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    Airblue 202 ACI Presentation

    Uploaded by

    Vikram Surana
    The document summarizes the investigation report into the 2010 crash of Airblue Flight 202 near Islamabad, Pakistan that killed all 152 people on board. The report found that poor crew resource management (CRM) and situational awareness by the pilots caused them to ignore warnings and fly into rising terrain. Contributing factors included poor communication between air traffic control and the pilots once visual contact was lost due to bad weather. Safety recommendations focused on improving CRM training, establishing better instrument landing procedures, enhancing aviation safety management systems, and improving emergency response capabilities.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Airblue 202 ACI Presentation

    Uploaded by

    Vikram Surana
    432 views23 pages
    The document summarizes the investigation report into the 2010 crash of Airblue Flight 202 near Islamabad, Pakistan that killed all 152 people on board. The report found that poor crew resource management (CRM) and situational awareness by the pilots caused them to ignore warnings and fly into rising terrain. Contributing factors included poor communication between air traffic control and the pilots once visual contact was lost due to bad weather. Safety recommendations focused on improving CRM training, establishing better instrument landing procedures, enhancing aviation safety management systems, and improving emergency response capabilities.

    Original Description:

    Aircrash Investigation Air Blue 202 - Investigation Report Analysis

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    The document summarizes the investigation report into the 2010 crash of Airblue Flight 202 near Islamabad, Pakistan that killed all 152 people on board. The report found that poor crew resource management (CRM) and situational awareness by the pilots caused them to ignore warnings and fly into rising terrain. Contributing factors included poor communication between air traffic control and the pilots once visual contact was lost due to bad weather. Safety recommendations focused on improving CRM training, establishing better instrument landing procedures, enhancing aviation safety management systems, and improving emergency response capabilities.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    432 views23 pages

    Airblue 202 ACI Presentation

    Uploaded by

    Vikram Surana
    The document summarizes the investigation report into the 2010 crash of Airblue Flight 202 near Islamabad, Pakistan that killed all 152 people on board. The report found that poor crew resource management (CRM) and situational awareness by the pilots caused them to ignore warnings and fly into rising terrain. Contributing factors included poor communication between air traffic control and the pilots once visual contact was lost due to bad weather. Safety recommendations focused on improving CRM training, establishing better instrument landing procedures, enhancing aviation safety management systems, and improving emergency response capabilities.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 23
    At a glance
    Powered by AI
    The key takeaways are that the crash of Airblue flight 202 was caused by poor crew resource management and loss of situational awareness by the pilots, leading them to fly into the Margalla mountains while attempting a visual approach in marginal weather conditions.

    The key events of the crash were that the Airbus A321 was flying from Karachi to Islamabad with 152 people on board. While attempting a circling approach to land at Islamabad airport, the pilots flew into the Margalla mountains, likely due to losing sight of the runway in clouds/fog and not following proper procedures.

    The report concluded that the probable causes of the crash were poor CRM, pilot error, marginal weather conditions, and loss of situational awareness and control by the pilots.

    1

    Airblue 202 Crash


    Vikram Surana

    Air Blue 202

    FirstRemember
    The sole objective of the investigation of an accident
    or incident shall be the prevention of accidents and
    incidents. It is not the purpose of this activity to
    apportion blame or liability
    Annex 13, Chapter 3
    BUT

    Air Blue 202

    Summary

    Airblue Airbus A321(AP-BJB)


    Flying from Karachi to Islamabad (Domestic)
    152 TOB including 6 Crew
    Flew into Margalla mountains while executing a
    circle to land approach for Rwy 12 at 04:41 UTC

    Air Blue 202

    A closer Look
    on the
    approach Plate

    Air Blue 202

    Airport Surroundings

    Air Blue 202

    Factual
    Information 1
    History of Flight (Crash)
    Injuries to persons (All Perished)
    Damage to Aircraft (Destroyed)
    Other Damages (Greenery / Forest)
    Flight Crew information (Experienced & Fit to Fly)
    Aircraft Information (Was Airworthy)
    Meteorological Information (3500m Visibility / Clouds)
    Aids to Navigation (ILS, VOR
    Air Blue 202

    Factual Information 2
    Aerodrome Information (Types of approaches & numbers)
    Flight Data Recorders (Contained full flight information)
    Wreckage & impact information
    Fire (No Fire Fighting, but rain)
    Survival Aspects (No ELT mentioned)

    Air Blue 202

    What does the Procedures Say ?

    Air Blue 202

    Factual Information Deficiencies


    Extra A320 explanations (FMS / EGPWSetc.)
    ICAO recommended sequencing was not followed
    Medical and Pathological information was not up to
    expectations
    Communications part was not clear (whos responsible?)
    Organizational and management Information
    No consideration of Pilots activities prior to the flight.

    Air Blue 202

    10

    Critical Analysis - 1
    Report concludes the following to be responsible for the
    disaster:
    a. Poor CRM
    b. Pilot Error
    c. Marginal Weather
    d. Loss of Situational Awareness and control.
    Although the facts presented in the report strongly points
    towards the above mentioned reasons however I strongly feel
    there are few facts which are shadowed behind these facts and
    it becomes immensely important to try and understand such
    hidden facts which in turn might help us to understand few
    more probable reasons for the accident
    Air Blue 202

    11

    Critical Analysis - 2
    In the factual information on page 14 no. 5.8.5, it says:
    The Flight Recorders contained the complete flight
    data as well as cockpit voice recording for the entire
    flight duration from take off to crash.
    If the voice recording was available than why is the
    initial cockpit voice recording not shown in the report
    and never made public, as this conversation is
    described to be offensive, absurd and absolutely
    unacceptable and the investigation report believes
    that this is the reason why the FO became
    submissive.

    Air Blue 202

    12

    Critical Analysis - 3
    The Capt. might have taken it on his personal ego
    that a PIA aircraft had just landed before them and
    given the fact he was an ex air force and ex PIA
    Capt.
    The military culture still existed between the two
    crew members as both were from air force.

    Air Blue 202

    13

    Critical Analysis - 4
    The body of the first officer was taken away by the
    Air Blue staff and handed over to his family for burial
    even before the investigation team arrived as a
    result no autopsy/ postmortem was carried out for
    the first officers body and the Captains body was
    already shattered and burnt so there was no
    possibility to do that.

    Air Blue 202

    14

    Critical Analysis - 5
    Findings 10.2 on page 29 states that the Captain
    was scheduled only the night before but there is no
    information as to when the Capt. was informed to
    conduct the flight and how much rest he had before
    flight. There is a possibility that he was fatigued
    which in the report is briefly mentioned on page 32
    at 11.4 where it says that the chain of events started
    at commencement of the flight where the captain
    confused BBIAP (Islamabad) with JIAP (Karachi)
    while planning FMS and Khanpur lake with Khatua
    Area during holding pattern. Unfortunately the report
    never investigated on these lines which reveals
    there was on organizational failure and the report is
    trying to protect the organization.
    Air Blue 202

    15

    Critical Analysis - 6
    The Capt. was a religious guy as revealed from his company
    and colleagues and was probably fasting and praying for the
    whole night prior to the accident as 27th of July in 2010 was the
    15th of Shaban which is considered holy in the religion and
    people like to fast and pray contrary to what the factual
    information which states in 10.3 that they were not fasting at
    first place why do you need to put that point there.
    The role of ATC is not clearly stated in the facts however it
    reveals that the Capt. disregarded the ATC instruction to fly a
    bad weather circuit and decided to fly managed approach on a
    preselected PBD unbeknown to ATC
    At the same time ATC was unable to follow the traffic and give
    the crew the information about terrain in a timely manner.

    Air Blue 202

    16

    Critical Analysis - 7
    As per the article in Published in The Express Tribune,
    March 29th, 2013:
    Airblue
    crash re-investigation: ATC staff failed to navigate plane t
    o safety, reveals CAA report
    http://tribune.com.pk/story/528123/airblue-crash-re-invest
    igation-atc-staff-failed-to-navigate-plane-to-safety-revea
    ls-caa-report
    /

    Air Blue 202

    17

    Critical Analysis - 8
    As per the article posted on the internet by Geo News
    on the 24th of April 2012, one of the leading news
    channel in the country:
    Captain of crashed Air Blue flight ignored Air Traffic
    Controller: CAA
    http://
    www.geo.tv/article-45972-Captain-of-crashed-Air-Blue-fligh
    t-ignored-Air-Traffic-Controller-CAA

    Air Blue 202

    Conclusions as per CAA


    1. AC is airworthy
    2. Poor weather condition
    3. 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.
    4. The chain of event started when Captain confused Islamabad with Karachi. This state
    continued when Captain ignored the circling approach
    5. Aircrew captain not only clearly violated 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).
    6. 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.
    7. Description of ATS Radar and Air crew actions, in poor visibility conditions
    8. 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
    9. 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
    Air Blue 202
    PULL UP

    18

    Cause of the accident and


    contributing factor

    19

    Probable Cause:
    Poor CRM and no situational awareness made Aircrew fail to operate
    in the adequate manner.

    Contributing Factors
    o Air Traffic Control and AC had failure to communicate in time effective
    manner once the AC lost sight of the runway:
    o Poor weather condition
    o Failure to establish standard operating procedure of ATS and Radar
    o Failure to react on EGPWS alarm in proper and timely effective manner by
    the Captain and First Officer

    Air Blue 202

    Safety Recommendations as per the


    Report - Part 1
    1. All aircrew be re-briefed on CFIT avoidance and Circling Approach
    procedures and a strict implementation of this procedure be ensured
    through an intensive monitoring system.
    2. Aircrew scheduling and pairing being a critical subject be preferably
    handled / supervised by Flight Operations.
    3. The implementation of an effective CRM program be ensured and the
    syllabus of CRM training be reviewed in line with international
    standards.
    4. Existing aircrew training methodology be catered for standardization
    and harmonization of procedures.
    5. Human factor / personality profiling program for aircrew be introduced
    to predict their behavior under crises.
    6. Instrument landing procedure for RWY-12 be established, if possible.
    7. Safety Management System be implemented in ATS as per the spirit of
    the ICAO document (doc. 4444).
    Air Blue 202

    20

    Safety Recommendations as per


    the Report Part 2
    8. New Islamabad International Airport (NIIA) be completed and made functional
    on priority.
    9. Visual augment system (Approach Radar Scope) be installed in control tower to
    monitor the positions and progress of aircraft flying in the circuit.
    10. Review of the existing Regulations for the compensation and their expeditious
    award to the legal heirs of the victims be ensured.
    11. Adequacy of SIB resources comprising qualified human resource and equipment
    be reviewed.
    12. Information to public on the progress of the investigation process through the
    media by trained / qualified investigators of SIB be ensured on regular
    intervals.
    13. NDMA be tasked to acquire in-country airlift capability for removal of wreckage
    from difficult terrain like Margalla etc. As an interim arrangement, some
    foreign sources be earmarked for making such an arrangements on as and when
    required basis.
    14. Civil Police Department be tasked to work out and ensure effective cordoning
    and onsite security arrangements of crashed aircraft wreckage at all the places
    specially remote / difficult hilly locations.
    15. Environment Control Department be directed to recover the ill effects of
    Air Blue 202
    deterioration / damages caused to Marghalla hill due to the crash.

    21

    22

    What Should Have Been there


    RADAR vectoring procedures shall be established for all
    runways especially in the marginal weather conditions.
    The wreckage and human bodies should not be touched
    until investigation team arrives.

    Air Blue 202

    23

    Any Questions ?

    Air Blue 202

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