Map 1

Trident DC-9 Map 2


“The town of Split lies on the coast of Yugoslavia almost exactly between Italy to the north and Albania to the south. Since earliest times travellers have been attracted to its sunny shores and the warm Adriatic Sea. In the third century AD the Roman Emperor Diocles built a magnificent fortified palace for his retirement on an attractive cove which now forms the harbour of the modern town. Many parts of the building can be seen to this day. In the Emperor’s footsteps have followed armies of tourists from the cold north, seeking sun and relaxation in the pleasant resort. West German holiday makers, especially, have found it a popular destination.

On the morning of 10 September 1976, a party from Cologne holidaying in the Split area prepared for their return home after an enjoyable stay. As they faced the trauma of check-in at busy Split Airport, another group of travellers was already beginning its journey from the distant airport of London, Heathrow. British Airways scheduled flight BE 476 from London to Istanbul lifted off from Heathrow at 08.32 hrs GMT (09.32 hrs. local). The Trident 3B, registration G-AWZT (Zulu Tango) was less than half full for the 3 1/2 hour journey to Turkey with only 54 passengers on board. The travellers formed a disparate group of various nationalities and even included one stateless person. Captain Dennis Tann commanded the Trident with First Officer (F/O) Brian Helm as co-pilot and F/O Martin Flint in the P3 position. Six cabin crew tended the passengers’ needs. Flight BE 476 crossed the channel at Dover, then proceeded south-east over Belgium, passing overhead Brussels, and continued to West Germany. About 1 ¼ hour after take-off, with breakfast completed, Flight BE 476 passed over the city of Munich and reported its position at 09.43 hrs.. The Trident settled on airway Upper Blue 1 (UB1), flying at flight level 330 (thirty three thousand feet above mean sea level) towards the radio beacon of Villach in the south of Austria. At such quiet moments in the cruise, with eyes and ears still alert, crews often keep their minds active with the daily cross-word puzzle. F/O Helm was still struggling with a clue and engaged the assistance of the others. As the quiet discussion ensued Trident Zulu Tango slipped from West Germany into Austrian airspace at 09.48 hrs. At precisely the same moment, Flight JP 550, a DC-9 of the Yugoslav charter airline Index-Adria Aviopromet, lifted off from Split airport carrying the party of tourists returning to Cologne. The DC-9, registration YU-AJR (Juliet Romeo), was almost full with 108 passengers, of whom all, except one Yugoslav, were West Germans. On the DC-9’s flight deck were two pilots, Captain Joze Krumpak and F/O Dusan Ivanus. In the cabin,  the passengers were attended by only three stewardesses who had their work cut out catering for so many people on the short 2 ½ hour journey.

Flight JP 550 on its north-westerly route towards Cologne and Flight BE 476 on its south-easterly course towards Istanbul, were both flight-planned to traverse the busy area over the Zagreb radio beacon. A glance at a map of the region clearly indicates Yugoslavia’s important position in aviation, as air traffic between Europe and the East routes south of the Eastern Bloc nations. Charter flights from Northern Europe in summer to Yugoslavia, Greece and Turkey also swell the flow of traffic. Five high level airways criss-cross the Zagreb region like a disjointed Union flag with three airways—Upper Blue 5 (UB 5), Upper Blue 9 (UB 9) and Upper Red 22 (UR 22)—intersecting over the Zagreb radio beacon. A fourth airway, Upper Blue 1 (UB1), routes to the south of Zagreb while Upper Amber 40 (UA 40), the fifth airway, originates at Zagreb on a direct to Sarajevo. In the previous five years a rapid and sustained growth of air traffic over Western Yugoslavia had resulted in over 76,000 aircraft movements being handled by Zagreb Air Traffic Control Centre (ATCC). By 1976 the Zagreb was the second busiest in Europe and 30 controllers were struggling to handle traffic which required more than double that number. An extensive training programme had been introduced but the centre was still desperately short of experienced controllers. Three years earlier a modern radar flight control system had been installed but it had not yet been properly calibrated and was considered unreliable. It was claimed that the Swedish equipment did not meet contract requirements. As a result the radar system had not been properly commissioned and was not depended upon for aircraft separation. The Zagreb ATCC relied very much on procedural control with pilots transmitting their positions at specified reporting points along the airways. These position reports were then monitored by the radar system.

The increased work load for the Zagreb staff in the years of air traffic growth produced a very difficult working environment. Lapses in concentration were perhaps not surprising and a number of incidents had resulted, with 32 near-misses being experienced over the last five years. Two controllers had been dismissed for negligence. On a lesser scale lapses in discipline resulted in lateness for duty, and unauthorized absence from the control station. These failings, however, had to be viewed in the light of trying circumstances and in the very high volume of traffic which had passed safely through the region.

On the morning of 10 September 1976, as BE 476 and JP 550 converged on the Zagreb area, the staff at the Zagreb ATCC faced another day of heavy traffic. The airspace over Zagreb was divided into three distinctly separate layers—lower, middle and upper—with middle and upper sections each directed in the short-staffed centre by a controller and his assistant, where normally three personnel—radar controller, procedural controller and assistant controller—would be required. JP 550, on its climb over the Zagreb radio beacon to its planned flight level of 310, would pass through the middle control layer (from 25,000 to 31,000 ft), while BE 476, already cruising at level 330, would pass through the upper control section (above 31,000 ft). On the duty shift that morning, under the supervision of Julije Dajcic, was five controllers responsible for the middle and upper stratums of airspace. Apart from the 43-year old Dajcic, their ages ranged from late 20s to early 30s. The controllers worked a 12-hour duty day with normally 2 hours at a control station followed by a one hour break. By 10.00 hrs GMT (11.00 hrs local) the morning shift, which started at 07.00 hrs local, had already been on duty for four hours. At the middle section console sat Bojan Erjavec as controller, who had been at his station for the past hour, with assistant controller Gradimir Pelin, who had just started duty. Mladen Hochberger controlled the upper section and was due, at that moment, to be relieved by Nenad Tepes. Hochberger’s assistant for the past hour had been Gradimir Tasic who had already spent the first two hours of the shift as duty controller. When Hochberger’s relief, Tepes, who was now late, arrived Tasic would also act as his assistant for the next hour, monitoring procedures and co-ordinating flights with other regions on ground telephone links. Of the staff mentioned, all except Tasic, had had a period of at least 24 hours off duty in the last few days. Tasic was on his third day in a row of 12 hours on duty.

As the Inex-Adria flight climbed out of Split, the approach controller who, in spite of his title, also handled airport departures, was having trouble coordinating JP 550’s ascent with Zagreb lower east sector. As a result the Yugoslav DC-9 was required to cross the Split radio beacon at level 120 before continuing its climb to level 190 while proceeding towards the radio beacon at Kostajnica. At 09.55 hrs GMT JP 550 established contact with the Zagreb lower controller and was further cleared to level 240. One minute later, the clearance to climb to level 250, in the middle level airspace, was received by JP 550. A request for the DC-9 to call passing level 220 was also made as a reminder for the lower controller to instruct JP 550 to change frequency to the middle controller at that point. JP 550 had flight planned for level 310 but levels higher than 260 in the middle sector were not available because both levels above were blocked by other traffic. Westbound jet cruising flight levels are 260, 280, 310, 350 and 390 while eastbound levels are 270, 290, 330, 370 and 410. In the middle sector, Adria 584 from Split to Nuremberg was at level 280, estimating Zagreb at 10.08 hrs and Olympic 187 from Athens to Vienna at 310, estimating overhead Zagreb at 10.11 hrs. At that time JP 550 was estimating Zagreb at about 10.16 hrs. At 10.02 hrs JP 550 radioed passing level 220 and was instructed to transmit the next call on the middle sector’s frequency at 135.8 MHz. After the frequency change the DC-9 crew waited about 30 secs for a break in the flow of conversation then established contact with Erjavec, the middle sector controller.

10.03:21 JP 550 R/T: ‘Dobar dan [Good day], Adria 550, crossing two two five, climbing two six zero.’

10.03:28 Zagreb middle (Erjavec) R/T: ‘550, good morning, squawk alpha two five zero six, continue climb two six zero.’

10.03:34 JP 550 R/T: ‘Squawk alpha two five zero six, continue climb two six zero.’

10.03:38 Erjavec R/T: ‘That is correct. Inbound Kostajnica, Zagreb, Graz next.’

Alpha 2506 is one of the radar identification codes used in secondary radar operation. With primary radar a signal pulse is simply transmitted from a ground station and reflected back from a target to the station as a weak echo. Secondary radar, on the other hand, involves a ground transmitted radar signal being received on board an aircraft by a small receiver/transmitter known as a transponder, which responds by transmitting a second signal which is in turn received by the ground based radar receiver. The resultant signal on the ground is much stronger than the weak echo detected using primary radar. An added advantage is that the transponder transmits on a frequency different from the ground based radar transmitter. Since the radar receiver is tuned to the transponder frequency, weak echoes of the transmitted radar signal that may be reflected from the target or from storm clouds in the vicinity are eliminated on the radar screen. A distinct clear image of the target is displayed. On instruction from the control the transponder is programmed by the pilots selecting a four number code, and the procedure is known as squawking. Each aircraft is allocated its own code which displays on the radar screen by the target a flight label consisting of the squawk code, flight number, and the aircraft flight level. As a further refinement the centre at Zagreb used a radar height filtering procedure where only certain codes were assigned to each control layer. In any airspace layer, only aircraft with appropriate codes (middle sector 2500-2577, upper sector 2300-2377) showed up with a flight label on that controller’s radar console. All other aircraft in the vicinity, higher or lower, showed up only as target blips. As a precaution, however, if an aircraft strayed unannounced in another layer, for example from the middle to the upper section, then the flight label would in that case appear automatically when the aircraft climbed above level 315. A controller could also obtain the flight label on his screen of an aircraft outside his airspace layer in order positively to identify an unlabelled target. This could be achieved in a number of ways, but the simplest method was to position a ‘pointer’ on the radar screen over the unidentified blip and then request the computer for information. The identification label would then appear by the selected flight for 30 seconds. This procedure, however, took time, and involved the use of a separate key board thus distracting the controller from radar monitoring.

The hand-over of JP 550 from the lower east sector to the middle sector during its climb was completed in good time, which was just as well. Contrary to instructions no progress strip with JP 550’s flight details had been prepared in advance for the middle sector. The flight progress strip is about eight inches by one inch and contains important information on a particular flight including call sign, aircraft type, requested flight level, airway routing and squawks code. The strips are mounted on metal backing plates which are slotted in racks by the controller. Checking, altering, and arranging the strips are part of the assistant controllers’ tasks. The Zagreb middle controller had to adjust quickly to accept JP 550 into his sector without prior knowledge of the flight, but since the changeover was conducted in the lower airspace, the transition was accomplished with safety.

BE 476 crossed over the Klagenfurt radio beacon on the Austrian/Yugoslav border at 10.02 hrs, about the time of JP 550’s exchange, and was instructed by Vienna Control to contact Zagreb on frequency 134.45 MHz. As the Trident flew eastbound on airway UB 5 towards Zagreb at level 330, all was not well at the Zagreb upper control station. Controller Hochberger, still waiting on his relief, was showing his impatience with his colleague’s late arrival and vacated his seat to go and look for Tepes. By the time BE 476 called Zagreb upper, Tasic, who was supposed to be in the position of assistant, was now completely on his own, controlling flights, monitoring procedures, and liaising with adjacent control centres. Although at 28 Tasic was the youngest in the room he was an experienced and competent controller, but the flow of air traffic through his sector was as much as any man could handle.

  • 10.04:12 BE 476 R/T: ‘Zagreb, Bealine 476, good morning.’
  • Zagreb upper (Tasic) R/T: ‘Bealine 476, good morning, go ahead.’
  • 10.04:19 BEA 476 R/T: ‘476 is Klagenfurt at zero two, flight level three three zero, and estimating Zagreb at one four.’
  • Tasic R/T: ‘Bealine 476, roger, call me passing Zagreb, flight level three three zero, squawk alpha two three one two
  • 10.04:40 BEA 476 R/T: ‘Two three one two is coming.’

Previous radar stations had recorded the Trident level precisely 330, but on Tasic’s screen the flight label indicated BE 476 to be at 332 (33,200 ft) or 335 (33,500 ft). Since the equipment was not considered to be completely reliable the discrepancy was ignored.

  • 10.04:11 TK 889 R/T: ‘Zagreb, Turkair 889, over Charlie, three five zero.’
  • Tasic R/T: ‘Turkair 889 contact Vienna control one three one er . . . sorry, one two nine decimal two (129.2 MHz). Good day.’
  • 10.04:54 TK 889: ‘one two nine decimal two. Good day, sir.’

On the Trident flight deck the crew watched the opposite direction Turkish aircraft flash past above them at level 350. ‘There he is’, called one of the crew. Tasic now required onward-clearance from Belgrade for an Olympic Airways’ flight proceeding eastbound on UB1 towards Sarajevo. He called the Belgrade ATCC on the ground telephone link to speak to the relevant upper controller’s assistant.

  • Tasic Tel: ‘I need Sarajevo upper.’
  • Belgrade Tel: ‘Right away?’
  • 10.05:17 OA 182 R/T: ‘Zagreb, Olympic 182, passing Kostajnica at zero five, three three zero, estimate Sarajevo at one seven.’ (Olympic 182 eastbound on UB1)
  • Tasic Tel: ‘You can hear the message over the phone.’
  • 10.05:20 Tasic R/T: ‘Olympic 182 contact. Olympic 182 report passing Sarajevo.’
  • 10.05:25: Belgrade Tel: ‘Hello?’
  • 10.05:28 Tasic Tel: ‘Hello, hello, listen, give me the controller . . .’

No sooner had the controller taken the phone that another aircraft called.

  • 10.05:30 9KACX R/T: ‘Zagreb, Grummen 9KACX with you, flight level four one zero.’ Tasic ignored the call and continued with the telephone conversation.
  • 10.05:35 Tasic Tel: ‘Er, Lufthansa 360 and Olympic 182 – they’ve got nine minutes between them. Is that OK for you?’

Normally along route should be ten minutes apart but Tasic hoped the Sarajevo upper controller would accept them with the reduced separation.

  • Belgrade Tel: ‘I’ve got it . . . OK.’ The incoming radio calls continued.
  • 10.05:44 IR 777 R/T: ‘Zagreb, this is Iran Air triple seven, good . . . morning.’
  • 10.06:15 OM 148 R/T: ‘Zagreb, Monarch 148, we checked Kostajnica zero five, level three seven zero, Sarajevo one nine.’ (Monarch 148 on UB1 eastbound)
  • 10.06:37 9KACX R/T: ‘Zagreb, Grumman 9KACX is with you, level four one zero.’

Meanwhile, in the middle sector, JP550 was just levelling at 260. His position was 34nm south of the Kostajnica radio beacon, heading north due north on UB9, and estimating overhead Kostajnica at just after 10.09.

  • 10.05:57: JP 550 R/T: ‘Adria 550, levelling two six zero, standing by for higher.’
  • 10.06:03 Zagreb middle (Erjavec R/T): ‘550, sorry three three zero . . . eh . . . three one zero is not available, two eight zero also. Are you able to climb maybe to three five zero?’
  • 10.06:11 JP 550 R/T: ‘Affirmative, affirmative.  With pleasure.’
  • 10.06:13 Erjavec R/T: ‘Roger, call you back.’
  • 10.06:14 JP 550 R/T: ‘Yes sir.’

On leaving the control room in search for Tepes, Hochberger had met his replacement on the way and the two men stopped to discuss the air traffic situation. Contrary to instruction they continued to complete the hand-over outside the control room. Tasic, still at the upper control station on his own, was just about managing to handle the volume although the pressure was beginning to tell. JP 550 remained level at 260 while Erjavec attempted to attract Tasic’s attention for clearance to climb the Yugoslav DC-9 to level 350 in the upper sector. Climbing aircraft through the layers of airway traffic travelling in both directions requires careful coordination by all concerned. Erjavec was satisfied with the situation in the middle sector, but climbing JP 550 up through the opposite direction traffic at 330 and checking separation with other aircraft already cruising at 350 was Tasic’s responsibility. Erjavec’s raised hands were seen by Tasic who, in an obvious gesture, waved him away. All his attention was needed for his own traffic. The middle and upper control stations were only a half a metre apart so Erjavec’s assistant, Pelin, who held a radar licence, simply moved across to Tasic’s screen. Pelin pointed at JP 550’s unlabelled target and asked Tasic for clearance. The confused exchange was only a brief moment in the sequence of events but proved to have far reaching consequences for those concerned. As far as Tasic understood the situation, he was only being indicated an aircraft in the vicinity of Kostajnica, whereas Pelin assumed climb clearance had been received. He moved back to Erjavec with the all clear.

  • 10.07: 40 Erjavec R/T: ‘Adria 550 re cleared flight level three five zero.’ At the upper control station Tasic struggled on alone.
  • 10.07:45 Tasic R/T: ‘Beatours 778, squawk alpha two three zero four.’
  • 10.07:50 BE778: ‘Alpha two three zero four coming down, 778.’

Again he was on the line to Belgrade for BE 778’s clearance, but interrupted the call to reply on the radio.

  • 10.08:26 Tasic R/T: ‘778 radar contact, continue.’

Belgrade was having trouble retrieving Beatours information. Eventually the details were found and BE 778’s routing from London to Istanbul confirmed. ‘How do you spell Constantinople?’ asked Belgrade, using the old name. This was too much for Tasic and he replied in exasperation with the phonetic spelling of that city’s international four-letter designator. ‘Lima Tango Bravo Alpha.’ There was still no sign of Tepes taking up the controller’s position. In the middle sector Erjavec continued to monitor JP550’s climb and confirmed by radar that the DC-9 was approaching Kostajnica. Captain Krumpak was instructed to proceed via Zagreb and Graz and to call passing level 290.

  • 10.09:49 JP550’s R/T: ‘Zagreb, Adria 550 is out of two nine zero.’
  • 10.09:53 Erjavec R/T: ‘Roger, call me passing three one zero now.’

As the Yugoslav DC-9 ascended to 350, the BEA Trident 3B, BE 476, cruised at flight level 330 with a true airspeed of 480 knots. A south westerly wind aloft at 45 knots resulted in a ground speed of 489 knots. The estimate for overhead Zagreb remained at 10.14 hrs. In spite of the wind direction the Trident had tracked a little to the south of the airway and at 10.11:41 turned left from a heading of 121 degrees on to a heading of 115 degrees to home directly over the Zagreb radio beacon. JP 550’s rate of climb was 1,800 ft/minute and the 2,000 ft ascent from level 290 to level 310 was achieved in a period of about 1 ¼ minutes. The DC-9 passed into the upper control sector.

  • 10.12:03 JP 550 R/T: ‘Zagreb, Adria 550, out of three one zero.’
  • 10.12:06 Erjavec R/T: ‘550 for further Zagreb one three four decimal four five (134.45 MHz). Squawk stand-by and good day, sir.’
  • 10.12:12 JP 550 R/T: ‘Squawk stand-by, one three four four five. Good day.’

Erjavec had instructed JP 550 to squawk stand-by on the transponder in order to release the DC-9’s middle sector squawk code for another aircraft. Although a not acceptable procedure, the selection of stand-by laid the foundation of a lethal trap for the unsuspecting Tasic. The radar computer was programmed to activate automatically on the upper controller’s screen the flight label of any aircraft transmitting a middle sector transponder code when it climbed above level 315.With the squawk code in stand-by mode no flight label would automatically appear. Tasic’s first task on being contacted by JP 550 would be to allocate an upper sector transponder code.

On the DC-9 flight deck the frequency was changed, and once again the crew waited for a gap in the flow of radio conversation before attempting to contact Tasic.

  • 10.11:53 Tasic R/T: ‘Finnair 1673, go ahead now, copy 1673, go ahead.’
  • F1673 R/T: ‘Finnair 1673 passed Graz at one zero, level three nine zero, estimate . . .’ (Southbound from Austria)
  • 10.12:10 Tasic R/T: ‘Finnair 1673, report passing Delta Oscar Lima. Maintain level three nine zero, squawk alpha two three one zero.’
  • 10.12:20 F1673 R/T: ‘Will report passing Dolsko.’

A few seconds before the last Finnair transmission, Tasic received from Pelin JP 550’s flight progress strip which once again, contrary to regulations, was simply an alteration of the one already held by the middle sector. A new strip should have been prepared by Peeling. Tasic had hardly time to glance at the information. The upper sector station had not received a strip in advance because JP 550 was originally flight planned for level 310 which lay in the middle sector. It was not known until the last minute that the DC-9 was sufficiently light to climb to level 350. Unannounced JP 550 penetrated the upper sector airspace and showed only on Tasic’s screen as an unlabelled target.

  • 10.12:24 LH 310 R/T: ‘Lufthansa 310, Sarajevo at zero nine, three three zero, Kumunovo three one.’
  • Tasic R/T: ‘Lufthansa 310, contact Beograd one three four decimal four five (134.45 MHz) – sorry – sorry, one three three decimal four five (133.45 MHz). Good day.’
  • LH 310 R/T:’Good day.’
  • 10.12:38 Tasic R/T: ‘Good day.’

Just after Tasic received JP 550’s flight progress strip Tepes eventually arrived. He had completed the hand-over from Hochberger outside the control room but would need to be updated by Tasic on the latest situation. Tepes was rostered as the controller for this duty period so with Tasic at the controller’s station, they would have to change seats. As the two waited for an appropriate moment Tasic, controlling aircraft in his sector, briefing Tepes in the gaps between, and still coordinating flights on the telephone with Belgrade, was reaching saturation point. There were eleven aircraft in the upper sector. Having received JP550’s flight progress strip at such a late stage, Tasic had no time to examine the details or to appreciate the developing situation. A further error confused the situation. Marked on the strip was JP 550’s level of 350 but omitted was an arrow pointing upwards beside the figures to indicate the aircraft still climbing. As JP 550 continued on its ascent to level 350, heading 353 degrees on UB 9 towards Zagreb, Tasic was unaware of its height. The DC-9 had still to pass through the opposite direction flight level of 330. The south westerly wind at that level increased JP 550’s true airspeed of 440 knots to a ground speed of 470 knots. At that rate, it would cross Zagreb still climbing, at 10.14 hrs, at the same time as BE 476.

  • 10.12:40 OA 172 R/T:’Zagreb, Olympic 172, good morning, level three three zero.’
  • 10.12:48 Tasic R/T: ‘Olympic 172, go ahead.’
  • OA 172 R/T: ‘Olympic 172, level three three zero estimate Dolsko at one six.’
  • 10.13:00 Tasic R/T: ‘Olympic 172, report passing Dolsko, flight level three three zero. Squawk alpha two three zero three.’
  • 10.13:07 OA 172 R/T: ‘Olympic 172, squawk two three zero three. Report passing Dolsko level three three zero, and after Dolsko direct Kostajnica?’
  • 10.13:15 Tasic R/T: ‘Affirm, sir.’
  • 10.13:18 OA 172 R/T: ‘Thank you.’
  • 10.13:19 BE 932 R/T: ‘Zagreb, Beatours 932 is level three seven zero, estimate Dolsko one eight.’

Tasic was distracted again with the attempt to change places with Tepes who was now filling the post of assistant and was in contact with Belgrade on the ground telephone link. Beatours repeated the call and Tasic misheard.

  • 10.13:34: BE932 R/T: ‘Zagreb, Beatours 932.’
  • Tasic R/T: ‘962 go ahead.’
  • 10.13:42 BE 932 R/T: ‘Beatours, three seven zero, estimate Dolsko at one eight.’

Once more Tasic’s attention was drawn to other matters.

  • 10.213:53 Tasic R/T: ‘Beatours, maintain level three seven zero and report overhead Dolsko. Squawk alpha two three three two.’
  • BE932 R/T: ‘Roger, two three three two. (A2332)

Still no message had been received from the DC-9 in spite of the short breaks in radio transmissions. The Yugoslav aircraft had 2,500 feet left to go to its cruising level of 350 but was only 500 feet below the opposite direction Trident at level 330. The two aircraft were both almost overhead the Zagreb radio beacon and were dangerously close. At last the DC-9 made initial contact with the upper controller.

  • 10.14:04 JP550 R/T: ‘Dobar dan, Zagreb, Adria 550.’
  • 10.14:07 Tasic R/T: ‘Adria 550, Zagreb, Dobar dan. Go ahead.’
  • 10.14:10 JP550 R/T: ‘Three two five crossing, Zagreb at one four.’

Tasic could hardly believe his ears. Did JP 550 say crossing level 325? Anxiously he called back.

  • 10.14:14 Tasic R/T: ‘What is your present level?’
  • 10.14:17 JP550 R/T: ‘Three two seven.’

A possible collision between the Trident and the DC-9 was only seconds away. Neither flight crew was aware of the impending danger but both would be maintaining a normal watch, although spotting another shining aircraft in that bright morning sky would have been very difficult. The Trident was leaving a long contrail which the DC-9 crew may have seen, but judging another’s height especially with the aircraft nose up in a climb is almost impossible. Also the sun was behind the Yugoslav aircraft and eye contact for the Trident crew would have been hard to establish. The ability of the eye to detect other traffic is improved when two aircraft move relative to each other. The important factor of an impending collision is that a line of constant bearing between two aircraft involved in an encounter and the phenomenon makes it more difficult for them to spot each other. On the Trident flight deck JP550’s radio message would have alerted the crew to the danger, but since position reports are normally passed after passing a reporting point they may have assumed that the DC-9 was already behind them. Whatever, the circumstances, the two aircraft were closing with a speed through the air of around 920 knots – at almost 1,100 mph faster than a rifle bullet—and there was almost no time to take avoiding action.

At JP 550’s last call there were only 300 ft and a few seconds separating the flights. It was too late for Tasic to interrogate the computer for the DC-9s flight label as drastic action was required. BE 476’s flight label incorrectly showed the Trident level at 335. Tasic surmised that if he could hold the DC-9 at its present level of 327 they would pass each other with 800 feet to spare. It would be close, but something had to be done. Turning the aircraft on to another heading would take more time and the action of holding JP 550 level should have the desired effect. Tasic broke into Croatian and stammering, called back in a desperate attempt to avert a tragedy.

  • 10.14:22 Tasic R/T: ‘. . . e . . . zadrzite se za sada na toj visini i javite prolazak Zagreba.’ (. . . e . . . hold yourself at that height and report passing Zagreb).

By now the DC-9 was climbing through 330.

  • 10.14:27 JP550 R/T: ‘Kojoj visini?’ (What height?)

Captain Krumpak immediately attempted to level the aircraft but for a few seconds its momentum carried it higher.

  • 10.14:29 Tasic R/T: ‘No kojo ste sada u penjanju jer . . . e . . . imate avion pred vama na isn . . .? 335 sa leva na desno.’ (The height you are climbing through because . . . you have an aircraft in front of you at . . .? three three five from left to right).
  • 10.14:38 JP550 R/T: ‘OK, ostajemo tocno 330.’(OK, we’ll remain precisely at three three zero).

Unfortunately, in spite of BE 476’s flight label on Tasic’s screen indicating the Trident cruising at 335, the aircraft was flying level at exactly 330. The DC-9 reached maximum altitude of 192 feet above the Trident at 10.14:35 then drifted in a gentle descent towards the selected flight level of 330. For a few seconds, as the two aircraft sped headlong towards each other they were both precisely level. Tolerances in radio beacon calibration on altimeter mechanisms, slight variations in headings or wind fluctuations might just have combined to avoid a catastrophe, but it was not to be. At 10.14:41 the outer five metres of the DC-9’s left wing sliced through the Trident’s flight deck as the aircraft collided, killing the crew instantly. The stricken machines dropped out of control from the sky. The DC-9’s wing broke off and the left engine disintegrated with ingested debris. As the aircraft descended in flames the empennage detached. The Trident lost its rudder in the collision and dived steeply towards the ground. The cockpit voice recorder on the Yugoslav aircraft had not been working properly but the impact jolted it into action. As the DC-9 tumbled towards the ground it recorded Dusan Ivanus’ last words.

‘We are finished. Goodbye,’ he said, ‘goodbye.’

The two aircraft struck the ground about four miles apart near the town of Vrbovec lying about 16 miles north-east of Zagreb. All 54 passengers and nine crew aboard the Trident and 108 passengers and five crew aboard the DC-9 were killed. A total of 176 people lost their lives.

The first civilian airborne collision occurred on 7 April 1922 between a de Havilland 18 (G-EAWO) of Daimlar Airways and a Farman Goliath. The accident happened between Paris and Beauvais, the town associated with the R101, killing the two crew of the UK registered aircraft. History was also made over Zagreb that morning of 10 September 1976, for the mid-air collision between the Trident and the DC-9 proved to be the worst accident of that type on record.

In the few seconds after the crash Tasic, in despair, called both aircraft in turn several times but to no avail. A Lufthansa Boeing 737, travelling eastbound on UB5 at level 290 towards Zagreb, was positioned only 15 miles behind the Trident. The co-pilot ‘saw the collision as a flash of lightning and afterwards, out of a ball of smoke, two aircraft falling towards the ground.’ The Boeing 737 commander, Captain Joe Kroese, reported the sighting to Erjavec, the middle sector controller.

  • 10.15:40 Capt. Kroese R/T: ‘. . . e Zagreb! It is possible we have a mid-air collision in sight—we have two aircraft going down, well, almost below our position now.’ Erjavec was unable to understand and Captain Kroese had to repeat his words several times.
  • 10.18:12 Capt. Kroese R/T: ‘it’s possible that the other aircraft ahead of us had a mid-air collision . . . er . . . just overhead Zagreb. We had two aircraft going down with a rapid rate of descent . . . and there was also smoke coming out.’

When the implication of what was being said dawned on Erjavec he glanced across at the upper sector controller. At his station sat a stunned Tasic, white faced with shock. Slowly he lifted the head-set from his ears and placed it on the console in front of him.

As the alarm was raised and rescue services were launched, operations ceased in the Zagreb control centre. Incoming aircraft to the airspace were diverted along other airways. The middle and upper sector controllers involved in the collision were suspended, and off-duty staff was summoned from their homes as replacements. Within an hour normal air traffic services were resumed. Soon police and officials arrived at the centre to interview those of the morning shift implicated in the catastrophe. Erjavec, the middle controller who had cleared JP 550 to climb; Pelin, his assistant, who had coordinated the flight with the upper sector; Hochberger, the upper controller who had vacated his station; Tepes, his replacement, who had been late for duty; Tasic, the upper sector assistant who had been left on his own for up to eight minutes at a critical phase; and Dajcic, the shift supervisor who had overall responsibility. Within hours they were placed under arrest. At Cologne Airport relatives and friends waited in vain for the arrival of the Index-Adria charter aircraft. Also kept waiting were the outbound group of tourists checked-in for the return flight to Split. All they were told was that the flight was delayed until 5pm owing to a technical problem. Even 21/2 hours after the accident telephone callers were still being given the same facts. It wasn’t until early evening that news of the crash was officially released to those waiting, but by then many had already heard of the tragedy from reporters assembling at the airport.

An initial accident inquiry established that the controllers had a case to answer, but the civil aviation authorities were released from the requirement to publish details. Instead, under Yugoslav law, the controllers also faced charges of criminal misconduct and arrangements were undertaken to place the accused on trial. Within two months all except Tasic were released. He, alone, remained in custody.

Seven months after the collision the hearing of the criminal case opened in the Zagreb District Court before Judge Branko Zmajevic at 8 am on the morning of 11 April 1977. The court assembled in the same room where Tito had been tried as a communist in 1923. In the dock sat eight accused: the five controllers and the shift supervisor, plus two senior officials, the head of the Zagreb flight control service, Antere Delic, and the head of Zagreb district flight control, Milan Munjas. Deputy Public Prosecutor Slabodan Tatarac read the long list of charges of criminal negligence.

The trial was well conducted and followed Yugoslav law to the letter. The evidence was carefully presented and formal courtesies observed. The court, however, was not concerned to analyse the cause of the accident, which had been the purpose of the inquiry. It had assembled to apportion blame and to administer punishment. All defendants faced long prison sentences of up to 20 years if found guilty. As the trial progressed the atmosphere at times became heated and tempers flared. Claim and counter-claim followed accusation and counter-accusation. Statements by some of the accused contradicted or embellished evidence presented at the earlier accident inquiry and it became increasingly difficult to establish the facts. Pelin, the middle sector assistant, now claimed that Tasic had been shown JP550’s flight progress strip as early as 10.07 hrs when co-ordination of that aircraft’s climb first took place between the two. Pelin’s evidence was supported by Erjavec, the middle controller. None of this had been mentioned in the earlier court of inquiry. In turn Tasic presented fresh revelations. He now recalled that he had told Pelin JP 550 could climb to 350 only if it could make level 310 by Kostajnica. If not, it would have to wait for climb until after Zagreb. Pelin denied this exchange. He countered by saying that during co-ordination of JP550’s climb he had also pointed out to Tasic Olympic 182 at Kostajnica level 330, which might have caused conflict with a clearance to climb. According to Pelin, Tasic replied that after they crossed, JP 550 was cleared to climb.

The web of information became so tangled that any attempt at establishing the true facts seemed remote. The judge encouraged the accused to challenge each other with the facts but Tasic seldom appeared unscathed from these statements. He became increasingly isolated and fell ill under the strain. Proceedings had to be adjourned for a week.

In court, representing the prosecution was a British lawyer, Richard Weston. He attended in the capacity of attorney for the parents of one of the stewardesses killed aboard the Trident. His interest, of course, was that justice should be done, but as the proceedings continued he became genuinely concerned with the course of the trial. The evidence clearly demonstrated that the air traffic system was as much under scrutiny as the behaviour of the defendants and that changing the system would be far more beneficial than imprisoning the victims of the system. The accused, if found guilty, would be suitably disciplined by the civil aviation law. Weston, as an accredited representative, was entitled to be heard by the court. Before the judge’s summing-up he decided to exercise that right and, through a Yugoslav colleague reading a translation of his statement, he made an impassioned plea to the court for leniency. Although the controllers may be held responsible, they should not be sentenced to prison like common criminals. It was a most unusual comment from the prosecution benches, but one which was received with applause both within the court room and the world beyond.

On Monday 16 May 1977, the court assembled for the last time to hear the findings read by Judge Zmajevic. In short, of the eight accused, seven were found not guilty. Only Tasic was left to shoulder the blame. The evidence presented by Pelin and Erjavec regarding co-ordination of JP 550’s climb was preferred to Tasic’s. He had made a number of contradictory statements. Tasic had not expressed surprise when given JP550’s flight progress strip 11/2 minutes before the collision. If he had not given permission to climb why did he not question the hand-over of the strip? On ascertaining the danger of the situation Tasic had neither issued to Captain Krumpak an order with authority nor stipulated an exact height. Had he done so expert witnesses had testified that there was sufficient time for the DC-9 to take avoiding action. The court concluded that Tasic was not overloaded and as such was in a position properly to assess the situation. He was found guilty of criminal negligence and was sentenced to seven years imprisonment.

An appeal was launched immediately and was supported by the sympathetic services of the International Federation of Air Traffic Controller’s Associations (IFATCA) who retained Weston on Tasic’s behalf. The Supreme Court reconsidered the case on 29 April 1978, and halved the jail sentence. IFATCA were determined to stop at nothing short of freedom for Tasic and organized a petition which was presented to Marshall Tito. The petition achieved the desired effect and on 29 November 1978, just over two years after the collision, Tasic was eventually released from detention.

Over the years pressure grew for re-examination of the facts which were first released after the original accident inquiry but were never made available for public scrutiny. In February 1982 the investigation into the collision was re-opened and in September of that year the results were finally published after a painstaking inquiry. Owing to conflicting statements, the report concluded, it was impossible to establish whether co-ordination of JP550’s climb had been effected. If co-ordination had been effected it had been conducted improperly by the middle controllers. It was impossible to establish whether Tasic approved JP550’s climb. The absence of Tasic’s partner at the upper station was against regulations and his departure remained unnoticed by the shift supervisor in spite of him being responsible for all staff. As a result, by any standard, Tasic had become overloaded as he tried to cope alone.”

Air Disasters by Stanley Stewart, Published by Ian Allen in England 1986

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What is personality?

The term ‘personality’ refers to the enduring characteristics of an individual as shown in ways of behaving in a wide variety of circumstances. Personality can be thought of as being made up of more circumscribed characteristics known as traits, such as socialability, aggressivity, and impulsivity.

What is personality disorder?
Extreme deviations of personality can be recognized as disordered but it is difficult to define a dividing line between normal and abnormal. If personality could be measured like intelligence, a statistical cut-off could be used (e.g. two standard deviations from the population mean). However, although psychologists have devised measures of some aspects of personality there are no reliable and valid measures of the aspects of personality that are most important to clinical practice. In the absence of such measures, a simple pragmatic criterion is used: a personality is disordered when it causes suffering to the person or to other people.

Assessment of personality
In everyday life we build a picture of the personality of people we know by observing how they respond in various circumstances. General practitioners do the same with patients who they see over many years, but they and other doctors have to be able to assess the personality of patients whom they have not met before. To do this they can use four sources of information:
• Patients’ own description of their personality
• Patients’ behaviour during the interview with the doctor
• Patients’ accounts of their behaviour in a variety of past circumstances
• The views of relatives and friends

In a job interview, the applicant’s behaviour in the interview is often considered a useful guide to personality. When assessing patients, however, interview behaviour can be highly misleading because it is affected by temporary factors relating to illness as well as by personality. Thus anxiety or depression can make patients appear more irritable or less self-confident than they generally are. Depression is particularly important since it affects a second source of evidence, namely patients’ account of their own personality: depressed patients tend to underestimate their strengths and exaggerate their weaknesses. It is important, therefore, to check the evaluation of personality formed from patients’ own accounts and from their behaviour during the interview by comparing it with the other two sources of information listed above: their record of past achievements and difficulties and, whenever possible, the accounts of relatives and friends.

In assessing personality, attention should be given not only to traits that lead to difficulties but also to those that are strengths. Sometimes a trait that is a strength in one situation leads to difficulties in others; for example, obsession traits enable people to be reliable and set high standards at work but often lead to excessive worry when they are ill. It is useful to ask a general question; for example: ‘How do you think your friends would describe your personality?’

1. Social relationships: relationships at work (with colleagues, people in authority, and junior staff); friendships with the same and opposite sex; and intimate relationships. The interviewer asks whether the person makes friends easily, has few friends or many, has close friends in whom he can confide, and has lasting friendships. The interviewer asks also whether, in company, the person is sociable and confident, or shy and reserved.

2. Mood: the aim here is to discover the person’s habitual mood, not the present or recent mood

3. Personality traits-common personality traits: (for brevity only negative attributes are listed). Each characteristic has a positive as well as a negative side and it is appropriate to ask persons where they lie between the extremes; for example, some people are placid, others get into arguments—where do you fit in? Characteristics such as jealousy or lack of feeling for others may not be revealed because the person is ashamed of them or does not recognize their presence. When there is doubt the person’s previous record and the account from an informant usually help to resolve it. When the observations are noted, pejorative and imprecise terms such as ‘mature’ or ‘inadequate’ should not be used, instead the interviewer should record in what ways the person has difficulty in meeting the demands of adult life.
a. Prone to worry
b. Strict , fussy, rigid
c. Lacking self-confidence
d. Sensitive
e. Suspicious, jealous
f. Untrusting, resentful
g. Impulsive
h. Attention seeking
i. Dependent
j. Irritable, quarrelsome
k. Aggressive
l. Lacking concern for others

4. Attitudes and standards: relevant points include attitudes to illness, religious beliefs, and moral standards.

5. Habits: although not strictly part of personality, it is usual to ask at this point in the interview, about the use of tobacco, alcohol and illicit drugs since their use relates in part to personality—though there are other important influences.

Is there personality disorder?
The interviewer decides whether to diagnose a personality disorder by reviewing evidence from the history to decide whether the person or others has suffered as a result of the person’s personality. This judgment is subjective and it may be difficult to decide how much the person’s problem has been caused by personality and how much by circumstances.

Courtesy: Psychiatry by Michael Gelder, Richard Mayou and John Geddes, Oxford University Press, Oxford, New York, Tokyo, 1999

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Training and route clearances

Initiation at Lahore Flying Club after replying to  pilot trainee advertisement in newspaper in Oct.1966 and selection process. Flying Club hours on Cessna 150 were 10.00

Aptitude Assessment at Lahore Flying Club 18/3/1967—16/4/1967 = 10.00 hours

PIA Flying Academy flying started 13/2/1968

  • First Solo: 5/3/1968= 14.00 hours
  • Total Time: 10+14 (academy hours)= 24.00
  • PPL #748 (3/8/1968)
  • FRTO # 445 (3/8/1968)
  • Dual Day: 35.05
  • Solo Day: 28.45
  • Navigation Dual: 04.00
  • Total Time: 67.50

Navigation 2

  • 14/11/1968, KHI-Sujawal-Mulla Katiar-Sari Sing-KHI, Instructor Hyder Baluch, AP-ATE, 02.15
  • 19/11/1968, KHI-T.B. Khan-Mirpur Batoro-KHI, Instructor Mahmood, AP-ATZ, 01.45
  • 27/11/1968, KHI-Mirpur Batoro-Bholari-Sari Sing-KHI, Instructor Group/Capt. M.J. Khan, AP-ATD, 02.10
  • 28/11/1968, KHI-Matli-Sujawal-KHI, Instructor Group/Capt. M.J. Khan, AP-ATZ, 02.25

Navigation 3

  • 29/11/1968, KHI-Sujawal-Mulla Katiar-T.B. Khan-KHI, Self, AP-ATZ, 02.25
  • 2/12/1968, KHI-Thatta-Mulla Katiar-Jungshahi-KHI, Self, AP-ATB, 02.15
  • 2/12/1968, KHI-Thatta-Mulla Katiar-Jungshahi-KHI, Self, AP-ATE, 02.05
  • 3/12/1968, KHI-Matiari-Sujawal-KHI, Self, AP-ATE, 02.45
  • 4/12/1968, KHI-Mirpur Batoro-Petaro-Gharo-KHI, Self, AP-ATE, 02.55
  • 5/12/1968, KHI-Gharo-Petaro-Mirpur Batoro-KHI, Self, AP-ATE, 02.55
  • 6/12/1968, KHI-T.B. Khan-T.M. Khan-Mirpur Batoro-KHI, Self, AP-ATE, 02.45
  • 6/12/1968, KHI-Kalu Kuhar-T.B. Khan-Petaro-Pir Patho-KHI, Self, AP-ATB, 02.45
  • 21/1/1969, KHI-Sujawal-Hyderabad-KHI, Self, AP-ATD, 02.35
  • 22/1/1969, KHI-Thatta-Hyderabad-KHI, Self, AP-ATD, 02.05
  • 23/1/1969, KHI-Bholari-Sujawal-KHI, Self, AP-ATD, 02.25
  • 24/1/1969, KHI-Sujawal-Bholari-KHI, Self, AP-ATD, 02.4

25/3/1969, KHI-Local, Cessna 310B, AP-AKP, Instructor F.H.K. Ghori, 01.10

25/3/1969, KHI-Local, Cessna 310B, AP-AKP, Instructor F.H.K. Ghori, 01.05

1/4/1969, KHI-Local, Cessna 310B, AP-AKP, Instructor F.H.K. Ghori, 00.50

Final Navigation Test—2/4/1969, KHI-Sujawal-Jhimpir-KHI, Instructor F.H.K. Ghori, AP-ATB, 01.55

Final Handling Test–9/4/1969, KHI-Local, Instructor F.H.K. Ghori, AP-ATD, 01.00

Instrument Rating Check 5/5/1969, KHI-Local, Cessna 310B, AP-AKP, Instructor Manzoor, 01.30

  • Dual Day: 81.30
  • Solo Day: 94.00
  • Night Dual: 02.25
  • Night Solo: 02.35
  • Navigation Dual Day: 14.30
  • Navigation Day Solo: 30.35
  • TTL: 225.35

CPL # 442 awarded 17/6/1969

The following cities and towns of the province of Sind, Pakistan were flown by us on the Navigation forays from KHI (Karachi):

Pir Patho; Sujawal; Thatta; Gharo; Kalu Kuhar; Mirpur Batoro; Sari Sing; Thana Bulla Khan; Jungshahi; Mulla Katiar; Bholari–abandoned WWII airfield; Matli; Petaro; Hyderabad; Matiari; Thana Mohammad Khan

AP-ATZ, AP-ATB, AP-ATE, AP-ATB were Cessna 150s

AP-AKP was a Cessna 310B

Experience: When & where did you receive your professional flying training?

PIA Karachi May 1967 to Dec 1985

United Airlines Denver CO Feb/ Mar 1977

PIA Training Centre June 1990 to Aug 1994


  • PPL #748 Aug 3 1968
  • FRTO #445 Aug 3 1968
  • CPL #442 June 17 1969
  • ATPL #441 July 3 1975
  • ATP #2336211 Nov 1982
  • FOO #563 Oct 22 1995

Note: PPL = Private Pilot’s Licence CPL = Commercial Pilot Licence ATPL = Airline Transport Pilot’s Licence ATP (USA) Airline Transport Pilot FOO = Flight Operation Officer’s Licence FRTO = Flight Radio Telephony Operator’s Licence

Group A

Aircraft with MTOGW above 25, 000 Kgs (Multi-engine turbojet or turboprop)

Hours Flown on Aircraft Type

  • B707/720B Airline (PIA) Commander P1 = 2566.8, Date of Last Flight 12/12/1985
  • B707/720B Airline (PIA) Copilot P2 = 1030.1, Date of last flight 08/01/1980
  • B747-282B Airline (PIA) Copilot P2 = 1493.5, Date of last flight 04/12/1980
  • B747-100 Airline (UA) Copilot P2 = 02.00, Date of last flight 03/27/1977

Group Total A = 5092.4

Group B

Aircraft other than above

Hours flown on Aircraft Type

  • Fokker F-27 Airline (PIA) Commander P1= 500.2, Date of last flight 04/18/1976
  • Fokker F-27 Airline (PIA) Copilot P2 = 1278.7, Date of last flight 02/09/1975
  • Cessna 310B Airline (PIA) P3 = 5.4, Date of last flight 04/01/1969
  • Cessna 150 Airline (PIA) P1= 151.1, Date of last flight 02/14/1975
  • Cessna 150 Airline (PIA) P3= 94.0, Date of last flight 05/08/1969
  • Cessna 177RG ( Long Island NY) P3 = 2.0, Date of last flight 11/18/1982
  • Grumman Cougar PA-7 (Cranfield UK) P3 = 5.0, Date of last flight 08/18/1983


  • MTOGW = Maximum Take Off Gross Weight
  • Group Total B = 2036.4
  • Grand TTL = 7128.8
  • RF= Route Familiarization
  • RC = Route Check
  • P1 = Pilot in Command

Command Training Fokker F-27

  • 03/04/1975 AP-ALW, F.H.K. Ghori, P3, KHI-KHI, 1500-2000, Night Second = 0110, IF= 0010
  • 03/10/1975 AP-ATO, F.H.K. Ghori, P3, KHI-KHI, 1230-1630, Night Second= 0110, IF= 0100
  • 03/18/1975 AP-ATU, T.H. Naqvi, KHI-KHI, 1455-1745, Night Second = 0100, IF = 0030
  • 03/28/1975 AP-ATU, F.H.K. Ghori, P3, KHI-KHI, 1450-1715, Night Second = 0110, IF = 0025
  • 03/31/1975 AP-ALW, F.H.K. Ghori, P3, KHI-KHI, 1435-1910, Night Second 0120, IF = 0020
  • 04/01/1975 AP-ALW, F.H.K. Ghori, P3, KHI-KHI, 1200-1555, Night Second = 0120, IF = 0030
  • 04/06/1975 AP-ALW, Dara, KHI-KHI, P3, 1500-1805, Night Second = 0100, IF = 0020
  • 04/10/1975 AP-ATO, F.H.K. Ghori, KHI-KHI, P3, 1230-1630, Night Second = 0110, IF = 0020
  • 04/11/1975 AP-ALW, Dara, KHI-KHI, 1430-1745, P3, Night Second = 0155, IF = 0100
  • 04/25/1975 AP-ALW, F.H.K. Ghori, KHI-KHI, P3, 2105-0015, Night Second = 0135, IF = 0030
  • 04/27/1975 AP-ATO, F.H.K. Ghori, KHI-KHI, P3, 1430-1745, Night Second = 0115, IF = 0020 Pre-Rating Check
  • 04/28/1975 AP-ALW, T.H. Naqvi, KHI-KHI, P3, 1415-1620, Night Second = 0205, IF = 0040 Command Check
  • 05/01/1975 AP-ATU, T.H. Naqvi, P2, KHI-PJG-PSI-GWD-PSI-PJG-KHI, Day Second = 0530, Initial Route Command Check

From 05/12/1975 to 07/02/1975, 100 hours as P1 U/S (under supervision) with following captains, F.H.K.Ghori; Aqeel; Razi to the following stations: Mohenjo Daro, Jiwani, Pasni, Panjgur, Hyderabad, Multan, Gwadar, Muscat (Oman), Sukkur, Sui and Nawabshah.

First Command Flight F-27

  • 07/03/1975 AP-ATU Self (P1) KHI-MUX-KHI, 1240-1740
  • Day In charge 0140, Night In charge 0250, IF 0015

Command Training B707/720B

  • 07/21/1980 AP-AXL, Shaukat Ali, P2, KHI-KHI, 1600-1645, Night Second = 0045
  • 07/22/1980 AP-ATQ, Shaukat Ali, P2, KHI-KHI, 1735-1900, Night Second = 0045
  • 07/23/1980 AP-BAF, Mughal, P2, KHI-KHI, 1850-1930, Night Second = 0040
  • 07/25/1980 AP-BAF, Mughal, P2, KHI-KHI, 1630-1730, Night Second = 0100- Command Check
  • 07/31/1980 AP-BAA, S. Quraishi, P2, KHI-MCT (Oman), 1412-1605, Day Second = 0018, Night Second = 0135-Technical night stop at Muscat, Oman
  • 08/01/1980 AP-BAA, S. Quraishi, P2, MCT (Oman)-KHI, 0930-1115, Day Second 0145, IF= 0010 Initial Route Command Check

From 08/15/1980 to 09/16/1980, 50 hours as P1 U/S (under supervision) with following captains: S.Quraishi; Najam; Manzoor; Bashar, Ejaz ul Haq; Wajid Shah to following stations:

Jeddah; Colombo; Peshawar; Istanbul; Multan; Quetta; Rawalpindi

Final Route Command Check B707

09/16/1980 AP-ATQ, Dara, P1 U/S, KHI-BOM (Bombay)-KHI, 0203-0345, Day In charge 0142, IF 0010/0550-0740 Day In charge=0150, IF= 0010

First Command Flight B707

09/18/1980 AP-AXM, Self P1, KHI-PEW-KHI, 0950-1135 Day In charge 0145/1225-1425 Day In charge 0110 Night In charge 0050


  • AP-BAA is a B707
  • All time is GMT
  • Format M/D/Y
  • IF = Instrument Time
  • Command Training = training to fly as captain of aircraft (P1)

Airline Route Clearances

  • 10/05/1980 AP-AXL T.R. Mir P1 Karachi-Kuwait-Karachi (RF)
  • 10/11/1980 AP-AXK Dara P1 Karachi-Quetta-Islamabad-Quetta-Karachi Pk326 (RF)


  • 01/29/1981 AP-AXM Suri P1 Karachi-Dubai-Nairobi-Pk 745, RF
  • 02/01/1981 AP-AXL Suri P1 Nairobi-Dubai-Karachi-Pk744 RF
  • 02/15/1981 AP-AXK Junaidi P1 Karachi-Dubai-Nairobi-Pk743 RC
  • 02/19/1981 AP-ATQ Junaidi P1 Nairobi-Dubai-Pk746 RC
  • 02/20/1981 AP-ATQ Junaidi P1 Dubai-Karachi-Pk746 RC
  • 04/02/1981 AP-AXM Self P1 Karachi-Dubai-Nairobi Pk745
  • 04/06/1981 AP-AXK Self P1 Nairobi-Dubai-Karachi Pk744


  • 06/09/1981 AP-AWY Iftekhar P1 Karachi-Damascus RF
  • 06/12/1981 AP-AWU Iftekhar P1 Damascus-Amsterdam RF
  • 06/13/1981 AP-AXG P1 Iftekhar Amsterdam-London (Heathrow)-Amsterdam(RF
  • 06/16/1981 AP-AXM P1 Iftekhar Amsterdam-Damascus RF
  • 06/23/1981 AP-AXL P1 Iftekhar Damascus-Dubai-Karachi(RF
  • 07/01/1981 AP-AWU P1 Aqeel Karachi-Damascus RC
  • 07/03/1981 AP-AWY P1 Aqeel Damascus-Amsterdam RC
  • 07/04/1981 AP-AXG P1 Aqeel Amsterdam-London (Heathrow)-Amsterdam RC
  • 07/06/1981 AP-AXG P1 Aqeel Amsterdam-Damascus RC
  • 07/11/1981 AP-AXK P1 Aqeel Damascus-Islamabad RC
  • 08/03/1981 AP-AXL Self P1 Karachi-Dubai-Damascus
  • 08/05/1981 AP-AWY Self P1 Damascus-Amsterdam
  • 08/08/1981 AP-AZW Self P1 Amsterdam-Damascus
  • 08/13/1981 AP-AWY Self P1 Damascus-Dubai
  • 08/14/1981 AP-AWY Self P1 Dubai-Karachi

Atlantic-New York

  • 10/26/1981 AP-AXL P1 Iftekhar Dubai-Damascus-Amsterdam
  • 10/30/1981 AP-AWY P1 Iftekhar Frankfurt-JFK, RF
  • 11/02/1981 AP-AWU P1 Iftekhar JFK-Frankfurt, RF
  • 12/04/1981 AP-AWU P1 S.Quraishi Frankfurt-JFK, RC
  • 12/07/1981 AP-AWY P1 S. Quraishi JFK-Frankfurt, RC
  • 03/21/1982 AP-AWY Self P1 Paris (Orly)-Boston (Logan) Pk801
  • 03/22/1982 AP-AWY Self P1 Boston (Logan)-JFK Pk801
  • 03/27/1982 AP-AWU Self P1 JFK-Frankfurt-Pk 806
  • 03/29/1982 AP-AWY Self P1 Frankfurt-Cairo-Pk802


  • 04/18/1981 AP-BAA Mansoor E. Khan P1 Karachi-Islamabad Pk752 RF
  • 04/19/1981 AP-BAA Mansoor E. Khan P1 Islamabad-Beijing Pk752 RF
  • 04/23/1981 AP-AXG Mansoor E. Khan P1 Beijing-Tokyo (Narita) Pk750 RF
  • 04/27/1981 AP-BAA Mansoor E. Khan P1 Tokyo (Narita)-Beijing Pk751 RF
  • 05/01/1981 AP-AZW Mansoor E. Khan P1 Beijing-Islamabad-Pk753 RF
  • 05/21/1981 AP-AXG Osman Khan P1 Karachi-Beijing-Pk750 RC
  • 05/24/1981 AP-AZW Osman Khan P1 Beijing Tokyo (Narita)-Pk752 RC
  • 05/29/1981 AP-BAA Osman Khan P1 Tokyo (Narita)-Beijing-Pk753 RC
  • 06/01/1981 AP-AZW Osman Khan P1 Beijing-Islamabad-Karachi-Pk751 RC
  • 04/03/1982 AP-AZW Self P1 Karachi-Islamabad-Pk752
  • 04/04/1982 AP-AZW Self P1 Islamabad-Beijing Pk752
  • 04/08/1982 AP-AXA Self P1 Beijing-Tokyo (Narita)-Pk750
  • 04/09/1982 AP-AXA Self P1 Tokyo (Narita)-Beijing-Pk751
  • 04/12/1982 AP-AXA Self P1 Beijing-Karachi-Pk751


  • 06/15/1982 AP-BAA Junaidi P1 Karachi-Kuala Lumpur-Singapore Pk770 RF
  • 06/17/1982 AP-AZW Junaidi P1 Singapore-Karachi Pk773 RF
  • 08/17/1982 AP-AZW Najam P1 Karachi Kuala Lumpur-Singapore Pk770 RC
  • 08/19/1982 AP-AZW Najam P1 Singapore-Karachi Pk773 RC
  • 12/28/1982 AP-BAA Self P1 Karachi-Kuala Lumpur-Singapore Pk770
  • 12/30/1982 AP-AXA Self P1 Singapore-Kuala Lumpur-Karachi Pk773


  • 04/29/1983 AP-AZW Munir Khan P1 Karachi-Kathmandu-Dhaka-Karachi Pk264/265 RF
  • 05/24/1983 AP-AZW Self P1 Karachi-Dhaka-Kathmandu-Karachi Pk266/267

Hong Kong

  • 05/05/1982 AP-AWY Iftekhar P1 Karachi-Islamabad-Pk004 RF
  • 05/05/1982 AP-AWY Iftekhar P1 Islamabad-Hongkong Pk004 RF
  • 05/15/1982 AP-AWY Iftekhar P1 Hongkong-Karachi Pk003 RF
  • PIA cargo operation ceased thereafter at Hongkong

First Flights as P1 after clearances

  • Nairobi 04/02/1981,  AP-AXM,  Self P1,  Karachi-Dubai-Nairobi,  Pk745
  • European 08/03/1981 AP-AXL Self P1 Karachi-Dubai-Damascus
  • Atlantic-New York 03/21/1982 AP-AWY Self P1 Orly-Boston Pk801
  • Beijing-Tokyo 04/03/1982 AP-AZW Self P1 Karachi-Islamabad-Pk752
  • Singapore 12/28/1982 AP-BAA Self P1 Karachi-Kuala Lumpur-Singapore, Pk770
  • Kathmandu 05/24/1983 AP-AZW Self P1 Karachi-Dhaka-Kathmandu-Karachi Pk266/267
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The Lost Art of Paying Attention—Susan Parson


Managing the Attraction to Technological Distraction

Our inventions are wont to be pretty toys, which distract our attention from serious things. They are but improved means to an unimproved end.

— Henry David Thoreau

Several years ago, I had just finished an enjoyable GA glass cockpit flight with an FAA colleague. During the post flight discussion, he made the following observation. “When it comes to programming the avionics, you know these systems as well as anybody I’ve seen. But you probably don’t have any idea how much time you spent heads-down. There was a lot of traffic out there today.”

Gulp. He got my attention — attention that, during the flight, had admittedly been sucked into the vortex of the shiny multi-colored whiz-bang gadgetry at my disposal in the DA-40 Diamond Star we had been flying. Yes, TIS (Traffic Information Service) was available for most of the flight, but I know better than to regard it as a failsafe and foolproof method of collision avoidance. It was sobering to realize that, without even noticing, I had allowed all the pretty toys in the panel to distract my attention far too much from the serious business of see and avoid. Even more sobering was the knowledge that such failure could easily have resulted in some version of Mr. Thoreau’s “unimproved end.” I’ve never forgotten the lesson, nor have I ceased to mentally replay my colleague’s cautionary comment whenever I fly.

As I began to instruct more frequently in glass cockpit aircraft, I noticed that the eyeball and attention vacuum effect of the glass panel technology was not unique to me. My fellow pilots would similarly fixate not just on periodic programming requirements, but also on monitoring the myriad bits and bytes of flight information on the various glass cockpit displays. In an effort to offer them the kind of awareness my colleague gave me, I sometimes used a stopwatch to provide very specific feedback on how long they really spent in the technological time warp. The attraction to technological distractions is even greater now that so many of us have acquired extremely capable tablets stocked with equally capable flight planning, managing, and monitoring apps.

So what’s a safety-conscious pilot to do? Here are a few pitfalls to see and avoid.

It’s painfully easy to succumb to the subtle tyr­anny of technology. The glorious gadgets tempt us to shirk not only our see-and-avoid responsibilities, but also a vast swath of the flight management work. They lull us away from the discipline of critical think­ing and true situation awareness, a term that implies far more than a position check on the moving map. And, as several air carrier accidents in the past few years demonstrate, highly trained and experienced airline pilots are no less vulnerable to over-reliance on technology and the resulting errors in automation management. So what’s a safety-conscious pilot to do? Here are a few pitfalls to see and avoid.

Mistakes Magnified

The first rule of any technology used in a business is that automation applied to an efficient opera­tion will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency.

— Bill Gates

This observation clearly applies to aviation as well as to business. Technology and automation applied to an actively-managed flight can magnify its safety and efficiency, but when applied to a non-managed flight, they can very efficiently get you into very big trouble. That’s because regardless of how good they are, today’s avionics and handheld devices do not have sufficient intelligence to do more than exactly what we command them to do. If we issue the wrong commands because of inattention or incom­plete understanding of the technology, the flight will potentially go off track in every possible way.

Improper understanding and/or poor manage­ment of technology has also contributed to major air carrier accidents. Remember the 1995 B-757 crash near Cali, Columbia? More recently, how about Air France 447, lost over the South Atlantic on a flight from Brazil to Paris? Or Asiana 214, which crashed while attempting to land at SFO last July?

It’s painfully easy to succumb to the subtle tyranny of technology. The glorious gadgets tempt us to shirk not only our see-and-avoid responsibilities, but also a vast swath of the flight management work.

Knowledge is the key to avoiding this particular technology pitfall. You need to know the equipment cold. When I teach use of GPS moving map naviga­tors, I stress the importance of knowing how to pre­cisely navigate both the mechanical structure (aka the “knobology”) and the library structure — that is, how to efficiently find and display the information you need for any given phase of flight. You need to know its normal and abnormal operations, so you can avoid those pesky and potentially dangerous “what’s it doing” situations. You need to know its limitations — what the technology can do for you and, equally important, what functions are simply beyond its capability.

As Kenny Rogers sang in “The Gambler,” you also need to “know when to hold ‘em, and know when to fold ‘em.” If you find yourself baffled, confused, or in any way uncertain about what the technology is doing, it’s time to turn it off and reorient yourself. That certainly applies to the autopilot, but it also includes panel-mount, hand-held, or tablet-based navigators if you don’t understand where they are taking you — or if you have any doubts as to the safety of the suggested course. Never forget that the magenta line can guide you direct to anywhere … including direct through regulatory obstacles (e.g., restricted/prohibited/controlled airspace), man-made obstacles, or natural ones such as terrain.

Role Reversal

There is a real danger that computers will develop intelligence and take over. We urgently need to develop direct connections to the brain so that computers can add to human intelligence rather than be in opposition.

— Stephen Hawking

We are so beguiled by our electronic tools that we expect them to compensate for functions that we cannot perform. We expect the technology to do not just the work, but also the thinking

Even if you’ve never watched 2001: A Space Odyssey, the story of the spacecraft’s domineering computer, HAL 9000, has long since passed into popular culture. HAL asserts that he is “foolproof and incapable of error.” At least initially, the crew is content to believe in HAL’s infallibility and let their computer run the show. And yes, that decision leads to a bad end.

How often are we aviators guilty of the same thing?

There is no dispute about the astonishing capability and reliability of today’s technology. Tablet flight management apps and panel-mount GPS moving map navigators provide an enormous range of information. Even the most modest GA autopilots can often manage stick and rudder duties far more smoothly than many human pilots. What’s not to like?

The problem is that we humans are so beguiled by our electronic tools that we expect them to compensate for functions that we cannot, or choose not, to perform. We expect the technology to do not just the work, but also the thinking. We are too often content to completely relinquish command and control functions to our on-board technologies. In effect, we implicitly delegate our PIC authority, and entrust our very lives, to mere machines.

Because even our best technologies are thankfully not (yet) up to HAL-like intelligence that can actively decide to assume command, both safety and good airmanship demand that we retain the role of PIC, and that we keep the technology under firm control. Never let the airplane or any of the on-board technology do anything you don’t know about, and — as the cliché reminds — never let the airplane or any of its high-tech equipment take you to any place your brain hasn’t already passed through.


Out of the Loop

I think it’s very important to have a feedback loop, where you’re constantly thinking about what you’ve done and how you could be doing it better. — Elon Musk

Delegating the PIC role to your on-board technology provides a very direct path to loss of situation awareness — more colloquially known as being out of the loop. When I was a student pilot, making my solo cross-country flights in a C152 with only a single nav/com radio, my fear of getting lost motivated a near maniacal focus on positional and situation awareness. In addition to double-, triple-, and quadruple-checking the VOR frequencies and courses, I used pilotage to ensure that I could constantly match features on the ground passing below me to the proper location on my well-worn paper sectional chart.

There is no doubt that GPS provides a much more precise position indication than anything I could have calculated in the pre-moving map Stone Age. Ironically, though, the advent of at-a-glance position awareness capability has sharply diminished the “where-am-I-now” discipline that was the hallmark of being in the loop. When you don’t have to put any mental effort into ascertaining positional awareness, it’s easy to stop paying attention.

If you are lucky enough to have a good autopilot, it’s great to have “George” tend to the basic flying chores while you — at least in theory — focus on more important things … like positional awareness (see above) and, more broadly, overall situation awareness (e.g., status of weather, fuel, engine indications). The challenge, of course, is to actually direct that freed-up mental and physical capacity to those more important positional and situation awareness considerations. That means overcoming the very human tendency to lapse into “fat, dumb, and happy” complacency … complacency that could cause you to miss something like an abnormal indication on an engine gauge.

Avoiding this potential technology pitfall means finding ways to keep yourself continuously in the loop. For example:

  • Use callouts to maintain positional awareness (e.g., “crossing WITTO intersection, next waypoint is MITER intersection”).
  • Annunciate changes to heading, altitude, and frequency.
  • Record those changes in an abbreviated navigation log. The act of speaking and writing bolsters your awareness.
  • Annunciate any change to navigation source (e.g., “switching from GPS to VLOC”) and autopilot modes. I encourage pilots to read each item on the autopilot status display aloud every time there is a change, stating which modes are armed and which modes are engaged.

These practices can be the backbone of the feedback loop Mr. Musk recommends, but you can make it stronger still by peppering yourself with a steady stream of “howgozit” questions about the flight.

Today’s technology provides the foundation for an unprecedented level of situation awareness. We just have to use it for that purpose, and pay attention in order to repel the all-too-human attraction to technological distractions that could detract from flight safety.

Courtesy: The FAA- Susan Parson is editor of FAA Safety Briefing. She is an active general aviation pilot and flight instructor.

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Signs of Inadequate Coping

The indicators of excessive stress often show as three types of symptoms:

  1. emotional
  2. physical, and
  3. behavioral.

These symptoms differ depending upon whether aggression is focused inward or outward. Those individuals who typically turn their aggressive feelings inward often demonstrate their emotions as symptoms of depression,  preoccupation, sadness and withdrawal. The individual who typically takes out frustration on other people or objects exhibits few physical symptoms. On the other hand emotional symptoms may show up as overcompensation, denial, suspicion, paranoia, agitation, restlessness, defensiveness, excessive sensitivity to criticism, argumentativeness, arrogance, and hostility.

Life Stress Management

There are many techniques available that can help reduce the stress in your life or help you cope with it better. Not all of the following ideas may be the solution, but some of them should be effective for you.

  • Become knowledgeable about stress itself.
  • Take a realistic assessment of yourself.
  • Take a systematic approach to problem solving
  • Develop a life style that will buffer against the effects of stress.
  • Practice behavioral management techniques.
  • Establish and maintain a strong support network.

Cockpit Stress Management

Good cockpit stress management begins with good life stress management. Many of the stress coping techniques practiced for life stress management are not usually practical in flight.  Rather, you must condition yourself to relax and think rationally when stress appears. The following checklist outlines some thoughts on cockpit stress management.

  • Avoid situations that distract you from flying the aircraft.
  • Reduce your workload to reduce stress levels. This will create a proper environment in which to make good decisions.
  • If an emergency does occur, be calm. Think for a moment, weigh the alternatives, then act.
  • Maintain proficiency in your aircraft; proficiency builds confidence. Familiarize yourself thoroughly with your aircraft, its systems, and emergency procedures.
  • Know and respect your own personal limits
  • Do not let little mistakes bother you until they build into a big thing. Wait until after you land, then “debrief’ and analyze past actions.
  • If flying is adding to your stress, either stop flying or seek professional help to manage your stress within acceptable limits.

Courtesy: FAA

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Ships of the Air

The Firsts      Copilot and FE

Pan American was the first airline to use nautical terms. Words like “captain” and “stewards” attracted customers used to luxury ship travel. By the early 1930s, airlines were introducing distinctive uniforms for their employees, and women were entering the ranks of flight attendants. Pilots were given military-style uniforms to reflect their status. Pan American emulated luxurious ocean liner service by calling its flying boats “Clippers” and its pilots “Captains,” and attiring its crews in naval-style uniforms with white hats and navy-blue, double-breasted jackets and rank insignia on the sleeve cuffs. Other airlines followed suit. Many of these customs continue today. While Pan Am and other airlines employed men as stewards, Boeing Air Transport introduced the first female stewards. The first stewardess, a nurse from Iowa, Ellen Church wanted to become an airline pilot but realized that was not possible for a woman in her day. So in 1930, she approached Steve Simpson at Boeing Air Transport with the novel idea of placing nurses aboard airliners. She convinced him that the presence of women nurses would help relieve the traveling public’s fear of flying. Church developed the job description and training program for the first stewardesses. She first flew as a stewardess between Oakland and Chicago, and had only served for 18 months when an automobile accident grounded her. After her recovery, she completed her college degree and returned to nursing.

There is still a newness about air travel, and, though statistics demonstrate its safety, the psychological effect of having a girl on board is enormous.”–comment about the addition of stewardesses from an airline magazine, 1935

Credit: Smithsonian National Air and Space Museum
America by Air–Airline Expansion and Innovation 1927-41

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Study Accident and Incident History Data to Avoid Risks

Learn Lessons from Past Mishaps

Robert Breiling, head of the half-century-old Boca Raton, Florida, safety consulting firm that bears his name, just shakes his head when he reviews the causes of recent accidents and incidents. It’s the same story, different day. “Fifty percent of all business aircraft mishaps still occur during approach and landing.”

The proportion of landing accidents, relative to other phases of flight, actually has increased, Breiling notes. That’s primarily due to a plunge in the percentage of accidents between the final approach fix and runway threshold because of the availability of vertical guidance on more ILS, WAAS and FMS approach procedures.

What galls Breiling is the apparent lack of attention on the part of many pilots to the root causes. “Nothing is being done about it. There also has been a marked increase in single-pilot, owner-flown landing accidents in single-engine turboprops and light jets.”

Breiling’s point is that if people don’t study accident, incident and air safety history, drilling down into the root causes of these events, they’re then destined to repeat the same errors. He’s especially concerned by the single-pilot, owner-operator demographic as it has experienced a disproportionately large increase in accidents in recent years.

Owner-flown high-performance turboprops, such as TBM 700-series aircraft, are involved in a relatively large percentage of loss-of-control accidents, many involving stalls during landing and takeoff, resulting in a sudden, sharp wing drop and subsequent ground strike. Low ceilings and visibility were factors in a significant number of accidents. Use of prescription drugs, known to impair judgment and mental acuity, also was a factor in a significant number of single turboprop fatal accidents. Breiling says, however, that considerably fewer Pilatus PC-12 aircraft are involved in such mishaps, perhaps because a larger percentage of these single-engine turboprops are professionally crewed rather than owner-flown. Single-pilot twin turboprops also suffer a significant number of loss-of-control accidents, runway light misidentification causing off-pavement landings, CFIT mishaps and inadequate pre-flight of fuel quantity remaining. Breiling believes that many of the accidents involving N-registered airplanes are the result of the FAA’s not requiring aircraft type-specific pilot training and qualification in most light generation aviation turboprops. “The exception is the Mitsubishi MU-2. When the FAA created a Special Federal Aviation Regulation that required type-specific qualification and recurrency training, the accident rate dropped to near zero.”

Mishap patterns also emerge for turbofan aircraft. Learjet operators, for instance, appear to have more than their share of altitude busts, based upon looking at FAA Aviation Safety Report System data. Gulfstream IV-series pilots seem to be involved in a notable number of runway excursions. In general, business jets are involved in a disproportionate number of altitude deviations caused by pilot input error, FMS database anomalies or lack of proficiency with high-level automation.

Aviation Safety Reporting System

The FAA’s Aviation Safety Reporting System (ASRS) evolved because its safety team realized that, regardless of the development of new technologies, there would be no substantive improvement in accident, incident and violation rates without operators, pilots and air traffic controllers volunteering to provide critical information about inadvertent human errors and lapses in judgment. Historically, the FAA, along with other government agencies, had a tendency to group such honest mistakes with deliberate criminal wrongdoing. While the individual who made the error might have learned from the mistake, the aviation community, as a whole, couldn’t learn from the event because it was kept secret for fear of retribution.

By developing the ASRS, the FAA acquired a means of collecting, analyzing and acting on reports in a non-punitive manner so that others could learn from individual mistakes. Air traffic controllers, maintainers and ground service providers also can file ASRS reports, thereby contributing to the body of knowledge used to help pilots avoid unnecessary risks, to make improvements to the airspace system and to correct maintenance procedures on the ground.

There are a variety of prepared reports available at the ASRS website, including altitude deviations, air traffic controller reports, records of bird or animal strikes, icing encounter reports and crew fatigue records. Reports also are available on CFIT, GPS problems, RNAV navigation and CRM issues, along with fuel management problems, near-midair collisions and runway incursions, plus upsets, special-use airspace penetrations and wake turbulence encounters.

The GPS report, for instance, shows a pattern of GPS signal disruption near the Mateo (SMO) VOR near Mexico City’s Benito Juarez Airport and also in eastern New Mexico near the White Sands Missile Range. Those snippets warn pilots to be wary of depending solely on GPS for IFR navigation in those areas, to fall back on VOR/DME, DME/DME and/or IRS navigation with appropriate adjustments to navigation performance requirements.

As another example, the RNAV report reveals a continuing pattern of pilots not being fully aware of the capabilities and limitations of FMSes. Certain approach procedures may not be contained in FMS databases, step-down fix altitude crossing restrictions may be missing and vertical guidance may not function as required by the published procedure. Such shortcomings prompt pilots to double check each waypoint and crossing altitudes associated with approach and departure procedures, to study and understand vertical navigation functions and to monitor closely the performance of the automation system to assure that lateral and vertical navigation guidance is in accordance with published procedures.

Few turbine business aircraft are involved in inadvertent special-use airspace incursions, according to ASRS reports. However, one Gulfstream V crew, departing Reagan Washington National Airport northbound, reported violating the P-56 prohibited airspace in Washington, D.C., surrounding the White House due to the lack of ATC issued departure procedures or knowledge of required avoidance procedures as contained in the Airport/Facility Directory Special Notices and as charted on the LAZIR FIVE RNAV departure procedure. A Hawker crew reported inadvertently violating a Presidential TFR around Martha’s Vineyard and landing at the airport without prior permission after departing a non-gateway airport.

ASRS is the accident safety equivalent of a canary in a coal mine. It provides early warning indications of safety risks that, if not checked, can develop into major or fatal accidents.

NTSB Aviation Accident/Incident Database

The NTSB provides one of the most-comprehensive online aircraft accident and incident databases of any reporting agency. It supports search queries including dates, places, aircraft and engine types, scheduled and non-scheduled certificated air carrier, and name of air carrier. These filters enabled business aircraft operators to identify risks associated with the aircraft they operate, the types of operations and procedures they typically fly, and the airports they frequent.

Search for accidents and incidents involving Gulfstream IV series aircraft, for example, and you’ll find several post-landing runway excursion mishaps. These events have occurred in the U.S., Canada, France and Africa, among other regions. The most-common themes in these mishaps are the apparent failure to stabilize the aircraft during landing approach, the apparent failure to execute a go-around or missed approach when it was not safe to land and the apparent willingness of the flight crew to attempt to land the aircraft in unsafe conditions.

The NTSB database also indicates a significant number of maintenance-related issues that caused or contributed to GIV-series accidents or incidents, plus a few instances of flight crews failing to conduct thorough preflight inspections. Case in point: One mishap occurred when a crew, before departing on a mission, forgot to reconnect the nosewheel gear linkage after the aircraft was towed.

Search for mishaps around certain airports and many trends become apparent. Teterboro, for example, experiences plenty of challenging weather conditions, gusting crosswinds and contaminated runway conditions. GIV-series aircraft, among other types of turbofan business aircraft, have been involved in several runway excursions when pilots attempted to land there. Few of these mishaps resulted in fatalities, but several caused major aircraft damage.

NTSB data alerts operators to a significant uptick in accidents in older Learjets, high-performance light jets that now can be purchased for well under $1 million but still require top-notch pilot proficiency skills. On Nov. 9, 2014, for example, a Learjet 35A descended more than 1,200 ft. below the 1,349-ft. glideslope intercept altitude at the outer marker on a second ILS approach to Runway 06 at Freeport’s Grand Bahama International Airport, as the crew attempted to land the aircraft visually in hard rain and obscured visibility conditions. The aircraft struck a crane in a shipyard at 115 ft. AGL, shearing off part of the right wing and fuel tank and causing the aircraft to crash into a garbage mound at a recycling plant next to the shipyard, about 1.9 mi. short of the runway. Both pilots and seven passengers were killed.

In November 2013, the crew of a 1979 Learjet 35, repositioning to Cozumel, Mexico, after a medevac flight from Costa Rica, departed Fort Lauderdale International Airport’s Runway 10L. At 2,200 ft. and 200 KIAS, the crew declared an emergency after the aircraft suffered an engine failure. ATC instructed the crew to fly northbound and climb to 4,000 ft. The crew said it was unable to comply and they attempted to return to the airport in VFR conditions. But the aircraft lost altitude and airspeed, crashing into the Atlantic Ocean at close to 150 KIAS according to ATC radar data. Both crewmembers perished as did a physician and flight nurse.

In December 2012, a 1969 Learjet 25, en route at night from Monterrey to Mexico City – Toluca, lost control at 28,700 ft., climbing to FL 370. It then plunged almost 23,000 ft., crashing into 6,766-ft. elevation mountainous terrain at an 89-deg. angle on Rancho El Tejocote due to undetermined causes. However, the aircraft did have a previous damage history and a record of vibration as airspeed increased to 265 KIAS or Mach 0.74. On at least one occasion, the crew thought the vibration was caused by the stall-warning stick shaker, but when they turned off the system, the vibration continued. Mexican accident investigators suspect that both the vibration and loss of control might have been caused by a horizontal stabilizer control malfunction, but at no time did the crew declare an emergency to air traffic controllers nor did they switch the transponder to squawk 7700.

In August 2008, a Learjet 23 crew attempted a short 25-nm night flight from Puebla, Mexico (MMPB) north to Tlaxcala (MMTA). But Tlaxcala had no runway or approach lights and thus was limited to daylight VFR operations. The crew misjudged their position and suffered a CFIT crash short of the runway in a nearby lake that claimed their lives.

In November 2007, a crew of a Brazilian-registered 1981 Learjet 35A departed São Paulo Campo de Marte Airport for a short hop eastward to Rio’s Santos Dumont Airport. On takeoff, the tower noted that the aircraft pitched up at a steep attitude and then rapidly rolled 90 deg. to the right. The aircraft continued its right turn, descending toward a residential area before rolling left and crashing into houses about 1 mi. from Campo de Marte. In addition to the two crew fatalities, six people on the ground were killed on the ground.

FAA Accident and Incident Data System (AIDS)

This is one of the most difficult databases to exploit because the FAA’s AIDS search engine isn’t user friendly and selection information is limited to report numbers, dates, operators and aircraft types. The FAA says this is an accident and incident database, but the records contain only incidents that didn’t result in major aircraft damage. Most reports are generated both by operators’ maintenance or defect reports and by FAA Form 8020-23 aircraft accident or incident reports.

Searches are limited to one aircraft manufacturer or model at one time. It’s not possible to search for the type of event, such as accident or incident, or the severity of accident damage. Clicking on a link brings up a brief history of the event. But when returning to the search results page the hyperlink doesn’t change color, so it’s easy to lose your place on the results page matrix.

In addition, there are numerous errors in the listings. For example, Dassault Aviation obviously does not manufacture Husky Aircraft. But, the Aviat-A-1B is listed as one of Dassault’s models. As another example, Falcon 10 aircraft are powered by TFE731 turbofans, not GE CF700 engines, the powerplants fitted to legacy Falcon 20 aircraft. Jets don’t create prop wash. Hurricanes don’t accompany snowstorms. Falcon 900 aircraft are not Falcon 50 aircraft, even though the larger jet is grandfathered on the original Falcon 50 type certificate.

Nonetheless, much can be learned from visiting this site. Of the more than 300 Falcon Jets incidents on file, for instance, there only are seven involving Falcon 50 series aircraft. There was only one record of an engine failure, an event that occurred when the center engine failed as the aircraft climbed through 9,000 ft. Lesser events include ruffling the control surface feathers of a Cessna CE421 Golden Eagle with jet blast when leaving the ramp of an FBO, a minor ground wingtip to wingtip collision and hail damage while an aircraft was en route from Broomfield, Colorado, to Oklahoma City.

Falcon 10 aircraft suffered a significant number of TFE731 engine failures, according to AIDS records. Most were handled without incident by proficient flight crews. Falcon 900 series aircraft also suffered a substantial number of TFE731 engine malfunctions, but none resulted in an aircraft accident.

Having excellent short-field capability, Dassault Falcon Jets can use general aviation airports with shorter runways than can some other large-cabin business aircraft. As a result, they may operate on narrow runways and taxiways and in close proximity to light aircraft, fences, unlighted obstacles and wildlife. Runway excursions are rare, according to AIDS records, but there have been several instances of bird or deer strikes, minor ground collisions and even a few general aviation aircraft that have been damaged by jet blast.

Big Picture and Context

It takes substantial time and effort to mine all available databases. To learn the lessons of history applicable to your flight operations, you need to retrieve and review accident and incident reports by aircraft type, by airport and by weather condition, among other variables. Sift through the reports and you’ll find where there are significant risks of engine and systems malfunctions, runway excursions, wildlife strikes and ground collisions.

Probe deeply into accident details and you’ll discover that pilots make fatal errors in judgment due to external pressures. Otherwise preventable accidents occurred when pilots “were dying to complete the flight” because of their perceptions of passenger expectations for mission success. Forensic investigation into the fatal accidents involving a GIV departing Bedford, Massachusetts, in May 2014, a GIV landing mishap at Le Castellet, France, in July 2012 and a GIV runway crash at Bukavu-Kavumu in the Democratic Republic of the Congo, among others, all appear to involve flight crews’ yielding to external pressures.

Studying accident and incident histories can help flight departments develop risk assessment and reduction toolkits. For instance, if you’re planning a flight into an airport that has a history of large-cabin aircraft runway excursions in wet and windy conditions, if you’re on a time-sensitive mission with key passengers aboard and if available runway length is an issue for the type of aircraft you operate, then you might want to carefully assess the risks associated with using that landing facility. The average age of the business aircraft fleet, particularly in the light and midsize segments, is getting older. Accident and incident reports clearly indicate that older aircraft are involved in more mishaps than newer aircraft. Pilot training, judgment and proficiency are factors, as are substandard maintenance practices. Pilots of older aircraft tend to miss more discrepancies on preflight inspection that result in mishaps, according to accident records.

In addition, Breiling notes that veteran captains with 10,000 to 15,000 logged hours, or more, may be susceptible to complacency regarding such risk factors, based upon his examination of accident reports. Having flown accident free for their entire careers, they may not appreciate that they’ve been extraordinarily lucky during their careers not to have suffered a mishap. A proactive approach to safety requires operators to be aware of specific aircraft type, airport, weather condition and external pressure risk factors. But the only sure way to avoid risks associated with past accidents and incidents is to study mishap history. The databases are available online at no cost to website visitors. Invest the time to learn from others’ past errors and misfortunes and you’ll substantially increase your immunity from suffering the same problems.

Courtesy: Business & Commercial Aviation, Feb 2, 2015:  Study Accident and Incident History Data to Avoid Risk by Fred George

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