
Circumstances:
On final approach to Jomsom Airport runway 06, the crew lowered the landing gear when they noticed a technical issue. On short final, the captain decided to initiate a go-around procedure and to divert to Pokhara. He made a sharp U-turn to the left at a speed of 73 knots when the left wing impacted a rocky hill located 270 meters above the runway 24 threshold. The aircraft stalled and crashed on the slope of the hill and was destroyed by impact forces. The stewardess and five passengers were seriously injured while all 15 other occupants, among them both pilots, were killed.
Probable cause:
The captain took the decision to make a sharp turn to the left at 73 knots without considering the turn radial and the rising terrain, which resulted in a continuous stall warning during the remaining 12 seconds of flight. The left hand wing of the aircraft struck a rock and the aircraft crashed. The decision of the captain to initiate a turn to the left at this stage of the flight was against all published procedures. It was reported that the commander was a senior flight instructor employed by the Civil Aviation Authority of Nepal.

Crash of an Antonov AN-24RV in Galkayo

Date & Time: Apr 28, 2012 at 1433 LT
Type of aircraft:
Operator:
Registration:
3X-GEB
Survivors:
Yes
Schedule:
Hargeisa - Galkayo
MSN:
3 73 084 03
YOM:
1973
Flight number:
6J711
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Hargeisa, the crew started the descent to Galkayo-Abdullahi Yusuf Airport runway 05L. On short final, at a height of about 5-7 feet, the captain spotted an animal crossing the runway from left to right. He attempted to extend the flare in order to avoid a collision but the aircraft subsequently touched down hard and bounced several times. Out of control, it veered off runway and came to rest with both wings partially detached. All 36 occupants evacuated safely while the aircraft was damaged beyond repair.

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: