Airblue 202 ACI Presentation

7/24/2019 Airblue 202 ACI Presentation

1/23

Airblue 202 Crash

Vikram Surana

Air Blue 202

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2/23

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

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3/23

Summar Airblue Airbus A321!A"#B$B%

Flin& 'r(m )ara*hi t( +slamaba !-(mesti*%

1.2 T/B in*luin& Cre

Fle int( ar&alla m(untains hile exe*utin& a*ir*le t( lan appr(a*h '(r R 12 at 041 UTC

Air Blue 202

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4/23

A *l(ser 5((k

(n theappr(a*h "late

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5/23

Airp(rt Surr(unin&s

Air Blue 202

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6/23

Fa*tual

+n'(rmati(n 1

6ist(r (' Fli&ht !Crash%

+n7uries t( pers(ns !All "erishe%

-ama&e t( Air*ra't !-estr(e%

/ther -ama&es !8reener 9 F(rest%

Fli&ht Cre in'(rmati(n !:xperien*e ; Fit t( Fl%

Air*ra't +n'(rmati(n !


7/23

Fa*tual +n'(rmati(n 2

Aer(r(me +n'(rmati(n !Tpes (' appr(a*hes ; numbers%

Fli&ht -ata Re*(rers !C(ntaine 'ull 'li&ht in'(rmati(n%


8/23


9/23

Fa*tual +n'(rmati(n -e'i*ien*ies

:xtra A320 explanati(ns !FS 9 :8"


10/23

Criti*al Analsis # 1Rep(rt *(n*lues the '(ll(in& t( be resp(nsible '(r the

isaster4

a "((r CR

b "il(t :rr(r

* ar&inal e menti(ne reas(ns h(e>er + str(n&l 'eel

there are 'e 'a*ts hi*h are sha(e behin these 'a*ts an

it be*(mes immensel imp(rtant t( tr an unerstan su*h

hien 'a*ts hi*h in turn mi&ht help us t( unerstan 'e

m(re pr(bable reas(ns '(r the a**ient

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11/23

Criti*al Analsis # 2

+n the 'a*tual in'(rmati(n (n pa&e 1 n( .., it sas4

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 theinitial 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.

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12/23

Criti*al Analsis # 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 militar culture still existed between the two

crew members as both were from air force.

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13/23

Criti*al Analsis #

The bod of the first officer was taken awa b the

Air !lue staff and handed over to his famil for burial

even before the investigation team arrived as a

result no autops" postmortem was carried out for

the first officer#s bod and the Captain#s bod was

alread shattered and burnt so there was no

possibilit to do that.

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14/23

$indings %&.' on page '( states that the Captain

was scheduled onl the night before but there is noinformation as to when the Capt. was informed to

conduct the flight and how much rest he had before

flight. There is a possibilit that he was fatigued

which in the report is briefl mentioned on page )'at %%.* where it sas that the chain of events started

at commencement of the flight where the captain

confused !!IAP +Islamabad, with -IAP +arachi,

while planning $/0 and hanpur lake with hatua

Area during holding pattern. 1nfortunatel the report

never investigated on these lines which reveals

there was on organi2ational failure and the report is

tring to protect the organi2ation.

Criti*al Analsis # .

Air Blue 202

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15/23

Criti*al Analsis # The Capt. was a religious gu as revealed from his compan

and colleagues and was probabl fasting and praing for thewhole night prior to the accident as '3thof -ul in '&%& was the

%4thof 0haban which is considered hol in the religion and

people like to fast and pra contrar to what the factual

information which states in %&.) that the were not fasting at

first place wh do ou need to put that point there.

The role of ATC is not clearl stated in the facts however it

reveals that the Capt. disregarded the ATC instruction to fl a

bad weather circuit and decided to fl managed approach on a

preselected P!5 unbeknown to ATC

At the same time ATC was unable to follow the traffic and give

the crew the information about terrain in a timel manner.

Air Blue 202

1.


16/23

Criti*al Analsis # ?

As per the arti*le in Published in The Express Tribune,

arch !"th, !#$%&

Airblue

*rash re#in>esti&ati(n4 ATC sta'' 'aile t( na>i&ate plane t( sa'et, re>eals CAA rep(rt

http499tribune*(mpk9st(r9.21239airblue#*rash#re#in>est

i&ati(n#at*#sta''#'aile#t(#na>i&ate#plane#t(#sa'et#re>ea

ls#*aa#rep(rt9

Air Blue 202

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http://tribune.com.pk/story/528123/airblue-crash-re-investigation-atc-staff-failed-to-navigate-plane-to-safety-reveals-caa-report/http://tribune.com.pk/story/528123/airblue-crash-re-investigation-atc-staff-failed-to-navigate-plane-to-safety-reveals-caa-report/http://tribune.com.pk/story/528123/airblue-crash-re-investigation-atc-staff-failed-to-navigate-plane-to-safety-reveals-caa-report/http://tribune.com.pk/story/528123/airblue-crash-re-investigation-atc-staff-failed-to-navigate-plane-to-safety-reveals-caa-report/http://tribune.com.pk/story/528123/airblue-crash-re-investigation-atc-staff-failed-to-navigate-plane-to-safety-reveals-caa-report/http://tribune.com.pk/story/528123/airblue-crash-re-investigation-atc-staff-failed-to-navigate-plane-to-safety-reveals-caa-report/http://tribune.com.pk/story/528123/airblue-crash-re-investigation-atc-staff-failed-to-navigate-plane-to-safety-reveals-caa-report/http://tribune.com.pk/story/528123/airblue-crash-re-investigation-atc-staff-failed-to-navigate-plane-to-safety-reveals-caa-report/http://tribune.com.pk/story/528123/airblue-crash-re-investigation-atc-staff-failed-to-navigate-plane-to-safety-reveals-caa-report/http://tribune.com.pk/story/528123/airblue-crash-re-investigation-atc-staff-failed-to-navigate-plane-to-safety-reveals-caa-report/http://tribune.com.pk/story/528123/airblue-crash-re-investigation-atc-staff-failed-to-navigate-plane-to-safety-reveals-caa-report/http://tribune.com.pk/story/528123/airblue-crash-re-investigation-atc-staff-failed-to-navigate-plane-to-safety-reveals-caa-report/http://tribune.com.pk/story/528123/airblue-crash-re-investigation-atc-staff-failed-to-navigate-plane-to-safety-reveals-caa-report/http://tribune.com.pk/story/528123/airblue-crash-re-investigation-atc-staff-failed-to-navigate-plane-to-safety-reveals-caa-report/


17/23

Criti*al Analsis #

As per the arti*le p(ste (n the internet b 8e( =es

(n the 2th(' April 2012, (ne (' the leain& nes

*hannel in the *(untr4

Captain of crashed ir !lue flight ignored ir TrafficController" C

http499

&e(t>9arti*le#.?2#Captain#('#*rashe#Air#Blue#'li&h

t#i&n(re#Air#Tra''i*#C(ntr(ller#CAA

Air Blue 202

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http://www.geo.tv/article-45972-Captain-of-crashed-Air-Blue-flight-ignored-Air-Traffic-Controller-CAAhttp://www.geo.tv/article-45972-Captain-of-crashed-Air-Blue-flight-ignored-Air-Traffic-Controller-CAAhttp://www.geo.tv/article-45972-Captain-of-crashed-Air-Blue-flight-ignored-Air-Traffic-Controller-CAAhttp://www.geo.tv/article-45972-Captain-of-crashed-Air-Blue-flight-ignored-Air-Traffic-Controller-CAAhttp://www.geo.tv/article-45972-Captain-of-crashed-Air-Blue-flight-ignored-Air-Traffic-Controller-CAAhttp://www.geo.tv/article-45972-Captain-of-crashed-Air-Blue-flight-ignored-Air-Traffic-Controller-CAAhttp://www.geo.tv/article-45972-Captain-of-crashed-Air-Blue-flight-ignored-Air-Traffic-Controller-CAA


18/23

C(n*lusi(ns as per CAA1 AC is air(rth

2 "((r eather *(niti(n

3 Th(u&h air*re Captain as 'it t( unertake the 'li&ht (n the mishap a, et hisp(rtrae beha>i(r an e''i*ien* as (bser>e t( ha>e eteri(rate ith thein*lement eather at BB+A" +slamaba

The *hain (' e>ent starte hen Captain *(n'use +slamaba ith )ara*hi This state*(ntinue hen Captain i&n(re the *ir*lin& appr(a*h

. Air*re *aptain n(t (nl *learl >i(late *ir*lin& appr(a*h but als( i n(t at all

ahere t( FC/ pr(*eures (' isplain& rea*ti(n 9 resp(nse t( timel an *(ntinu(usterrain an pull up arnin&s !21 times in ?0 se*(ns% G espite these >er l(u,*(ntinu(us an exe*uti>e *(mmans, the Captain 'aile t( re&ister the ur&en* (' thesituati(n an i n(t resp(n in kin !break ('' 9 pull (''%

F/ simpl remaine a passi>e bstaner in the *(*kpit an i n(t parti*ipate as ane''e*ti>e team member 'ailin& t( supplement 9 *(mpliment (r t( *(rre*t the err(rs ('his *aptain asserti>el in line ith the tea*hin&s (' CR ue t( CaptainDs beha>i(r inthe 'li&ht

? -es*ripti(n (' ATS Raar an Air *re a*ti(ns, in p((r >isibilit *(niti(ns

:nsuin& is*ussi(n an mutual situati(nal upate !(n lan line% *(ntinue an, in 'a*t,the ATC *all Hmessa&e 'r(m Raar immeiatel turn le'tI as th(u&h transmitte, butb the time the *all &(t transmitte, the air*ra't ha *rashe at the same time

The a**ient as primaril *ause b the air*re h( >i(late all establishepr(*eures '(r a >isual appr(a*h '(r Reral *alls b ATSC(ntr(llers an :8"


19/23

Cause (' the a**ient an

*(ntributin& 'a*t(r

"r(bable Cause4

"((r CR an n( situati(nal aareness mae Air*re 'ail t( (perate

in the aeuate manner

C(ntributin& Fa*t(rs

o Air Tra''i* C(ntr(l an AC ha 'ailure t( *(mmuni*ate in time e''e*ti>e

manner (n*e the AC l(st si&ht (' the runa4

o

"((r eather *(niti(no Failure t( establish stanar (peratin& pr(*eure (' ATS an Raar

o Failure t( rea*t (n :8"e manner b

the Captain an First /''i*er

Air Blue 202

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20/23

Sa'et Re*(mmenati(ns as per the

Rep(rt # "art 1

1 All air*re be re#brie'e (n CF+T a>(ian*e an Cir*lin& Appr(a*h

pr(*eures an a stri*t implementati(n (' this pr(*eure be ensure

thr(u&h an intensi>e m(nit(rin& sstem

2 Air*re s*heulin& an pairin& bein& a *riti*al sub7e*t be pre'erabl

hanle 9 super>ise b Fli&ht /perati(ns

3 The implementati(n (' an e''e*ti>e CR pr(&ram be ensure an the

sllabus (' CR trainin& be re>iee in line ith internati(nal

stanars

:xistin& air*re trainin& meth((l(& be *atere '(r stanariEati(n

an harm(niEati(n (' pr(*eures

. 6uman 'a*t(r 9 pers(nalit pr('ilin& pr(&ram '(r air*re be intr(u*et( prei*t their beha>i(r uner *rises

+nstrument lanin& pr(*eure '(r R


21/23

Sa'et Re*(mmenati(ns as per

the Rep(rt G "art 2

=e +slamaba +nternati(nal Airp(rt !=++A% be *(mplete an mae 'un*ti(nal(n pri(rit

Visual au&ment sstem !Appr(a*h Raar S*(pe% be installe in *(ntr(l t(er t(m(nit(r the p(siti(ns an pr(&ress (' air*ra't 'lin& in the *ir*uit

10 Re>ie (' the existin& Re&ulati(ns '(r the *(mpensati(n an their expeiti(usaar t( the le&al heirs (' the >i*tims be ensure

11 Aeua* (' S+B res(ur*es *(mprisin& uali'ie human res(ur*e an euipmentbe re>iee

12 +n'(rmati(n t( publi* (n the pr(&ress (' the in>esti&ati(n pr(*ess thr(u&h themeia b traine 9 uali'ie in>esti&at(rs (' S+B be ensure (n re&ularinter>als

13 =-A be taske t( a*uire in#*(untr airli't *apabilit '(r rem(>al (' re*ka&e

'r(m i''i*ult terrain like ar&alla et* As an interim arran&ement, s(me'(rei&n s(ur*es be earmarke '(r makin& su*h an arran&ements (n as an henreuire basis

1 Ci>il "(li*e -epartment be taske t( (rk (ut an ensure e''e*ti>e *(r(nin&an (nsite se*urit arran&ements (' *rashe air*ra't re*ka&e at all the pla*esspe*iall rem(te 9 i''i*ult hill l(*ati(ns

1. :n>ir(nment C(ntr(l -epartment be ire*te t( re*(>er the ill e''e*ts ('

eteri(rati(n 9 ama&es *ause t( ar&halla hill ue t( the *rash Air Blue 202

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22/23

e Been there

RA-AR >e*t(rin& pr(*eures shall be establishe '(r all

runas espe*iall in the mar&inal eather *(niti(ns

The re*ka&e an human b(ies sh(ul n(t be t(u*he

until in>esti&ati(n team arri>es

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23/23

An Kuesti(ns @

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Airblue 202 ACI Presentation

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