Bhoja air crash: justice delayed

Bhoja air crash: justice delayed.

About these ads

About smhusain1

I first arrived at Halifax, Canada on board a PIA B747 in distress over the Atlantic on sector Orly to John F. Kennedy. I came again to Montreal, QC in 1994 as a landed immigrant. I am a former airline captain.
This entry was posted in Aviation accident analysis. Bookmark the permalink.

One Response to Bhoja air crash: justice delayed

  1. smhusain1 says:

    Bhoja Air Disaster—A Personal Assessment

    The Captain: he is carrying a lot of baggage from the previous job with Shaheen and even past that, from the service, the want for proficiency, and needs to demonstrate in the air that those findings were incorrect–hence the dare devilry. Maybe he has been getting away from such episodes earlier and this tended to give a “hell-of-a-flyer image,” before others. If we keep on absolving our colleagues from responsibility, then we are helping others who may be tempted to take the same path. This is civil flying with 127 passengers dead because a captain was lacking judgment. The cockpit voice recorder (CVR) and the Flight Data (FDR) along with the ATC transcripts are no joke. They tell the story when the actors are dead also.
    The pilot probably from his previous experience at this airfield knew how to get in, duck under as they say. The singing of the Punjabi ditty 15 minutes before the crash (Report), that is near the Top of Descent (TOD) points to an apprehensive assessment of the weather situation by captain—-making it light. It also means he is aware that a thunderstorm system is affecting the environs. He makes a straight-in to the Localizer without any instrument let down, guiding the aircraft through the gap observable on the weather radar irrespective of any other attendant weather phenomena. The radar controller who provided the weather gap details (VOR radials) may have done under prompting/request by the captain. He is not responsible for any role in the accident. Established on the Instrument Landing System (ILS) approach with auto pilot and auto throttles engaged, he probably got away till he was caught up by an active thunderstorm cell. Did not disengage the auto throttles when speed exceeded its limit of 190 knots; aircraft falls 1000 feet. With attendant Ground Proximity Warning System (GPWS)-wind shear aural and visual warning, rain reducing visibility and of course wind gusts, updrafts and downdrafts affecting the aircraft’s flight path, what do you do? Continue the approach? Leave the autopilot and autothrottles engaged which is making it worse? I hope you can imagine the noise of the power going up and down in all that mayhem. This is a judgment call and it was severely lacking. He is uneasy flying the aircraft manually and is fixated in getting to a landing. What do you make of his remarks “no… no” at the Locator Outer Marker (LOM) after the aircraft fell 1000 feet? Either the first officer tried to intervene….

    Demonstrated Judgment
    Landing may be permissible in the vicinity of a thunderstorm if the weather assessed by the individual is deemed safe. Wind shear is not a new term. It has always been there when aircraft have been flying in and out of airports. This didn’t happen in clear air and so was part of the thunderstorm prevailing in the area. Here, the aircraft is being made to fly to an airfield where an active thunderstorm is taking place on the approach, and it crashes 4.5 nm from the runway. An active cell is actually present in the approach path on the localizer, the rain, hail, updrafts and downdrafts are all significant indicators of its presence. Also it is flown unprepared for the task at hand to start with, and the persistence in flying on the autopilot with autothrottles engaged an electronic glideslope when the aircraft is falling out of the sky; is becoming un-flyable; extreme variations in airspeed are occurring; little while ago it fell one thousand feet on its own as a result of the weather, is sheer madness to continue the approach for a person who is aware.
    This pilot is deficient in this life-saving assessment of safe and unsafe, of life and death. It is also childish to suggest that one is not taught this subject in class. This is a professional field and one is judged on the task performed. It is unfortunate that the pilot is not here to defend his performance, but the other parameters show us what happened
    The issue is the lack of judgment demonstrated. It is not windshear or microburst(form of windshear) which is the focus but the intention to continue the approach for a landing in weather encountered so far by the pilot which requires an immediate diversion..
    The other glaring issue of the passivity of the copilot has been brought up not to ridicule a dead person but to point out that had he been a little more assertive, the aircraft would have diverted.

    You may recall an accident in Washington D.C. over the Potomac Bridge in winter with a Florida airline. They had no experience of winter weather and icing. Did that absolve them from the fact that so many people died. Or did they bring the excuse, this was not taught to us. How many aircraft fly over in Pakistan, and may have encountered similar conditions? They didn’t make headlines.

    First Officer: a similar scenario was earlier enacted at Islamabad with Air Blue, where the human factor aspect prevailed. In awe of the captain, the first officer just sat and gave verbal warnings and covered up for the captain’s lapses with the ATC, safety altitude and wandering out of the protected airspace. First Officer should have taken controls by pushing the power levers forward and rotating to the go-around attitude. This was required, and not the waste of time in talking to the tower in those critical moments, seconds, on final approach near locator outer marker when more graver issues requiring immediate attention were pressing. The Terrain Alert Warning (TAWS) followed by the stall warning (stick shaker) by the aircraft systems was a go-around final signal. His final verbal warning to the captain, ‘go around Sir.’ You see the discipline and awe of authority is still maintained till death. It is not clear what happened after 900 feet AGL (above ground level), whether the aircraft actually stalled or hit the ground as a result of a downdraft. Aircraft have been known not to recover in such situations even with full application of power and rotation. There have recorded cases in USA especially on take off, where an airliner was lost due to strong downdrafts despite using all the resources at its disposal.

    You see in both recent accidents at this airfield there is a case of passivity on part of the copilot. It is not implied, but due to a subordinate status of both copilots in service to authority, the discipline and obedience is carried to death. He is too intimidated to effect any change in plans of the captain to the extent that the inevitable occurred. In the KLM/Pan Am at Tenerife, how did that accident occur? Both the crew members other than the captain knew that the takeoff clearance had not been received. In an Avianca accident at New York in the 70s involving a 707, it was a low fuel situation, but due to such deference to the captain, the copilot did not impress upon him about it and during the overshoot from the attempted landing, the engines flamed out and everybody perished. How Capt. Sullenberger knew which way to turn, towards the safety of land or what he decided? If he hadn’t made it to the nearest airfield, Newark NJ, it was hard landing in the metropolis and sure death for everybody.

    The pilot of the A321 (Air Blue) and the pilot of the B737 (Bhoja Air) were both uncomfortable in manually flying the aircraft when the situation demanded. When you are flying in weather and it is turbulent, you either take over manually or let the autopilot fly in the basic mode in level flight to avoid over-stressing the aircraft. In this case, the weather during the approach is extremely turbulent for the autopilot and auto throttle to hold that mode and the aircraft’s flight path in descent. You can see the auto throttles could not hold the speed correctly and should have been disengaged immediately. In such gusty and turbulent conditions, the autopilot has difficulty flying the localizer and glideslope signals because of so many variations, changes, affecting (speed variations, altitude variations due to gusts, violent in nature). In such situations, won’t anybody with common sense take the autopilot off when the aircraft is near stall with the warning sounding, and the auto throttles has been noted to error on speed seconds earlier?

    Findings
    Crew pairing: In this accident, the captain had paired with the co-pilot to shield some of his shortcomings. Both are from a similar service background, hence the first officer is intimidated psychologically, being a subordinate. I am of the opinion that a first officer should be discouraged from flying with one captain consistently–there is always a reason.

    The CAA is responsible in letting an under qualified pilot sit on the copilot’s seat. He has incomplete training, not even a simulator to cover. I don’t know how the insurance will react here and what about all the lives lost and families destroyed with no compensation as it happens there. We have yet to pay compensation for the Ojhri Camp victims in Zia’s era.

    Both the captains are in the senior age bracket with respect to piloting career and both the copilots have undue respect for them, an awe which prevented them from correcting their captain’s actions immediately by voicing strong reservations when lapses in safety were occurring and later in taking over the controls when the aircraft was in imminent danger of crashing. So a human factor course or counselling has to be initiated among air crew there about the pitfalls of such an attitude and passive behaviour in face of looming disaster. Both copilots have shown behaviour where they have sat with folded hands, I would say wearing bangles and just watched an accident happen. This is one of the disadvantages of two man aircraft. When the third seat was occupied by a flight engineer there was another set of eyes watching. Maybe we can still use the cockpit jump seat for a similar purpose by an extra first officer if the situation so demands. There could be any number of reasons for this.
    So many airlines encounter adverse windshear and there are as many injuries to passengers as a result. At cruise level, the aircraft gets away with some injuries but at low altitude one has to be careful because the margin of error, the life-saving cushion of altitude is not there. Sympathies for one’s dead colleagues are understandable but look, there have been two accidents and about three hundred people have died for want of judgment by both captains in different aircraft. Both hesitated to fly manually, one forgot where he was actually through his own actions and then why are there two pilots? They have to speak up. This is what is being emphasized about ex-service officers. They are too disciplined for safety. It is rather odd that the same service officers have flown with me either as in charge or in a subordinate status in my career in PIA. This type of passive behaviour was never evident at all, so another more relevant factor comes in: the safety culture prevailing in both these airlines.

    Excerpts from: The Naked Pilot, David Beaty, Published in London in 1991 by Methuen.
    The Human Factors in Aircraft Accidents
    As long ago as 1980, Stanley Roscoe wrote that: The tenacious retention of “pilot error” as an accident “cause factor” by governmental agencies, equipment manufacturers and airline management, and even by pilot unions indirectly, is a subtle manifestation of the apparently natural inclination to narrow the responsibility for tragic events that receive wide public attention. If the responsibility can be isolated to the momentary defection of a single individual, the captain in command, then other members of the aviation community remain untarnished. The unions briefly acknowledge the inescapable conclusion that pilots can make errors and thereby gain a few bargaining points with the management for the future.
    Everyone else, including other crew members, remain clean. The airline accepts the inevitable financial liability for losses but escapes blame for inadequate training programs or procedural indoctrination. Equipment manufacturers avoid product liability for faulty design. Regulatory agencies are not criticized for approving an unsafe operation, failing to invoke obviously needed precautionary restrictions, or, worse yet, contributing directly by injudicious control or unsafe clearance authorizations. Only the pilot who made the “error” and his family suffer, and their suffering may be assuaged by a liberal pension in exchange for his quiet early retirement–in event that he was fortunate enough to survive the accident.

    What is clear is that no aviation accident can be justifiably blamed on one individual. The mistake is a collective mistake, and the responsibility is a collective responsibility.

    Yet it is only recently that very dubious management malpractices are being identified and their contribution to accidents given sufficient weight. For though the pilot’s actions are at the tip of the iceberg of responsibility, many other people have had a hand in it–faceless people in aircraft design and manufacture, in computer technology and software, in maintenance, in flying control, in accounts departments and in the corridors of power. But the pilot is available and identifiable, and, if he isn’t conveniently dead, he probably feels himself responsible. Besides he has no financial lobby like the aircraft manufacturers or the big airlines.

    That is not to say that there are not far too many human factor accidents on the flight deck. There are. And one of the reasons human factors took decades to be accepted is because of the pilot themselves, who understandably shied away from too much introspection. For the purpose of survival, nature appears to have endowed us with an inherited conviction that “success” is “good”‘ even though success often contains its own element of failure. As a result, we draw away from those who make mistakes, lest we are associated with them. That is why mistakes are so often repeated and why it is taking us so long to understand them.

    As we have seen, airlines are forced to survive in a cut-throat environment. Passengers, encouraged by newspapers and television, demand lower and lower fares. Airlines employees who suggest a cheaper way of carrying out an essential task can be assured of a good reception. Indeed many employers give awards to those who do, and the search for cost-cutting is continuous.

    It is only when disasters grab the headlines that the long, sad story of such human error is brought to light. Then the unbelievable practices are for a time examined but soon forgotten. Firstly, management is part of the Establishment, even small bits of the Establishment stick together, and there is a political and economic necessity not to rock the boat, nor to lower management status in their own eyes and those of other people.

    Secondly, management controls the operation, hiring, firing, promotion and, above all, the money.

    Thirdly, management controls most of the relevant papers (which sometimes go missing) after an accident, will rarely admit they are wrong, and duck for cover after any catastrophe. So after an accident it is extremely difficult to trace back, possibly for years, the people within the management who might have some responsibility. At the same time, it is human factor in society itself to demand retribution. Thus the errors of management are hard to identify. On the other hand, the errors of the pilot are self-evident and are often quick slips. The environments in which the errors are made are also different–in one case a comfortable office, and in the other a cockpit possibly surrounded by storm and darkness and with an engine on fire.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s