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Airblue 202 Crash
Vikram Surana
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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
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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
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A *l(ser 5((k
(n theappr(a*h "late
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Airp(rt Surr(unin&s
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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 !
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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%
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Fa*tual +n'(rmati(n -e'i*ien*ies
:xtra A320 explanati(ns !FS 9 :8"
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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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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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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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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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$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 $/0 and hanpur lake with hatua
Area during holding pattern. 1nfortunatel the report
never investigated on these lines which reveals
there was on organi2ational failure and the report is
tring to protect the organi2ation.
Criti*al Analsis # .
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Criti*al Analsis # The Capt. was a religious gu as revealed from his compan
and colleagues and was probabl fasting and praing for thewhole night prior to the accident as '3thof -ul in '&%& was the
%4thof 0haban which is considered hol in the religion and
people like to fast and pra contrar to what the factual
information which states in %&.) that the were not fasting at
first place wh do ou need to put that point there.
The role of ATC is not clearl stated in the facts however it
reveals that the Capt. disregarded the ATC instruction to fl a
bad weather circuit and decided to fl managed approach on a
preselected P!5 unbeknown to ATC
At the same time ATC was unable to follow the traffic and give
the crew the information about terrain in a timel manner.
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Criti*al Analsis # ?
As per the arti*le in Published in The Express Tribune,
arch !"th, !#$%&
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
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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/ -
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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
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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 -
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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"
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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
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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
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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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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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An Kuesti(ns @
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