Abstract
The case study on Airblue chronicles the events that led to the biggest plane crash in the aviation history of Pakistan. Airblue flight 202 destined from Karachi to Islamabad crashed while attempting to land under adverse weather conditions. The flight carried 146 passengers and 6 crew members; all died in the crash. Later investigations identified gross errors in judgment and decision making by the cockpit crew and unprofessional attitude as the sole cause of the crash.
The case study documents the events that unfolded prior to the crash and identifies a number of major factors that are important while communicating and making decisions under critical situations. It touches upon the themes of superior-subordinate communication and relationships, empowerment, sense of responsibility under life-threatening situations, making sense of crises, the role of initiative, self-confidence, and reliance on others. The case is suitable to be taught on topics dealing with communication, decision making, teamwork, and leadership in crises, at the graduate level (MBA) and in executive training courses on team building, leadership and crisis management. It highlights the situations which emerge as crises and where teamwork is paramount for the effective achievement of goals. Furthermore, it focuses on the possible relapses when effective teamwork and communication are not in play.
Discussion Questions
What were the possible immediate factors that led the flight to crash? What specific incorrect decisions were taken?
What could be identified as the latent factors that were the real reasons behind the apparent factors?
What should be the error prevention and management strategies when faced with critical situations and when standard procedures are not followed?
What is the importance of observing SOPs under critical situations? Under what circumstances pilots are likely to deviate from the standard course of action. Should airlines ensure that the SOPs are strictly followed? Should they be penalized for not following the procedures even if it causes no accidents?
What is the relevance of a case on aeroplane disaster to the world of business and management?
On the morning of July 28, 2010, Airblue flight 202 flew from Karachi, Pakistan, with 146 passengers and six crew members. As it approached its destination, the flight encountered poor weather and tried to land at the Benazir Bhutto International Airport, Islamabad, Pakistan. Due to monsoon rain, thick clouds, and fog there was extremely low visibility, the aeroplane drifted off and crashed in the Margalla Hills, 9.6 nautical miles 1 (NM) north of the airport at an altitude of 2,858 feet above sea level. 2 The plane caught fire instantly upon impact and crashed along the steep slopes of the mountain which was densely covered with trees. All passengers and crew members died on the spot.
It was the worst disaster in the commercial aviation history of Pakistan (Appendix B). The Civil Aviation Authority of Pakistan (CAA) came under heavy criticism by civil society and the media, demanding stringent action and preventive measures. The Government of Pakistan immediately ordered CAA to investigate the accident, determine its causes, and prevent the recurrence of such tragic disasters. As the president of the Safety Investigation Board of CAA read the detailed investigation report that included cockpit conversations recovered from the black box of the aeroplane and other essential information about the crew and the flight and about the circumstances that led to the crash, he started thinking about the steps that needed to be taken in order to avert such catastrophes in the future.
Civil Aviation Authority
Civil Aviation Authority (CAA), a public sector autonomous body, worked under the Ministry of Defence which reported to the Federal Government of Pakistan. Nearly all civilian airports in Pakistan were owned and operated by CAA. This autonomous body performed civil aviation-related activities, including the regulatory and safety controls, air traffic services, airport management, and infrastructure and commercial development. 3
The major regulatory functions performed by CAA included implementation and monitoring of a safety management system, checking the airworthiness of aircraft, flight inspection, and licensing (including the medical requirements of the pilots and their flying licenses). CAA also operated a training institute that conducted training on air traffic, engineering, fire control, and communication management throughout the year. A Safety Investigation Board was responsible for the control of accidents and incidents relating to air traffic.
CAA’s air traffic services included managing the air traffic through radar and controllers, maintaining the air transport flight management system, fire and safety at airports, and managing environmental hazards. Air traffic was controlled by ground-based controllers who directed aircraft on the ground and through a controlled airspace. They separated aircraft along different flight paths to prevent collisions, organized and expedited the flow of air traffic in the air and on the ground, controlled landings and takeoffs and provided crucially required weather and navigation information and other support services to pilots.
Air Traffic Control at the Islamabad Airport
As aircrafts entered the extended airspace of the Islamabad airport, a panel of radar controllers monitored them through radar, providing necessary navigational and other information as well as flight instructions. At Islamabad airport, the radar controllers monitored flights within a radius of 25 NM from the airport. 4 Within the airport’s immediate vicinity, the staff stationed at the control tower monitored and controlled takeoffs and landings, providing pilots with precise instructions. The primary method of controlling the immediate environment at Islamabad airport was a visual observation from the control tower, with assistance from radar controllers if needed.
Airblue
Airblue, a private-sector airline, started its operations in 2004 and was Pakistan’s second-largest and fastest-growing airline with over 20% share of the domestic market. It operated an all-Airbus A320-family aircraft fleet, aircraft having an average age of 7.9 years. 5 Airblue provided scheduled air service to 10 domestic and international destinations and received the ‘Best Pakistani Airline’ award by the consumer association of Pakistan in 2011. 6
The Aircraft
The aircraft A-321 was a stretched version of the single-aisle, short and medium-haul A-320 passenger plane, one of the most widely used jetliners in the world built by European plane maker Airbus (refer to Figure 1).
The aircraft typically accommodated 185 passengers in a two-class configuration (16 in first class and 169 in the economy class). 7 The flight 202 plane was manufactured in 2000 and was leased to Airblue in 2006. It had carried out 13,566 flights and accumulated 34,018 flight hours in service. 8 The aircraft was maintained properly according to the applicable aviation regulations.
Crew
Captain Pervez Iqbal Chaudhry, the pilot of flight 202, was the youngest sibling of five brothers and sisters. He was 61, 9 married, and had four sons, one daughter, and five grandchildren. In his 35 years of professional flying experience, he accumulated over 25,497 flight hours, 1,060 in the Airbus A-320. He joined Airblue after retiring from Pakistan International Airlines (the national airline of Pakistan) in 2008. 10 Pervez Chaudhry was scheduled the night before to fly the fateful flight due to the absence of the previously scheduled pilot. He’d earlier flown in from Italy which meant that he had taken the minimum prescribed rest.
First Officer Muntajib Chughtai, the co-pilot, was 34 years old. He was an ex-air force squadron leader, having flown F-16 fighter jet. 11 He had flown 1,837 hours, out of which 286 were on A-320.
The cabin crew included air hostesses Umme Habiba, Shahzia Razzaq, Hina Usman and Nahid Bhatti. 12 All of the crew were certified by CAA and were qualified to operate in domestic as well as international airspace.
Boarding the Flight
Captain Chaudhry left home at 6:00
Almost fifteen minutes before departure, the boarding process was completed, and 146 passengers took their seats. The passenger list consisted of 110 men, 29 women, five children, and two infants, 13 including six members of the Youth Parliament of Pakistan, 14 three off duty flight attendants, and four foreign nationals. The crew started to prepare the flight for departure as the passengers looked outside the windows at the early morning operations of the Jinnah International Airport, Karachi, the biggest and busiest airport of Pakistan.
Takeoff
At 07:35 a.m., the pilot made his regulation announcement, greeting the passengers whilst reminding them to keep seated and fasten their seatbelts during takeoff. The cabin crew demonstrated safety procedures and checked the passengers to ensure that everyone was ready for takeoff. Soon afterwards, the aircraft started up and was pushed back on the tarmac by ground crew.
Twenty-one-year-old Syeda Rabab Zehra Naqvi, sitting in her aisle seat before switching off her mobile, messaged her father that her flight was ready for takeoff from Karachi. Accompanied by five fellows parliamentarians, Rabab was on her way to attend the fifth session of the Youth Parliament in Islamabad. Five rows in front of her sat a newly married couple, Owais and Romaisa Khan, en route their honeymoon.
Down the aisle sat Abdul Ghani’s son, daughter-in-law and three grandchildren, while further down, in the 21st row sat Ali Sherazi, with a promising public relations career. 15
The passengers sitting in the window seats started gazing at their surroundings for signs of activity in anticipation of takeoff. Soon after the aircraft aligned itself with the runway, the pilot applied maximum thrust to takeoff, the engines roared, and the flight took to air at 07:41 a.m., three minutes ahead of its scheduled takeoff.
For a few minutes, the passengers were silenced by the noise and acceleration of the takeoff, some offering prayers for a safe journey. Everything came to life after a while as the seatbelt signs turned off. In minutes, the flight reached its cruising altitude of 33,000 feet and travelled towards Islamabad at a cruise speed of 600 km/hr. Although not a necessity, most passengers felt it obligatory to unfasten their seatbelts; some even got up to roam around in the densely packed passenger cabin. The flight attendants were already prepared and started serving passengers breakfast; tea with croissants.
At the time of departure, the weather had been pleasant. In the extremely hot climate of Pakistan, clouds and rains were heartily welcomed. The cheerful atmosphere of the passenger cabin reflected the outside weather. Everybody hoped that the weather in Islamabad would be cool and breezy, as it appeared so to those who looked outside the windows and saw clouds as far as the eye could see.
On the other hand, for pilots, the conditions for the flight were not good. The wind was blowing, and it was cloudy and rainy. The cockpit crew was intently watching the weather updates coming from their destination through cockpit monitors, and what they saw did not augur well.
Planning for the Landing
Coming from Karachi, located 620 NM south of Islamabad, the pilots had thought that the easiest approach to the landing strip would be in the direction of the flight. Approaching the airport from the south, it would have required taking a slight turn to the left and then landing directly onto the strip. The runway at Islamabad airport could also service planes coming from the north by allowing them to land directly through the northern side of the strip. The southern side of the landing strip was designated as Runway-30 and the northern side as Runway-12, approximating the degrees of angles on which the strip was located (refer to Figure 2).
Runway-30 was also equipped with the Instrument Landing System (ILS) that precisely guided an aircraft through the entire landing sequence, making the pilot’s job much easier. ILS was extremely useful under poor weather conditions. Runway-12 was not equipped with an ILS (refer to Appendix C for a description of ILS).
One hour into the flight, the plane maintained its altitude at 33,000 feet, 155 NM from the destination. During the intervening time, the pilot had been intermittently inquiring the co-pilot about the technical details of flying and had been advising and lecturing him on snobbish tone and harsh words. As they were talking, the pilots received information from the Islamabad airport that due to the poor weather conditions, Runway-30 was unavailable; hence the flight had to land on Runway-12, through visual circling approach (which required pilots to maintain visual contact with the runway while circling it, refer to Figure 2). Runway-30 was unavailable because of the fast wind blowing in the direction of the travel that could increase the landing speed and landing distance, consequently endangering the flight to overshoot the runway.
Weather Conditions
Close to the airport, winds were blowing from south-east to north-east with changing directions; wind speed ranged from 20 to 40 knots, 16 gusting up to 65 knots or more. The low visibility was not helping either, with multiple layers of scattered and dense clouds and fog between altitudes of 1,000 to 10,000 feet. Intermittent but intense thunderstorm and rain was also obstructing the view of the landing strip. Although the reported visibility was supposed to be around 1.5 km due to scattered dense clouds and rain, the actual visibility was 1 km or less in some areas. Due to these contributing factors, a weather warning was issued from 9:00 a.m., to 11:00 a.m., later extended to noon.
The pilots started thinking about how to deal with the weather in Islamabad. This did not only mean a turbulent and shaky experience for the passengers, but for pilots, the real question was whether to continue their journey or turn back. The weather at the destination was far away from ideal for landing, and the safety of passengers and crew was their top priority.
Approaching the Airport
The pilots discussed the inevitable change in their flight plan. Now they were required to approach the airport with the help of ILS to make visual contact with the airport, then circle the airport to reach the other side of the landing strip while maintaining visual contact with the airport, and finally hit the runway. The pilot started planning the path to landing and instructed the co-pilot to set flight path in the flight management guidance system by feeding four place-bearing-distance (PBD) waypoints, 17 contrary to the prescribed procedures for landing through the visual circling approach.
Pilot: ‘From abeam Runway-30, 3 to 5 miles abeam CF, then we go abeam CF and then landing’.
At 08:58 a.m., the pilot explained to the co-pilot how he planned to land. The pilots had received information about the weather and knew that they had to land on Runway-12. They planned to approach Runway-30 through ILS, fly across the airport while maintaining a distance of 3 to 5 NM from the runway centreline, and turn back to land on Runway-12. The prescribed procedure was required to maintain a maximum distance of 1.3 NM.
Pilot: ‘Right-Hand Downwind 18 to Runway-12?’
The pilot had flown to Islamabad earlier and knew that there were Margalla Hills to the north of Runway-30 and a no-fly-zone about 6 NM from the airport. He inquired from the radar controller whether they could circle the airport from the southern side, keeping it in the view from the right side of the cockpit to approach the landing strip. It would have allowed the flight to steer away from the Margalla Hillside, which sharply rose several thousand feet from the ground. The radar controller denied the request.
The flight started its descent from the cruising altitude of 33000 feet at 08:58 a.m., Descending from height and passing through layers upon layers of dark clouds, the crew and passengers experienced the adversity of the weather first hand, and the pilots grew worried about the weather down below.
Radar Controller: ‘Expect arrival to ILS Runway-30, circle to land Runway-12’.
At 09:04 a.m., the radar controller instructed the crew to connect to ILS upon reaching the airport. This time the co-pilot, also worried after having experienced the ferocity of the weather, inquired, ‘right downwind Runway-12 for the approach?’ radar controller immediately replied in negative, ‘right downwind Runway-12 is not available at the moment because of low clouds’. The pilot acknowledged and said, ‘We understand right downwind is not available; it will be ILS down to minima and then left downwind, OK’, indicating that the crew was ready to circle the runway from the northern side.
Approaching the Runway
Almost 20 minutes later, the aircraft had descended to 4,300 feet; the radar controller cleared the crew to continue the descent to 3,900 feet. Less than a minute later, at an altitude of 3,700 feet, the aircraft established contact with ILS, both autopilots were engaged, and landing gears had been lowered, while the plane continued to descend and align itself with the Runway-30.
Pilot/Co-pilot: ‘How’s the weather right downwind?’
Still worried about flying in close proximity of Margalla Hills, the crew indicated their preference to land from the southern side, which had a much shallower hillside than the other side. The controller from the tower immediately declined, indicating that only the northern side was available for landing.
At 09:36:33 a.m., the pilot, becoming anxious to establish visual contact with the runway, tried to descend to 2,000 feet but was reminded abruptly by the co-pilot that the prescribed minimum altitude for the descent to Islamabad airport was 2,510 feet. 19 The pilot acknowledged and levelled the aircraft at the required altitude. Autopilot 2 was disengaged, and the crew flew the aircraft in the constant direction towards the Runway-30, waiting to see the airport. Both the pilots were extremely worried by the weather because they were approaching the runway threshold very fast and should have seen the airport by now.
At 09:37:26 a.m., the control tower confirmed the safe landing of another flight, PK-356. Only moments later, the pilots and control tower simultaneously made visual contact with each other; the control tower confirmed by calling ‘Visual’ and instructed the flight to circle the runway from north and land on Runway-12. The pilots breathed a sigh of relief as the plane was late in establishing visual contact. Now the plane started turning right as the pilot complied with the control tower’s instruction and commanded the right turn through autopilot while at the same time reducing the altitude to 2,300 feet. He had been thinking about whether to land or not; a recent landing gave him confidence, yet he also knew that another flight had been diverted back.
At 09:37:36 a.m., on the pilot’s command, the co-pilot activated the secondary flight plan, for which they had entered the 4 PBD waypoints more than half an hour earlier.
Turning Away from the Airport
Tower Controller: ‘Fly a bad weather circuit.’
At 09:37:54 a.m., as the plane started its flight away from the runway after turning right, the control tower suggested the crew maintain a very close distance from the airport while circling it.
Pilot: ‘Let him say whatever he wants to say.’
By this time, the pilot was already committed to land following the flight path programmed earlier into the aeroplane computers, so he asked the co-pilot to ignore the suggestion.
Co-pilot: ‘Okay, Sir, but are you visual?’
The co-pilot was sitting on the right side of the cockpit and could not see across the left window of the aircraft. He inquired anxiously while agreeing with the pilot to ignore the suggestion of tower control.
Pilot: ‘Visual Hein! OK.’ (We have visual! Ok)
The pilot reassured the co-pilot that he could see the airport and reminded him to get prepared to follow the planned landing routine as they followed the programmed flight path.
The pilot had planned to fly the visual circling approach using autopilot in the navigation mode, for which the crew had fed the directions some time ago (refer to Appendix D for a description of flying the plane in the autopilot mode). In trying to maintain visual contact with the runway, the pilot had forgotten to switch the autopilot into navigation mode. The plane continued flying in the direction of 352 degrees toward the north, the path it had taken while turning right a few moments ago to begin circling the runway.
At 09:39:32 a.m., the aircraft had flown away more than 3.5 NM from the centreline of the runway, very close to the prescribed maximum limit of 4.3 NM. The crew commanded a left turn to 300 degrees through the autopilot to align the flight path parallel to the runway.
Drifting Away
At 09:39:43 a.m., the crew realized that the autopilot was still engaged in the heading mode, hence, they switched to the navigation mode. By that time, the plane was already past the prescribed circling procedures for the Islamabad airport. It continued deviating from the prescribed flight path and headed toward the Margalla Hills at the speed of 180 knots. At this moment, the aircraft was just 3 NM away from the hills shrouded in clouds and less than 1 NM from a no-fly-zone comprising the Federal Parliament Building, the Presidency, and the Consulates of dozens of foreign nations. A few moments later, the crew received instructions from the control tower to immediately turn left to avoid entering the no-fly-zone. The crew thought that they had already initiated a left turn some moments ago.
Alarm: ‘Terrain Ahead! … Terrain Ahead!’
At 09:39:58 a.m., almost 12 seconds later, the enhanced ground proximity warning system of the aircraft (EPGWS) predicted that the current flight path would take the aircraft dangerously close to rising terrain ahead and issued audible cautions in quick succession (refer to Appendix E for the emergency procedures upon EGPWS alerts).
Co-pilot: ‘Sir, the higher ground has reached. Sir, there is terrain ahead. Sir, turn left.’
The co-pilot alerted the pilot after hearing the cautions. The crew was very stressed and confused as to how things had unfolded in the last few seconds. First, the no-fly-zone alert from the control tower and now a couple of terrains ahead warnings; to top things off, next to zero visibility. They had already commanded the plane to turn left and never expected to encounter higher ground along the path they had programmed the plane to fly.
Tower Controller: ‘Airblue 202, do you have visual?’
At 09:40:10 a.m., the control tower asked the pilots. The air traffic controller at the control tower could not spot the aircraft flying across the runway. So he inquired from radar controllers the whereabouts of the plane. The radar controller asked the air traffic controller to confirm whether the pilots could see the airport and instruct them to climb and re-attempt to land if they were not visual.
Co-pilot: ‘Kia batauon Sir?’ (What should I tell him, Sir?)
The co-pilot was clueless at this time and asked the pilot if he could see the airport through the side window.
Tower Controller: ‘I repeat; Airblue 202 do you have visual?’
The control tower asked again when the pilots did not respond the first time.
Pilot/Co-pilot: ‘Airblue 202 visual with the ground.’
At 09:40:16 a.m., both pilots responded affirmatively as their voices were masked by another couple of ‘Terrain Ahead’ cautions.
Co-pilot: ‘Sir, terrain ahead is coming.’
Pilot: ‘Yes, we are turning left.’
The pilot replied to the warning of the co-pilot, thinking that he had already taken the desired action and it was only a matter of moments that the plane would be on a safe path toward the landing.
Alarm: ‘Terrain Ahead.’
At 09:40:26 a.m., the alarm system cautioned again, jolting the pilot into action. He frantically started looking at the control panel in front of him, trying to figure out what had gone wrong.
Click! At 09:40:28 a.m., after finally realizing that the plane was not turning left, the pilot switched the autopilot into heading mode while frenetically setting the direction anew to take a steeper left turn. At that point, the plane was heading in the direction of 307 degrees. The new setting required it to move toward the direction of 86 degrees. The autopilot optimized the approach to the new heading, and the aircraft started turning right instead of left, setting the flight into a direct collision course with Margalla Hills.
Alarm: ‘Terrain Ahead, PULL-UP.’
At 09:40:28 a.m., as the pilot switched to the heading mode, the warning system issued the first extremely serious warning demanding the crew to pull-up the aircraft to avoid an impending collision.
Co-pilot: ‘Sir, turn left, Pull-up Sir, Sir pull-up.’
At 09:40:30 a.m., the co-pilot dreadfully asked the pilot to turn left and pull-up the aircraft to avoid rising terrain, which was totally invisible in the midst of the clouds.
Alarm: ‘Terrain Ahead, PULL-UP.’
At 09:40:31 a.m., the warning system resounded in agreement with the co-pilot. A couple of seconds later, the pilot responded to the desperate pleas of the co-pilot and started pulling up the aircraft by increasing the thrust of the engines (refer to Appendix D for a description of thrust levers). However, he was still not sure what to do and did not follow the correct procedure prescribed under such situations. Instead of applying the maximum thrust (as applied during takeoff), the pilot kept the thrust at a relatively reduced level. Neither did he disengage the autopilot and pitch the side-stick fully backwards to pull-up the nose of the aeroplane (refer to Appendix D for a description of flying the plane manually).
Alarm: ‘Terrain Ahead, PULL-UP!’
At 09:40:34 a.m., the system continued its warnings as the pilot was still trying to comply with the ultimatum of the warning system. The very next second, the desired altitude was set to 3,700 feet. It worked, and the aircraft quickly started to gain speed and altitude while still turning to the right toward the hills.
Alarm: ‘Terrain Ahead, PULL-UP!’
At 09:40:37 a.m., the warning system continued to issue an alarm, as it was designed to do until the plane was ultimately out of danger.
At 09:40:39 a.m., after only a few seconds of the climb, the pilot moved the thrust levers a notch backwards to engage auto-thrust in climbing mode. He further set the altitude at 3,100 feet. Another ‘Terrain Ahead, PULL-UP!’ alert pierced through the cockpit. Meanwhile, the aircraft was still turning right, towards higher and higher hills. Amidst the panic created by multiple warnings, the pilot had again reset the direction to 25 degrees. Though it could not turn the plane to its safety, the new direction reduced the rate of a turn toward the right, providing a few precious moments to the pilots.
Co-pilot: ‘Sir, PULL-UP!’
At 09:40:41 a.m., the co-pilot implored the pilot that his efforts to climb the aircraft to a higher altitude were still insufficient. Just seconds later, multiple ‘Terrain Ahead, PULL-UP!’ warnings resounded in agreement.
At 09:40:46 a.m., as the plane rolled 25 degrees toward the right, the pilot finally decided to fly the plane himself. He disengaged the autopilot and pushed the control side-stick maximum toward the left while simultaneously pressing the left rudder pedal 6 degrees (refer to Appendix D on the manual controls to manoeuvre the aircraft). The plane had reached an altitude of 2,770 feet and was going up as it changed its direction and started turning left.
Pilot: ‘Left turn kiun naheen kar raha yar?’ (Why is the aircraft not turning left?)
At 09:40:49 a.m., the pilot, trying to figure out his failure in controlling the aircraft, sought the help of the co-pilot, who was looking out of the front windshield into the gaping darkness of the black morning that had engulfed the aeroplane. The alarm system continued shrieking out a warning after warning to pull-up in order to bring the crew back to their senses to do something to save the 152 souls on board.
Alarm: ‘Terrain Ahead, PULL-UP! Terrain Ahead, PULL-UP! Terrain Ahead, PULL-UP!’
At 09:40:52 a.m., the plane had rolled 30 degrees to the left, and the auto-thrust in climb mode was pushing the aircraft up by 15 degrees. Amidst blinding mist, dense clouds, drizzling rain and gushing winds, the aircraft continued to turn left and climb higher and higher, taking the crew closer and closer to their goal of avoiding possible collision with the hills that lay ahead in their path.
The pilot continued his struggle to manoeuvre the aircraft through a mix of desperate moves and pitched the plane nose downward. As the plane started pitching downward, it caught speed; the auto-thrust system kicked in to compensate by spooling down the engines to maintain airspeed on target.
At 09:40:58 a.m., the flight had reached an altitude of 3,110 feet but started going down afterwards while also rolling further toward the left.
Alarm: ‘Terrain Terrain!’
At 09:41:01 a.m., indicating that the current altitude was insufficient, the alarm system announced the high alert warning, predicting close proximity to incoming terrain. Detecting an increase in the alert level, the co-pilot called out ‘Terrain Sir!’ to the pilot, who had now rolled the aeroplane to an extreme limit of 52 degrees to the left. The plane continued losing its altitude, its nose down by 4.6 degrees.
Alarm: ‘Terrain Ahead, PULL-UP!’ ‘PULL-UP!’ ‘PULL-UP!’
At 09:41:03 a.m., warnings, coupled with the co-pilot’s worried calls, shocked the pilot of the extreme proximity of the aeroplane to Margalla Hills. He made the last-ditch effort to pull-up the aircraft, but it was insufficient to arrest the descent.
Co-pilot: ‘Sir, we are going down. Sir, we are going da…’.
At 09:41:06 a.m, the control tower lost contact with the aeroplane while commanding the crew to turn left immediately. A few minutes later, reports of a large explosion and fire started coming from inhabitants living close to the Margalla Hills (see Figure 3).
Soon afterwards, it was ascertained that the aeroplane had crashed at an altitude of 2,858 feet amidst dense forest on Margalla Hills facing Islamabad. The site of the crash was very close to the 11th PBD waypoint (refer to Figure 4). Search and rescue attempts were carried out under extreme weather conditions, but no one could be saved. Everyone on board had perished in the crash. The rain helped put down the flames.
As the president of the Safety Investigation Board of CAA completed reading the draft of the investigation report, he could hardly stop thinking about the reasons that led to the tragic accident and what measures CAA could put in place to avoid such disasters in the future. It was early March 2011, and the investigation report determining the causes of the accident and prescribing appropriate recommendations had to be submitted to the Government of Pakistan very soon. The president started noting down the remedial measures and steps he could discuss with the board for approval and implementation.
Footnotes
Notes
* The case study is based primarily on the investigation report by the Safety Investigation Board of Civil Aviation Authority (CAA), available on the CAA website.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.