FINAL REPORT (EXCERPTS)
AIRCRAFT ACCIDENT INVESTIGATION INTO M/s BHOJA AIR FLIGHT BHO-213, BOEING 737-236A, REG # AP-BKC CRASHED ON 20th APRIL 2012 NEAR BBIAP, ISLAMABAD
On 20th April 2012, M/s Bhoja Air Boeing 737-236A Reg # AP-BKC was scheduled to fly domestic Flight BHO-213 from Jinnah International Airport (JIAP) Karachi to Benazir Bhutto International Airport (BBIAP) Islamabad. The aircraft had 127 souls onboard including 06 flight crew members. The Mishap Aircraft (MA) took off for Islamabad at 1705 hrs Pakistan Standard Time (PST) from Karachi. The reported weather at Islamabad was thunderstorm with gusty winds. During approach for landing at BBIAP, Islamabad (OPRN), Flight BHO-213 was cleared by Islamabad Approach Radar for an Instrument Landing System (ILS) approach for Runway 30 (three zero). The MA, while established on ILS (aligned with Runway 30 at prescribed altitude) at 6 miles to touchdown was asked by the Approach Radar to change over to Air Traffic Control (ATC) Tower frequency for final landing clearance. The cockpit crew came on ATC Tower frequency and flight was cleared to land at BBIAP, Islamabad, but the cockpit crew did not respond to the landing clearance call. The ATC Tower repeated the clearance but there was no response. After a few minutes, a call from a local resident was received in ATC Tower stating that an aircraft had crashed close to Hussain Abad (A population around 4 nautical miles short of runway 30 BBIAP, Islamabad). It was later confirmed that Flight BHO-213 had crashed and all 127 souls onboard (121 passengers + 6 flight crew) had sustained fatal injuries along with complete destruction of aircraft.
Cockpit Crew Information. There was a set of two pilots onboard the aircraft including one Captain and one First Officer. The details are as under:
- Date of Birth: 15 February 1954
- ATPL # 948 (A)
- Medical Validity Date: 30 September 2012
- Total Flying Experience: 10158:20 hrs
- Flying Hrs on B737-200: 2027:00 hrs
- Flying Hrs on B737-236A: 82:30 hrs
- CRM Refresher Validity: 30 April 2013
First Officer (FO)
- Date of Birth: 30 April 1958
- CPL# 2934 (A)
- Medical Validity Date: 31 May 2012
- Total Flying Experience: 2832:00 hrs
- Flying Hrs on B737-200: 750:00 hrs
- Flying Hrs on B737-236A: 82:00 hrs
- CRM Refresher Validity: 28 February 2014
Cockpit Crew History, Flying Experience and Medical Fitness
The Captain was born on 15th February 1954. He belonged to village Babari Banda, Post Office Billitang, Distt Kohat but he was residing at Malir Cantt, Karachi with his family.
- As per the medical investigation / analysis, the Captain was fit to undertake the mishap scheduled flight (refer Medical Analysis).
- He was issued ATPL # 948 initially on 26th March 1996 which was renewed and valid up to January 2013.
- He possessed valid medical Class 1 till 30th September 2012. He possessed valid IRA-ME on Boeing 737/100-200 aircraft till January 2013.
- He possessed a very rich flying experience of military as well as commercial aircraft.
- He had served as a Captain of Boeing 737-200 in Shaheen Air International (SAI) before joining Bhoja Air.
- He was selected for Boeing 737-400 ground training in one of the batch of cockpit crew. However, he was taken off from the said training due to his past flying experience of semi-automated aircraft. It was felt at the supervisory levels of SAI that he may not be able to manage the automated flight deck effectively, efficiently and safely. As a reaction to discontinuation of his Boeing 737-400 aircraft training in SAI, he decided to leave the SAI and join Bhoja Air. It is important to note that mishap Bhoja Air Boeing 737-236A variant aircraft was equipped with automated flight deck.
The First Officer (FO) underwent his secondary education at Cadet College Hassan Abdal and then joined PAF as a cadet where his performance remained above average during his training before commencement of his flying training.
- During his initial flying training, he suffered from airsickness problem which adversely affected his flying performance and resulted in his under confident behaviour in flying profession.
- FO possessed a valid CPL # 2934 renewed up to July 2012.
- FO remained an under confident individual and could just perform average during his stay as first officer in Shaheen Air International (SAI).
- At SAI, he got the chance to fly with Captain. First Officer found refuge in the fatherly personality of the Captain who also started to provide him the required shelter.
- When Captain decided to leave SAI and join Bhoja Air, FO probably again felt insecure and under confident. He left SAI after flying his last flight on 15th January 2012 before joining Bhoja Air.
Aircraft Information. The Boeing 737-236A (Reg # AP-BKC) aircraft was inducted on the inventory of M/s Bhoja Air in January 2012. The detailed aircraft and engine related data is appended below:
- Aircraft Make and Model: Boeing 737-236A
- Manufacture Serial # 23167
- Aircraft Inducted in Bhoja Air: January 2012
- Registration Marking: AP-BKC
- Aircraft Line # 1074
- Year of Manufacture: 1985
- Total Hours at Induction: 46863.56
- Total Flight Hours at Crash: 46933.06
- Total cycles at Induction: 37783
- Total Flight Cycles at Crash: 37824
- Total hours/Cycles flown with Bhoja: 69.10 / 41
The details of engines installed at the time of crash are as below:
ENGINE # 1(Left); ENGINE # 2(Right)
- Engine Type and Model JT8D-15A; JT8D-15A
- Engine Serial Number 700469; 709211
- Total Hours at Induction 33666; 49398
- Total Cycle at Induction 19483; 36615
- Total Hours at Crash 33724.20; 49456
- Total Cycles at Crash 19521; 36653
The daily inspection / servicing of mishap aircraft was carried out on 20th April 2012 prior to the departure of Flight BHO-213 and no defect was recorded. No anomaly in the aircraft system performance was recorded before and during the flight till mishap aircraft impacted the ground 4.2 nm short of runway 30 at BBIAP, Islamabad.
- The aircraft encountered a storm cell during approach which was capable of producing strong downdrafts. The mishap flight encountered two downdrafts reaching maximum of 40 fps [2400 fpm] and 50 fps [3000 fpm], respectively. The second downdraft gradually increased over 15 seconds as the aircraft descended from 3500 feet altitude above sea level to approximately 2500 feet altitude above sea level.
- While in this downdraft, both autopilot channels were observed disconnected, but the auto-throttle remained engaged. For approximately 6 seconds following autopilot disconnect, no control wheel activity was recorded, and no physical control column activity was recorded for approximately 8 seconds.
- During this period of control inactivity altitude, pitch attitude, and thrust continued to decrease. A ground proximity warning sounded, which resulted in the Captain commanding nose-up control column inputs but thrust and altitude continued to decrease while airspeed started to increase. The downdraft dissipated, resulting in a rapid increase in angle of attack which momentarily activated the stick shaker. In response to the stick shaker, the cockpit crew commanded nose-down column and the stick nudger activated for almost 2 seconds. The Captain commanded nose-down control column inputs continued until the end of the data. The thrust remained at a low level and pitch attitude decreased to approximately 12 degrees nose down, resulting in an increase in airspeed and further decrease in altitude prior to the end of data.
- The analysis showed that when the simulation was driven at Boeing facility with the FDR data, the resulting flight path closely matched the FDR flight path which confirmed that the aircraft’s motion was due to the recorded control inputs and calculated atmospheric conditions.
- Therefore, cockpit crew ineffective management of thrust, altitude, and flight path in turbulent atmospheric conditions resulted in ground impact short of the runway.
- The investigation team discussed at length the factors which could have contributed towards ineffective management of thrust, altitude, and flight path by the cockpit crew despite knowing the associated dangers while operating aircraft into such a weather phenomenon. For these reasons the cockpit crew’s history and their professional competence at various stages of their flying career were specifically focused to find out all possible factors which could have directly or indirectly contributed towards this type of ineffective management by both the Captain and FO.
|Operational Analysis||Operational Findings|
|The operational analysis in the proceeding paragraphs is based on the data collected from various sources inclusive of FDR, CVR, wreckage and expert agencies’ inputs:||
|The mishap Flight BHO-213 was the first evening scheduled flight of Bhoja Air from Karachi to Islamabad.||
|At JIAP, Karachi the start-up, push back and taxi remained un-eventful. The mishap aircraft took off at 17:05:30 hrs for destination and climbed to FL310 en-route to Islamabad.||
|The FDR data was available for last 26 hours.||
|The FDR data indicated the engagement of autopilot command A at 17:05:50 hrs.|
|The aircraft (systems and sub-systems along with both engines) response was consistent with each other and as per the design performance parameters of JT8D-15A aero-engines.||
|The flight climb profile was consistent with a normal climb and at 17:27:00 hrs; the MA levelled off at FL310.|
|At 18:08:04.7 hrs, the cockpit crew monitored the Lahore ATIS broadcast and were aware of the overall weather picture.||
|At 18:08:05.6 hrs, Captain came on PA system and announced “it will be cloudy weather and thundery activity is also there and let’s see. Wahan ja kar dkhtay hein kaisa weather hai (we will go there and see how is the weather there). Temperature 25 degrees hai wahan (there temp is 25 degrees). Jab ham pohanchen gay to ho sakta hai keh barish bhi ho to Insha Allah tala abhi thori der main Lahore nazar aay ga (when we reach there maybe it would be raining anyway God willing after some time we will see Lahore on our right).||
|At 18:08:31.7 hrs, Captain continues with the route brief about the cities along the way.|
|At 18:08:50.3 hrs, Captain briefs the FO that he had briefed the passengers of light turbulence ahead.|
|At 18:09:15.1 hrs, Captain astonishingly questions the runway 18L in use at AIIAP, Lahore and FO informs him that wind is from 230 degrees. Captain responds that the winds are blowing from unusual direction at Lahore.||
|At 18:09:58 hrs, FO informs the Captain that Lahore has a weather warning for dust thunderstorm up to 2030 hrs.||
|At 18:10:14 hrs, Captain sings in a traditional qawali tone / style “Sadi kismet which chain say jina likh day (Let there be peace in my life also)”.|
|At 18:10:32.5 hrs, Captain and FO discussed Lahore as first alternate and Peshawar as second alternate.||
|At 18:15:01.8 hrs, Captain tells the cabin crew (flight attendant) while referring to weather radar, to inform the passengers, if the same weather persists at Islamabad, there will be lot of bumps. Captain was foreseeing a bad weather conditions while approaching BBIAP, Islamabad.||
|From 18:15:24.8 hrs till 18:17:05 hrs, Captain and FO discussed landing procedures for runway 12 and 30 at BBIAP, Islamabad including circle to land procedure.||
|At 18:17:53.2 hrs, Captain sings few lines of traditional Punjabi song “Sanoo nahar wali pul tay bula kay” (you called us on the canal bridge) and FO comments laughingly.|
|At 18:18:17.9 hrs, FO asked the Captain “Sir Peshawar ka bhi lay loon” (Sir should I take Peshawar weather).||
|At 18:18:19.4 hrs, Captain said “na na na Allah malik hay” (No God will help us). Probably Captain wanted to avoid diversion.|
|At 18:19:41.9 hrs, Captain said “Oh ho ho, yeh to pura hai yar” (Oh my God this is all over). Probably at this particular moment, Captain at a distance observed the squall line weather.||
|At 18:20:26.9 hrs, FO asked Captain “Sir descent kitna rakhan gay?” (Sir what would be the descent?) and again asked “hundred”.|
|At 18:20:31.7 hrs, Captain replied “Ah – hah”. At this moment Captain was probably pre-occupied due to the bad weather in front and not listening to FO attentively.|
|At 18:20:38.4 hrs, Lahore Approach called “Bhoja 213 approaching position MATIN, pilots discretion descent (flight) level 200, report leaving (flight level) 310”.||
|At 18:21:12.1 hrs, FO told Captain that he had put the seat belt sign “ON” and simultaneously a single chime like cabin sign change was heard.||
|At 18:21:21.6 hrs, flight attendant made announcement first in Urdu and then in English about the seat belt sign “ON” due to the possibility of turbulence.||
|At 18:21:22.7 hrs, FO informed Lahore Approach “Bhoja 213 leaving ah 310 for 200” and subsequently added “we will call you INDEK Bhoja 213”.|
|The flight commenced descent with Engine Pressure Ratios (EPRs) to approximately 1.0 which is consistent with flight idle setting.||
|At 18:22:00.5 hrs, Captain told FO “aik hazar honay do. Aik hazar honay do” (let it descend through one thousand feet. Let it descend through one thousand feet).|
|At 18:22:09.9 hrs, FO asked Captain “Sir, lights ON kar lain apni (sir put your lights on).|
|At 18:22:29.3 hrs, FO told Captain “Sir, QNH standby par 1009 laga lain (Sir put 1009 on your standby).|
|At 18:22:43.9 hrs, FO told Captain “Sir, one is one, aha both to Islamabad”.|
|At 18:22:47.2 hrs, Captain asked “both of them?”|
|At 18:23:42.5 hrs, Captain humming sound is heard.|
|At 18:23:54.6 hrs, Captain humming sound is heard again. Probably it is indicative of the anxiety of Captain about prevalent approaching weather.||
|At 18:23:56.2 hrs, FO told Captain “Ham say thora aagay lagta hai” (it seems to be slightly ahead of us). The cockpit crew worried about the weather and their apprehensions along with their state of mind, determined to land at BBIAP, Islamabad as it was the Bhoja Air first flight in the evening on KHI- ISB-KHI.||
|At 18:23:59.3 hrs, Captain asked FO “Kia?” (What?).||
|At 18:24:00.5 hrs, FO told Captain “yeh ah C-B” (this ah C-B).|
|At 18:24:03.1 hrs, FO told Captain “nahin yeh to eighty par baitha hua hay”(no it is sitting at 80 miles). FO is also observed participating actively in the interpretation of changing weather picture / conditions.|
|At 18:24:05.8 hrs, Captain said “kia? han han” (what? yes, yes). Probably it is also indicative of mental pre-occupation of Captain.|
|At 18:24:17.9 hrs, FO informed Captain “cabin descending, descent and approach checklist please”.|
|At 18:24:22.4 hrs, Captain told FO “yeh series hai, acha” (this is a series, okay).|
|At 18:24:26.8 hrs, FO acknowledged as by saying yes to Captain briefing.|
|At 18:24:27.7 hrs, Captain continues the briefing to FO “iss ko squal line kahtay hain” (it is known as squall line). Captain was seemed worried about the severity of weather in-front, however, they were not very clear about the exact location of the squall line at this moment.||
|At 18:24:29 hrs, FO told Captain “Sir, anti-ice?”.|
|At 18:24:38 hrs, FO told Captain “Temperature is minus nine sir”.|
|At 18:24:43.9 hrs, FO carried out his cockpit checklist actions.|
|At 18:24:58 hrs, Captain told FO “main speed barha raha hoon, 280 kts kar raha hoon” (I am increasing the speed, I am taking it to 280 kts) and FO acknowledged it. The speed was increased to 280 kts as it is the OEM recommended speed for turbulence.||
|At 18:25:03.2 hrs, Captain told FO “kuch agar ho gia to ham iss ko, we will maintain this theek hai na” (if anything happens then we will maintain this okay) and FO acknowledged it by saying “right sir”.|
|18:25:49.6 hrs, FO clears his throat (sound is heard) and told Captain “yeh paray ga” (this will affect us). The FO analysis of weather at this particular time is that they were most likely to enter the squall line / bad weather area.||
|At 18:25:54.1 hrs, FO again told Captain “yeh wala lagay ga, hain na sir?” (this one will affect, isn’t it sir). FO is sharing his concerns with Captain and indicating his analysis of encountering the bad weather en-route to BBIAP, Islamabad|
|At 18:25:57.5 hrs, Captain told FO “chakar mar kay aain” (take a round and come back). Captain had also realized the severity of the weather / presence of squall line and wanted to avoid entering the bad weather but intended to continue for destination.||
|At 18:26:05.2 hrs, Captain suddenly said “ooohhh”. Probably after experiencing some turbulence he said this.|
|At 18:26:19.4 hrs, Captain told FO “iss ko call day keh permission to change over to the route” (give him a call that permission to change over to the route).|
|At 18:26:23.2 hrs, FO coordinates with Lahore Approach and at 18:26:40.5 hrs coordinates with Islamabad Approach for approaching INDEK||
|At 18:26:54.1 hrs, Islamabad Approach identified Bhoja 213 and cleared flight to Islamabad via POMAR ONE FOXTROT arrival and informed to expect vector ILS runway 30. Flight was also cleared to descend to 9500 ft on QNH 1009 when ready. The said instructions were acknowledged by FO at 18:27:09.4 hrs.||
|At 18:27:20.6 hrs, Captain said “idhar say nikal jayen gay” (we will go from this side)|
|At 18:27:21.4 hrs, Islamabad Approach asked Captain “and ahhh Bhoja asslam o alaikum (greetings) if able can you give us ahh weather brief on Islamabad?”||
|At 18:27:28.8 hrs, Captain briefed Islamabad Approach “yah, it is a squall line through out from the (ah) almost it is going from 19 miles (ah) from the western side that is the (ah) my heading is 300 … and there is no gap…to come inside, so is it possible that I go and come from the (ah) west?” to here). From the abovementioned discussion between radar controller and captain it was evident that they both considered the prevalent weather covering BBIAP, Islamabad approach and there was apparently small gap for BHO-213 to penetrate the squall line.||
|At 18:28:22.5 hrs, Captain told Islamabad Approach “(ah) that is (ah) very small one, let me try on that one han (okay)”. As per operator Operational (Ops) Manual (approved by CAA Pakistan), Bhoja aircraft should avoid thunderstorm by at least 5 to 10 nm. Captain intentionally continued for destination while disregarding the documented procedures.||
|At 18:28:27.4 hrs, Islamabad Approach acknowledged by saying “roger”.|
|At 18:28:02.6 hrs, Islamabad Approach apprised Captain “Bhoja 213 (ah) radar is not observing any gap towards west, however I am observing some kind of gap (ah) between radial 160 to radial 220.|
|At 18:28:17.3 hrs, FO told Captain “theek hay na, iss main say nikal lain na, yeh 160 say 220 yahan tak” (it is right you go through from 160 to 220 up|
|At 18:28:32.4 hrs, Captain commented “yeh…iss pay ja sakta hoon” (this, I can go on this).|
|At 18:28:35.7 hrs, FO acknowledged and suggested to Captain “ji (yes), iss ko kaheen sir radar vector hamen kara day” (tell him he should give us radar vectors||
|At 18:28:39.8 hrs, Captain asked Islamabad Approach “ahhh… is it possible if I turn just now on a heading of uhm 040 degrees, there is some gap”.||
|At 18:28:53.2 hrs, Islamabad Approach told Captain “040 degrees from present position might not be feasible because ahhh because of the close proximity of Tilla range…however touching position ah INDEK you can turn right on to heading 040 degrees and ah confirm from 040 degrees heading you will be intercepting direct for final runway 30”. Captain acknowledged by saying yes at 18:28:59.2 hrs.||
|At 18:29:17.1 hrs, FO suggested to Captain again “issay kahen keh hameain radar vector day” (tell him he should give us radar vector).|
|At 18:29:18.3 hrs, Captain requested Islamabad Approach “…can you give me radar vectoring because there is small gap but that will be in between the almost thund—C-Bs?”|
|At 18:29:28.9 hrs, Islamabad Approach asked the Captain “ah understand are you picking up any weather ah towards southeast of Islamabad ah at a distance of about ah 10 to 15 miles”.||
|At 18:29:41.1 hrs, Captain told Islamabad Approach “ah nah negative, till 40 miles there is no not at all”.||
|At 18:29:45.1 hrs, Islamabad Approach advised Captain “roger, you can turn right onto heading 360 degrees vectors ILS runway 30. Pilot discretion descent 6500 ft”.|
|At 18:29:52.7 hrs, Captain acknowledged the Islamabad Approach and added “yes you are right uhm I can come because till 40 miles there is nothing, it is all towards the northern side”. Islamabad Approach also acknowledged by saying “affirm sir”.||
|At 18:30:19.1 hrs, Captain and FO discussed their altitude to descend and then FO confirmed clearance of descend to 6500 ft from Islamabad Approach.||
|At 18:30:31.0 hrs, Captain and FO selected few settings and acknowledged to each other.|
|At 18:30:34.9 hrs, Captain told FO “yar larki ko kah do in ko bitha dain” (tell the girl to make them sit).||
|At 18:30:45.9 hrs, FO announced on PA system “cabin crew take positions for landing please”. The cockpit crew probably were experiencing lot of turbulence at this moment and FO mistakenly made announcement for cabin crew to take positions for landing when they were still descending for 6500 ft.|
|At 18:31:05.8 hrs, Captain suddenly said “what”. Probably Captain realized the mistake of FO and showed his concern over the announcement.|
|At 18:31:08.1 hrs, FO suggested to Captain “yeh hammain right pay nikalna chahiyeh idher” (we should come out to the right here). FO suggested to Captain after his interpretation of weather picture that probably they should go towards right to avoid bad weather area.||
|At 18:31:10.4 hrs, Captain said “nahin, nahin, jana hi nahi hay ham nay, idhar land karna hay” (no no we don’t have to go there, we have to land here). It is evident from Captain’s remarks that he had made up his mind to land at destination irrespective of prevalent weather conditions during approach to BBIAP, Islamabad.||
|At 18:31:15.0 hrs, Captain told Islamabad Approach “Mukhtar very nice, it was very nice whatever you told me”.||
|At 18:31:20.5 hrs, Islamabad Approach thanked Captain as acknowledgement.|
|At 18:31:31.7 hrs, Islamabad Approach exchanged greetings with Captain while telling him his name as Mukhtar and asked him how he is.|
|At 18:31:34.9 hrs, Captain asked Islamabad Approach “oy sir khariat say hain (hey sir you are well) thank you very much God bless you”. At this time, it appeared that cockpit crew became relaxed and comfortable.|
|At 18:31:38.5 hrs, Islamabad Approach told Captain that he was talking to him after a very long gap and Captain laughed.|
|At 18:31:45.6 hrs, Captain told Islamabad Approach “bari achchi Masha Allah very nice actually yeh main nay ghalat kar diya tha (very good by the grace of God, very nice actually I did it wrong). I was going quite far away.”||
|At 18:31:52.0 hrs, Islamabad Approach briefed Captain and said “laikin sir main dekh raha tha keh uss side pay zara weather hay yeh shaid beech mein zara thora sa area zara clear banta hey (but in between on the other side this was the only clear which was slightly clear), laikin iss heading kay uopar bhi (but on this heading as well) after another about thirty miles you might intercept ah little bit of precipitation till intercepting the localizer”.||
|At 18:32:06.9 hrs, Captain told Islamabad Approach “very nice Masha Allah (by the grace of God), I just used to get it once I was in the abroad, such beautiful weather, very nice”.|
|At 18:32:20.2 hrs, FO while carrying out his cockpit checks told Captain of aircraft crossing 10, 000 ft of altitude.||
|At 18:32:24.8 hrs, FO asked Captain to keep the gasper ON or OFF which was replied by Captain as “han? (what?) ON karo (let it be ON)”.|
|At 18:32:31.0 hrs, Captain shared his apprehension of weather conditions with FO and said “bara zoor iss nay diya, aisay ghabrai huway they hum (it has kept us under pressure and we were afraid for nothing)”. At this moment Captain seemed to be quite relaxed and comfortable as far as the prevalent weather conditions were concerned.||
|At 18:32:41.6 hrs, Captain said to probably the jump seat occupant “yeh teri ammi ki wajah say hai (it is because of your mother)”. The occupant on jump seat was a non-operating cabin crew travelling on mishap flight accompanying his mother to his home station. This individual in no way had any contribution to the causation of accident.||
|At 18:32:48.5 hrs, Captain again said to probably the jump seat occupant Ámmar cigarette pee raha ji, ji han (Ammar is smoking, yes he is)” and it was followed by a laughter and then Captain at 18:32:56.1 hrs said “mera kiya jata hay (how does it affect me)”.|
|At 18:33:37.7 hrs, Captain briefed and asked FO “sara north pay hay dekho na, wo dekh rahay hain? Bijli chamak rahi hay (look all of it is in the north, can you see that? It is lightening)” and FO acknowledged by saying “sir”. Till now the Flight BHO-213 had encountered turbulence but had not entered the bad weather.||
|At 18:33:45.5 hrs, Captain shared a joke with FO in Punjabi dialect “hoon bahir say ji tussi jao” and FO laughed in reply.|
|At 18:33:48.3 hrs, FO asked the Captain about levelling off and in reply immediately Captain said “acha pahlay batana tha (okay you should have told me earlier)”.|
|At 18:33:56.2 hrs, Islamabad Approach cleared the flight to continue descent to 5500 ft and the instructions were acknowledged by FO. After this various sounds e.g., stretching and electronic fluctuations were heard on CVR recording for few seconds.||
|At 18:34:49.4 hrs, Captain told FO “ILS my side, ILS number one”.||
|At 18:34:54.8 hrs, FO told the Captain “final course is set sir, minima are set, speeds are set”. According to the SOPs requirement neither ATIS ISB was obtained by the cockpit crew nor the formal approach briefing was conducted by the Captain. However, FO reminded the Captain for setting of minima for the landing||
|At 18:35:00 hrs, the flight levelled off at 5,500 feet altitude above sea level and glide slope deviation A became active.||
|The altitude of 5,500 feet was maintained for 80 seconds and during this time both engines responded normal. The aircraft maintained Indicated Airspeed (IAS) Speed mode on descent through 4500 feet with autopilot and auto throttle engaged.||
|At 18:35:03.3 hrs, FO informed Captain “recheck speed 133, 138, 148”.||
|At 18:35:06.5 hrs, Islamabad Approach gave instructions to the flight and said “Bhoja 213 after five miles descend 3900 ft” and the said clearance was acknowledged by FO which indicates that Captain was PF and FO was PNF at this time and everything appeared normal in the cockpit.||
|At 18:35:36.1 hrs, there was first a laughter and then suddenly Captain said “wo gia (that has gone)”. Probably some lightening / weather phenomenon occurred which was observed and referred by the Captain.|
|At 18:35:39.6 hrs, Islamabad Approach gave weather update of BBIAP, Islamabad and said “Bhoja 213 surface wind at Islamabad ah is varying between 180 degrees to 270 degrees,10 kts and ah sometimes gusting to 20 kts and runway condition is wet, light drizzle is ah uhm going on, braking action not known” and Captain acknowledged it by saying “thank you very much, sir”.||
|At 18:36:06.7 hrs, Captain asked FO “3900 na (3900 ft ok)” and FO acknowledged by saying yes sir.|
|At 18:36:36.0 hrs, Captain commented on weather and told FO “yeh khulta nahin hay aur (it does not open anymore)” and probably FO did not understand due to which Captain repeated again “yeh khulta nahin hay aur (it does not open anymore)”.||
|At 18:36:38.5 hrs, FO replied and said “yeh jo hay na ahh (this one ahh), 10 miles, 15 miles darmian main hai yeh goodarh (the problem is in between 10 and 15 miles), hamarah abhi 14 hai miles (we still have 14 miles to go)”. At this moment squall line was at 10 to 15 miles away from aircraft and the aircraft was at 14 DME from BBIAP, Islamabad.||
|At 18:36:45.8 hrs, Captain said “uh exactly overhead hai (it is exactly overhead)”. Captain is confirming to FO that the squall line is exactly overhead BBIAP, Islamabad.||
|At 18:36:50.2 hrs, FO shared with Captain “so…we are likely to get very close to it”. It can be deduced from above discussion of cockpit crew that they had no confusion of their ending up very close to the squall line / prevalent adverse weather conditions.||
|At 18:36:55.3 hrs, Captain suddenly said “we are already, wo hit kar gia hay hamain (it has already hit us)” and then at 18:36:58.0 hrs, Captain again said “ussi waqat hit karay ga hamain (it will hit us at that time)”. Probably at this particular time, they experienced precipitation which alarmed the Captain however, after few seconds he realized that the severity of squall line was still close to the aerodrome.
|At 18:36:59.1 hrs, Captain said “one to go” and it was acknowledged and checked by FO.||
|At 18:37:15.1 hrs, FO commented on prevalent weather and said “jab ham turn Karen gay na idhar to it get ah thora intense (when we will turn this side then it will ah get slightly intense).||
|At 18:37:18.8 hrs, Captain suddenly said “haaa dark ho gia (haaa it has become dark)”. Now by this time, cockpit crew was very clear that they were actually entering the squall line / bad weather conditions but did not take a decision as per Bhoja Air (CAA approved) Operational Manual to discontinue the approach to the destination.
|At 18:37:25.2 hrs, radio altimeter alarm is heard. At this time the aircraft was passing through 2500 ft above ground level (AGL).
|At 18:37:26.5 hrs, Captain said “checked”.|
|At 18:37:28.9 hrs, Captain said “airspeed reaching 210 kts, flaps one” and it is acknowledged by FO.||
|At 18:38:07.5 hrs, Islamabad Approach advised mishap flight “Bhoja 213 turn left heading 3400, cleared ILS runway 30, report established” and the clearance was acknowledged by FO.||
|At 18:38:08 hrs, slats were extended to mid position. Additionally, during this time, the leading edge flaps transitioned to the full extended position.||
|At 18:38:10 hrs, the landing gear lever was selected to down position. The aircraft landing gear were selected to down position when the aircraft had not turned on the intercept heading for the ILS approach.||
|At 18:38:13 hrs, as the aircraft approached the target altitude, the autopilot transitioned into Altitude Select mode. At the same time, while in Heading Select mode, a left turn was initiated to intercept the localizer. The aircraft maintained an approximate 200 bank angle during the turn the Heading Select mode was de-selected while in the middle of the turn, and no recorded roll mode was engaged for the next 10 seconds. At this particular time, it is felt that Captain de-selection of heading select mode indicates his lack of confidence on automation.
At 18:38:16 hrs, the aircraft started to roll left till approximately 200 to 230 angle of bank followed by a momentary right roll to approximately 150. Subsequently the aircraft again roll left to approximately 300 angle of bank
|At 18:38:24.7 hrs, FO told Captain “speed 220” and immediately Captain responded by saying “haan? (what?)”. At 18:38:27.4 hrs, FO again repeated his information of speed 220 kts. The airspeed of aircraft with flaps to 1 position is supposed to be 190 kts, however, it was 30 kts higher than the recommended speed.||
|At 18:38:29.1 hrs, Captain in highly surprised tone asked FO “220, oh shit yeh kia hua yar? (oh shit what has happened?” Captain realized that with auto-throttle engaged the speed of aircraft should not have increased to 220 kts, however, probably he could not correlate the variation of aircraft speed to the presence of wind shear.||
|At 18:38:31 hrs, the thrust was increased as the aircraft began to level off at the target altitude (~ 3600 feet above sea level altitude). Ten seconds later, the autopilot transitioned to Altitude Hold mode that was likely selected on the MCP.||
|At 18:38:34.0 hrs, FO informed Captain to turn left 3400 as they had been cleared for ILS. The cockpit crew turned left to intercept the localizer with flaps at position 1 and landing gears down.||
|At 18:38:35.8 hrs, Captain seemingly in extreme anxiety said “oh”. At this time probably the intercept heading of 3400 for the ILS approach had been delayed.|
|At 18:38:37.4 hrs, sound of light to moderate precipitation began and simultaneously Captain said “oh shit”. The precipitation continued with varying intensity, until end of the recording / aircraft ground impact. At this particular moment, the aircraft was flying through the active weather cell. FO was also seemed unaware and ignorant of the severity of weather & its implications and did not recommend discontinuation of the approach||
|At 18:38:39.3 hrs, FO asked Captain “should I give you both on ILS”?||
|At 18:38:41.3 hrs, Captain asked FO “han yeh garhbarh hai, yeh kuun nahi hua (yes there is a problem, why it has not happened?)” Captain seemed to be extremely pre occupied and worried about the flight parameters variations and bad weather effects on the flight at that particular moment.||
|At 18:38:43.4 hrs, FO informed Captain “both on ILS?” and Captain replied “han ILS day do mujhay (yes give me the ILS)” in a highly low energy tone and with pre-occupied mind.||
|At 18:38:45.8 hrs, FO told Captain “auto armed”. The cockpit crew had the autopilot and auto-throttle engaged.
At 18:38:48 hrs, the glide slope deviation B became active and tracked similarly with glide slope deviation A until the end of the recorded data.
|At 18:38:49 hrs, after levelling off at 3600 feet pressure altitude, with
Heading Select mode engaged, VOR/LOC was Armed. The aircraft rolled back to the right, and the aircraft began to approach the localizer beam as evidenced by the localizer deviation moving towards zero.
|At 18:38:55 hrs, the Approach mode was engaged. However, the G/S Arm mode was not recorded, but selection of Approach mode engages G/S Arm mode during normal operation.||
|After asking Captain, FO extended flaps from flaps 1 to flaps 5 at 18:38:54.6 hrs and the stabilizer was trimmed approximately 2 units nose-up.
|At 18:38:56 hrs, the localizer deviation reached zero deviation and the aircraft rolled out of the left bank back to approximately 100 right bank. During the roll right, the autopilot reached its maximum control wheel authority (~ 25 degrees).||
|At 18:39:05 hrs, the aircraft rolled right to approximately 100.|
|At 18:39:09 hrs, autopilot command B was also engaged which is consistent with a dual autopilot approach.||
|At 18:39:13.4 hrs, FO informed Captain “localizer is right…VOR/LOC captured”. The Flare Arm gets engaged 23 seconds after the following conditions are satisfied: VOR/LOC Engage and G/S Engage and radio altitude < 1500 feet. During these 23 seconds, a number of system tests and checks are performed prior to Flare Arm engagement.
For the event flight, Flare Arm did not engage during the final approach prior to both autopilot channels disengaging at 18:39:33 hrs.
|At 18:39:13.4 hrs, FO informed Captain that VOR/LOC was captured.
The Flare Arm gets engaged 23 seconds after the following conditions are satisfied:
During those 23 seconds, a number of system tests and checks are performed prior to Flare Arm engagement. For the event flight, Flare Arm did not engage during the final approach prior to both autopilot channels disengaging at 18:39:33 hrs.
|At 18:39:15 hrs the pitch attitude of aircraft increased from about 00 to 90 and till the end of the FDR data, the aircraft remained in approximately 50 to 20 degrees right angle of bank.
|The autopilot transitioned to G/S Engage mode around time 18:39:16 hrs at approximately 175 knots computed airspeed, and the aircraft began its final approach, descending on the glide path. The glide slope deviation reached zero and was maintained for several seconds. According to the procedures, at G/S capture the aircraft should have been in landing configuration of flaps 300 with landing gears down. However, only flaps 5 were selected and the auto throttle maintained the recommended / selected speed of around 170 kts.||
|Between time 18:39:16 hrs and 18:39:21 hrs, calculated vertical winds showed the aircraft encountered an increasing downdraft. As it entered this descending air mass, the pitch attitude increased and computed airspeed decreased as the autopilot attempted to maintain the glide slope beam. The aircraft had to pitch up and, consequently, lose airspeed, to maintain the glide path. These are the indications that the aircraft had entered into a downdraft||
|At 18:39:21.5 hrs, a sound of rapid increase in precipitation intensity from moderate to extreme was observed on CVR recording. This elevated intensity in precipitation remained for next 26.5 seconds.||
|At 18:39:25 hrs, radio altitude decreased from 1,900 feet AGL to 900 feet AGL within 4 seconds while pitch attitude increased from 6 degrees nose up to 12 degrees nose up. During this time the computed airspeed decreased from 180 kts to 173 kts. At 18:39:26.2 hrs, GPWS Alarm “Wind shear – Wind shear – Wind shear” was recorded. Both the cockpit crew did not take any remedial action as per Boeing procedures (FCOM / QRH) with the auto-throttle and autopilot engaged. It was found that during the simulator training sessions, the cockpit crew was not exposed to wind shear training / exercises. It was observed that the customized QRH / FCOM were also not available at Bhoja Air on the day of accident. The actions of Boeing 737-200 and Boeing 737-236A are different as per both the QRH / FCOM.||
|At 18:39:28.6 hrs, Captain was heard yelling in extreme anxiety and desperation “no …no”. The cockpit crew still did not take any remedial action to recover out of unsafe set of conditions despite getting specific warnings of wind shear.
In the same extreme anxiety and desperation FO shouted, “go around, go around” at 18:39:29.3 hrs, but no action was taken by the Captain (PF), and FO (PNF) also did not take over the controls of aircraft to initiate a go around.
It appeared that Captain and FO were not sure about the behaviour of the aircraft in automation mode during wind shear conditions due to their lack of formal training during simulator sessions. While going through the records of FO, it was observed that an extension in respect of recurrent simulator training which was due in February 2012 was granted for two months on 09 March 2012 by CAA Pakistan as per the existing rules and regulations in vogue. Furthermore, his previous simulator session was carried out on B737-200 simulator in August 2011 which did not include the automated flight deck, as was the case of mishap aircraft.
The downdraft dissipated (vertical winds changed from approximately -40 feet per second fps to -10 fps, resulting in a change in angle of attack and the observed spikes in longitudinal acceleration and normal load factor.
Longitudinal acceleration and normal load factor reached a maximum of 0.2 g’s and 1.4 g’s, respectively. Nose-down column was commanded, and the pitch attitude decreased to its previous level (~5 degrees) over the next few seconds.
|At 18:38:00.0 hrs, Captain (in a worried tone) told Islamabad Approach “it is exactly on top”. At this time, the flight had ended up in the active bad weather cell.||
|In IAS Speed mode, the auto throttle modulates thrust to maintain the cockpit crew selected IAS on the Mode Control Panel (MCP). The auto throttle remained engaged during final approach.||
|The pitch mode transitioned between V/S mode and Level Change mode several times prior to levelling off at altitude of 3600 feet.||
|At 18:38:06 hrs, after passing through 4000 ft of altitude (2000 ft radio altitude), the flaps transitioned from flaps UP to flaps 1.||
|At 18:39:33 hrs, the aircraft deviated left of the extended runway centreline, eventually reaching a maximum of 2 dots localizer deviation and 5 degrees to 10 degrees right bank angle was commanded to return the aircraft to zero deviation (autopilot maximum authority is 80 of bank).|
|Both autopilot channels got disconnected at around 18:39:33 hrs and the subsequent FDR data is consistent with the aircraft being flown under manual control, however, the auto-throttle remained engaged in IAS Speed mode. Therefore, the auto-throttle continued to command thrust to track the airspeed selected on the MCP, but the autopilot stopped commands to the flight control surfaces. Probably the autopilot channels got disconnected due to the aircraft deviation beyond the autopilot maximum authority limits.|
|Following autopilot disconnect, there was no control wheel activity recorded for approximately 6 seconds and no control column activity for approximately 8 seconds. The cockpit crew was probably in a state of confusion and unsure of remedial actions to be taken to get out of unsafe set of conditions, as the aircraft was still observed flying with auto-throttle in engaged mode.|
|During this period of control inactivity, the aircraft deviated below the glide slope, and the altitude and pitch attitude decreased while approximately 160 knots computed airspeed was maintained.|
|At 18:39:37.1 hrs, Islamabad Approach cleared Bhoja 213 to contact BBIAP, ATC Tower which was acknowledged by FO on the reminder of Captain “channel kar lo na (deal with the channel)”. FO appeared to be highly pre-occupied due to severe weather conditions / precipitation and the aircraft encountering wind shear along with complete confusion in the cockpit to recover out of unsafe set of conditions. This was the last recorded communication of Captain with FO whereas the aircraft impacted ground after 21 seconds at 18:40:00.3 hrs.|
|At 18:39:41.9 hrs, Terrain Awareness Warning System (TAWS) alarm “Whoop, Whoop, Whoop” was recorded. The aircraft was in close vicinity of the ground and the cockpit crew did not carry out the recommended Boeing QRH / FCOM procedures, as remedial actions required after TAWS alarm||
|At 18:39:42 hrs, the pitch attitude decreased from approximately 5 degrees nose up to around 0 degree.||
|At 18:39:42.9 hrs, FO informed BBIAP ATC Tower that they were maintaining this frequency. The FO was busy giving calls to the BBIAP tower instead of assisting Captain or taking over controls of the aircraft. It appeared that the FO was not proficient and trained to handle the prevalent abnormal situation.||
|During this period thrust also decreased since the auto-throttle was still engaged in IAS Speed mode, thrust commands were input to maintain the airspeed selected on the MCP.||
|The aircraft encountered another descending air mass. This downdraft gradually increased over 15 seconds, reaching a maximum of approximately 50 fps (3000 fpm). The rate of descent increased rapidly, however after encountering this second downdraft cockpit crew again did not take required remedial actions which confirmed their ignorance on recovery procedures||
|At around 18:39:43.0 hrs, a TAWS alarm “(Whoop) Pull up, (Whoop, Whoop) Pull up” was recorded. The Captain responded with a nose-up column input. However, altitude and thrust continued to decrease.||
|With the auto-throttle engaged and autopilot disengaged, the aircraft in flaps 5 and landing gears down configuration, failure of the cockpit crew to undertake the Boeing recommended procedures to respond TAWS warning, aggravated the existing unsafe / dangerous conditions||
|At 18:39:45 hrs, the power on both engines was reduced to 1.0 EPR (flight idle) and remained at 1.0 EPR for the remainder of the recorded data. The ground proximity warning momentarily ceased before activating again until the end of data.||
|At 18:39:46.8 hrs, ATC Tower cleared the mishap flight for landing “Bhoja 213 check wheels down and locked, wind 180 to 270, 10 kts, rain runway 30 cleared to land”, however, the aircraft never acknowledged this call. It appeared that due to the complete confusion and chaos in the cockpit, the crew never responded the call of ATC tower.||
|At approximately 18:39:47 hrs, the downdraft dissipated, rapidly decreasing from 50 fps to close to zero fps in less than 4 seconds. This resulted in a rapid increase in angle of attack of the aircraft, which activated the stick shaker for almost 2 seconds.
It appeared that Captain was making desperate control column inputs to come out of the TAWS “pull up” warning regime. As a result, the aircraft achieved nose up attitude with flaps 5, landing gears down and auto-throttle engaged position, thus aircraft ended up in stalling regime.
During this period, the longitudinal acceleration and normal load factor (vertical acceleration) both rapidly increased, reaching maximums of 0.25 g’s and 1.7 g’s, respectively.
A nose down column input was commanded in response to the stick shaker (the stick nudger likely also engaged), this nose-down column input command continued until the end of the data.
It appeared that Captain lowered the nose down to get out of stick shaker regime however, proper and complete Boeing recommended stall and recovery procedures were not carried out.
The pitch attitude changed from approximately 2 degrees nose up to a maximum of approximately 12 degrees nose down over 8 seconds. During the initial rapid pitch down, normal load factor reached 0.45 g’s. The aircraft went into a critical unusual attitude of 120 nose down in close proximity of the ground.
The altitude continued to decrease while thrust remained at a low level (~ 40-45 percent engine N1) in order to maintain the computed airspeed.
At 18:39:45 hrs, the power on both engines was reduced to 1.0 EPR (flight idle) and remained at 1.0 EPR for the remainder of the recorded data.
The ground proximity warning momentarily ceased before activating again until the end of data.
|At 18:39:48.3 hrs, sound of wailer tones like auto pilot disconnect was recorded on CVR which continued till end of recording. This indicated that the Captain lacked the automation knowledge and experience due to which he was unable to silence the continuous wailer tone by pressing the autopilot disconnect switch on the control column. In addition, during this time warning of “wind shear, wind shear, wind shear” was recorded.||
|At 18:39:49.0 hrs, the CVR recording indicated decrease in precipitation intensity and decreased intensity remained constant till end of CVR recording.||
|At 18:39:49.0 hrs, both left and right stick shakers indicated “Operative” for approximately one second. As the Captain was struggling with the control column to recover out of unsafe set of conditions, he again exceeded the critical angle of attack of aircraft which resulted in activation of the stick shakers for one second.||
|From 18:39:49 hrs till 18:39:51, a significant variation in vertical acceleration was recorded from + 1.7 to +0.4 g’s and pitch attitude decreased from 2 degrees nose up to 8 degrees nose down.||
|At 18:39:52.2 hrs, FO shouted in desperation and extreme anxiety “stall warning, let’s get out”. It appeared that Captain was making desperate attempts to recover out of dangerous situation but was not following the Boeing recommended remedial actions. At the same time, FO was also not taking over the controls of aircraft to initiate a go around indicating his lack of system knowledge, experience and confidence.||
|At 18:39:54.4 hrs, when the ground proximity warning was active “Pull up (Whoop – Whoop), Pull up (Whoop, Whoop), Pull up (Whoop, Whoop), Pull–” was recorded, the bank angle increased to the right, and the aircraft returned to the extended runway centreline prior to the end of data.||
|The aircraft appeared to pitch up to at least 0 degrees at the end of the data while traveling at 215 knots computed airspeed, which is consistent with the wreckage / ground scar information that indicated the aircraft contacted the ground on main landing gears first.|
|Boeing records indicate that a stick nudger was installed on the event aircraft. The stick nudger is designed to activate (push the control column forward) at the same time stick shaker activates. However, the stick nudger activation in this event would have been brief (at the most 2 seconds) and then would have returned to a no-load position over 2 seconds following stick shaker de-activation.
Based on the Stall Warning System functional test in the Boeing 737-200 Aircraft Maintenance Manual (AMM), the force on the control column increases by approximately 20 pounds over 5.6 +/- 0.6 seconds when the stick nudger activates. At the most, control column force would have increased approximately 7 pounds during stick nudger activation in this event
|At 18:39:57.1 hrs, FO was observed shouting in desperation / anxiety and telling Captain “go around, go around sir, go around”. Neither the Captain nor the FO followed Boeing recommended remedial procedures / actions due to their lack of knowledge, training and experience to handle this type of abnormal situation. This resulted in the unfortunate flight to impact the ground.||
|The CVR last recorded data finished at 18:40:00.3 hrs.||
|Potential for a microburst|
An in-depth study was conducted by the meteorological investigation team member to find out all the factual information related to the reported / prevalent weather conditions in and around BBIAP, Islamabad prior to and at the time of accident. The relevant METARs, satellite picture of Pakistan weather, the weather relayed through ATIS and the weather announced by Approach Radar, along with weather analysis by Boeing by utilizing all available sources to ascertain the exact weather parameters on the mishap day were studied, the details are appended below:
As the CVR recording revealed exposure of mishap flight to wind shear, therefore, this specific phenomenon was studied in detail to see its contribution towards causation of occurrence.
Wind Shear. Wind shear is a micro scale meteorological phenomenon in which sudden and drastic changes in wind direction and speed take place with altitude over a short distance. It is usually associated with a microburst that often occurs in the vicinity of thunderstorms resulting in conditions that can cause rapid changes in lift and hence the attitude / altitude of the aircraft.
Generally, the winds travel horizontally, but under certain conditions in thunderstorms and frontal system, wind shear will travel in a vertical direction, causing up and downdrafts. Microburst wind shear is an extremely violent downward blast of air that hits the ground and radiates outward with its sharp shifts in wind speed. An aircraft flying through a microburst may first encounter an increasing headwind and lift, then a downdraft from above the aircraft, followed by an increasing tailwind and sink. To overcome the adverse effect of the microburst, the pilot needs to take timely corrective actions as recommended by the manufacturer to ensure aircraft safety.
On 20th April 2012 the weather around Rawalpindi/Islamabad), OPRN, was forecasted to be cloudy with chances of thunderstorm and rain. The same was passed in advance through Aerodrome Forecasts (TAFs). Duty Met Officer issued weather warning for thunderstorm rain at 1430 hrs on 20th April 2012 for OPRN which was initially valid from 1500 till 1800 hrs and later was extended. It included 1-2/8 Cumulonimbus (CB) at or above 2500 feet AGL with reduction trend of surface visibility from 3-1 km or even less in precipitation and wind 20-40 knots gusting 65 knots or more for BBIAP (IATA Code), Islamabad and 50 km around. The detailed Meteorological analysis is given in subsequent paragraphs.
On 20 April 2012 the weather around OPRN was forecasted to be cloudy with chances of thunderstorms and rain. The same was passed in advance through TAFs. Duty Met Officer issued weather warning for thunderstorm rain at 1430 hrs on 20 April 2012 for OPRN which was initially valid from 1500 hrs till 1800hrs and subsequently extended. It included 1-2/8 CB at or above 2500 feet AGL with reduction trend of surface visibility from 3-1 km or even less in precipitation and wind to be 20-40 kts QNT 65 kts or more for BBIAP Islamabad and 50 km around.
METARs revealed that the destination (OPRN) had a thunderstorm warning with 1/8 TCU and alternate AIIAP, Lahore (OPLA) had DRW warning with no sig clouds at the time of departure of Bhoja Air. All the Met reports in the shape of TAFs, Mets and Species were timely delivered by the concerned departments. The existing TCU at destination was converted into CB at 1251 hrs and was promptly reported by Duty Forecasting Officer but by then the ill fated aircraft was already en-route to OPRN. The comparison of three hours MET reports of Islamabad is given below:
Boeing Atmospheric Analysis
A weather analysis was conducted by the Atmospheric Physics Group at Boeing USA to determine whether the conditions were conducive to generating downdrafts of the magnitude observed in the calculated data. After an analysis of infrared satellite imagery, surface observations, and model derived thermodynamic profiles, it was concluded that high-based thunderstorm activity was present in Islamabad at the time of the accident.
Surface observations showed thunderstorms with gusty and variable winds associated with the convective system. Wind speeds between 20 and 34 knots were reported while the convective system was in the vicinity. Also, a theoretical downdraft strength potential of 40-50 knots (68-84 fps) was derived from the thermodynamic profile. Given these facts, the accident occurred in an environment with a high probability of producing strong downdrafts.
- Satellite imageries also depicted similar pattern of weather from 0900UTC when the severe weather development started over central KPK. The system first migrated slowly towards east and then northeast.
- At 1301UTC, the core was southwest of BBIAP, Islamabad whereas at 1401UTC, it engulfed the entire region of Islamabad-Rawalpindi, Mangla (Jhelum) and up north.
- To further focus into the weather system, infrared imageries received at 1315UTC and 1345UTC were also analysed in detail. Satellite data depicted that severe high impact weather activity was approaching airfield at 1315 UTC and engulfed en-route & BBIAP between 1315-1345 UTC.
- Radar echoes of weather system depict frontal weather activity that generated severe turbulence and caused high wind shears that were responsible for the microburst.
- Radar echoes from 1820 PST to 1845 PST of 20th April 2012 inserted above depicted that weather activity over BBIAP and east of Islamabad & Kashmir was more severe and embedded Cb clouds producing updrafts and downdrafts were mapped by radar system during the period.
Weather Related Organizational Responsibilities
- In fact, all the set procedures were adopted by various stake holders. Met Flight folder was issued to Flight BHO-213 from Met Office Karachi that contained METARs, TAFs, Warnings, Satellite Imagery, significant weather chart and wind charts. Significant weather chart, METARs, TAFs etc were a meaningful source of information to caution the pilots about disturbed weather in northern parts of country (Lahore-Islamabad).
- Weather updates were continuously provided to Islamabad Approach Radar Controller by Meteorological Department BBIAP, Islamabad and the same was communicated by Islamabad Approach Radar Controller to Flight BHO-213 when it contacted for the purpose. In fact, at 1327 UTC, Flight BHO- 213 appreciated the radar controller for weather observation provided to him by saying “it was very nice whatever you told me”.
Time in UTC (GMT)
Rawalpindi/Islamabad Weather Report
- A METAR is an aerodrome observation (actual)
- A TAFOR is an aerodrome forecast
1100 SE 16KTS VIS 6KM HAZE 1TCU030 4SCCU040 4AC100 QNH 1009 TEMP 32/13 WEATHER WNG FOR TSR valid up to 1300.
1200 SE 22KTS VIS 6KM HAZE 1TCU030 4SCCU040 6AC100 QNH 1008 TEMP 31/12 WEATHER WNG FOR TSR valid up to 1300.
1300 SW 20KTS VIS 4KM TS 1CB025 4SCCU040 6AC100 QNH 1009 TEMP 25/15 WEATHER WNG FOR TSR valid up to 1600.
As per the flight plan of Flight BHO-213 Lahore was kept as alternate aerodrome, in case pilots decide to divert due to unfavourable landing conditions at destination they might go to the alternate aerodrome submitted in the flight plan. The weather situation at alternate aerodromes was as per following detail.
The weather observation reports (METAR) on 20 April 2012 before and after the accident are as follows:
Lahore Weather Report
1100 SW 230/17G28KTS VIS 3500M DRDU SCT040 SCT100 QNH 1009 TEMP 32/13 TEMPO 22030KTS 2000.
1200 SW 240/18G28KTS VIS 3500M DRDU SCT040 BKN100 QNH 1009 TEMP 30/12 TEMPO 22040KTS 2000.
1300 SW 230/13KTS VIS 4000M HZ SCT040 BKN100 QNH 1010 TEMP 27/12 TEMPO 22030KTS 2000 DRDU.
Peshawar Weather Report
1100 SW 20KTS VIS 6KM HAZE STRA FEW030CB SCT040 BKN100 QNH 1012 TEMP 23/17
1200 SW 12KTS VIS 6KM HAZE STRA FEW030CB SCT040 BKN100 QNH 1011 TEMP 21/18
1300 SW 16KTS VIS 4KM HAZE STRA FEW030CB SCT040 BKN100 QNH 1011 TEMP 21/18
The following weather warnings were issued for Islamabad region on the day of accident:
Time in UTC (former GMT)
1200 (METAR) WX WNG FOR TSRA OVER OPRN AND 50KM AROUND DURING THE PERIOD OF 20-1000Z UPTO 20-1300Z SURFACE WIND NE-NW 20-40KT QNT 65KT OR MORE SURFACE VISIBILITY 3 TO 1 KM OR LESS DUE TO PPTN MORDERATE / SEVERE TURBULENCE MAY ACCURE 1-2/8 CB AT 2500FT ABOVE GROUND LEVEL PROB 70%)
1300 (METAR) (OUR PREVIOUS WX-WNG FOR TSRA OVER OPRN AND 50KM AROUND IS FURTHER EXTENDED UPTO 20-1600Z. S/WIND NW-NE 20-40KT QNT 65KT OR MORE. S/VIS MAY REDUCE 3-1KM OR LESS IN PPTN MOD/SEV TURB MAY OCCURE IN 1-2/8CB AT 2500FT AGL PROB 70%=)
1400 (METAR) WX WNG FOR TSRA OVER OPRN AND 50KM AROUND DURING THE PERIOD OF 20-1600Z TO 20-1900Z=
- Satellite image analysis and its animation depicted that Flight BHO-213 encountered severe weather system (high impact).
- NWP products fairly depicted that severe wind shear caused severe thunderstorms resulting in updrafts and downdrafts. NWP atmospheric sounding depicted severe convective cloud environment which is characterized by a dry sub-cloud layer (i.e. high convection near the surface).
- The surface inflow to the convective system had a temperature / dew point spread of 350 Fahrenheit (90F/55F), which indicates potential for strong convective downdrafts. Also, its Downdraft Convective Available Potential Energy (DCAPE) value is more than 300 J/kg. Such a high DCAPE has the potential to produce a downdraft of more than 40 knots. Therefore, sounding of Islamabad confirms the development of Cb clouds and thunderstorms activity with vertical winds more than 40 knots.
- The surface observation reports before and at the time of Bhoja Air aircraft accident near BBIAP, Islamabad confirmed high impact weather activity (TSRA, surface winds 36 knots at 1318 UTC and TSRA, surface winds 24 knots at 1340 UTC).
- Based on above facts, it is concluded that this accident occurred in an environment with a high probability of producing strong downdrafts coupled with strong wind shear.
- Satellite image analysis and its animation depicted that the mishap Flight BHO-213 encountered severe weather system (high impact) during final phases of her flight.
- NWP products depicted that severe thunderstorms resulted in updrafts and downdrafts.
- The maximum wind shear was produced between 1300UTC and 1400 UTC.
- NWP atmospheric sounding depicted severe convective cloud environment that is characterized by a dry sub-cloud layer (high convection near the surface). The surface inflow to the convective system had a temperature / dew point spread of 350 Fahrenheit, which indicated potential for strong convective downdrafts. Also, its Downdraft Convective Available Potential Energy (DCAPE) value is more than 300 J/kg. Such a high DCAPE has the
- potential to produce a downdraft of more than 40 knots. Therefore, sounding of Islamabad confirmed the development of Cb clouds and thunderstorms activity with vertical winds more than 40 knots.
- Surface observation reports before and at the time of crash at BBIAP, Islamabad confirmed high impact weather activity (TSRA, surface winds 36 knots at 1318 UTC and TSRA, surface winds 24 knots at 1340 UTC).
- The weather conditions at the time of the accident were conducive to producing strong down drafts and wind shear like conditions.
Factors Leading to the Accident
- The aircraft accident took place because of combination of various factors which directly and indirectly contributed towards the causation of accident. The primary causes of accident include the ineffective management of the basic flight parameters such as airspeed, altitude, descent rate, attitude and thrust management.
- The contributory factors include the crew’s decision to continue the flight through significant changing winds associated with the prevailing weather conditions and the lack of experience of the crew to the airplane’s automated flight deck.
- The reasons of ineffective management of the automated flight deck also include Bhoja Air’s incorrect induction of cockpit crew having experience of semi-automated aircraft, inadequate cockpit crew simulator training and absence of organizational cockpit crew professional competence and monitoring system.
- The incorrect decision to continue for the destination and not diverting to the alternate aerodrome despite the presence of squall line and very small gaps observed by the Captain between the active weather cells is also considered a contributory factor in causation of the accident.
- The operator’s Ops Manual (CAA Pakistan approved) clearly states to avoid active weather cells by 5 to 10 nm which was violated by the cockpit crew is also considered a contributory factor in causation of the accident.
- FO possessed average professional competence level and was due for his six-monthly recurrent simulator training for Boeing 737-200 aircraft (equipped with a semi-automated flight deck). Bhoja Air requested an extension for his recurrent simulator training on 07th March 2012. As per the existing laid down procedures of CAA Pakistan, two months extension was granted for recurrent simulator training on 09th March 2012. The extension was granted for Boeing
- 737-200 aircraft, whereas the newly inducted Boeing 737-236A aircraft was equipped with automated flight deck. It is important to note that Bhoja Air did not know this vital piece of information till their cockpit crew went for simulator training to South Africa. This critical information regarding automation of the newly inducted Boeing 737-236A was not available with Flight Standard Directorate CAA, Pakistan as the information was not provided by the Bhoja Air Management.
- Therefore, it is observed that due to the ignorance of Bhoja Air Management and CAA Pakistan, the said extension in respect of FO for simulator training was initially requested by former and subsequently approved by the latter. This resulted in absence of variance type training conformance of FO because of which he did not contribute positively in recovering the aircraft out of unsafe set of conditions primarily due to lack of automation knowledge,
- proper training and relying on captain to take remedial actions. This is also considered as one of the contributory factors in causation of accident.
- The Captain’s airline flying experience on semi-automated flight deck aircraft and his selection for automated aircraft without subsequent training and monitoring to enhance his professional competence and skill, is one of the factors in causation of the accident.
- None of the cockpit crew member challenged the decision of each other to continue for the destination despite violation of Ops Manual instructions which against the essence of CRM training.
- After experiencing the extremely adverse weather conditions, the cockpit crew neither knew nor carried out the Boeing recommended QRH and FCOM / Ops Manual procedures to handle the abnormal set of conditions / situations due to non-availability of customized Boeing documents for Boeing 737-236A (advanced version of Boeing 737-200 series).
- The ineffective automated flight deck management in extreme adverse weather conditions by cockpit crew caused the accident. The ineffective automated flight deck management was due to various factors including; incorrect selection of cockpit crew because of their inadequate flying experience, training and competence level for Boeing 737-236A (advanced version of Boeing 737-200 series), absence of formal simulator training in respect of FO for handling an automated flight deck, non-existence of cockpit crew professional competence / skill level monitoring system at operator level (Bhoja Air).
- The cockpit crew incorrect decision to continue the flight for destination and non- adherence to Boeing recommended QRH and FCOM remedial actions / procedures due to non-availability of customized aircraft documents (at Bhoja Air) for Boeing 737-236A (advanced version of Boeing 737-200 series) contributed towards the causation of accident. The inability of CAA Pakistan to ensure automated flight deck variance type training and monitoring requirements primarily due to incorrect information provided by the Bhoja Air Management was also a contributory factor in causation of the accident.
CAA, Pakistan is to ensure the following:
- The 100% monitoring of cockpit crew simulator training (initial / recurrent) by Flight Standard Inspectors.
- Strict monitoring of flight crew proficiency along with their recurrent training compliances at operator level.
- Strict compliance of her directives / instructions by all operators.
- To devise mechanism for close monitoring / tracking of simulator training waivers / extensions of the cockpit crew.
- The availability of all customized applicable aircraft documents with the operator before issuance / approval of operations specifications.
- The conduct of aircraft variance type ground and simulator training and submission of compliance report to CAA Pakistan by the operators prior to formal start of flying duties by cockpit crew.
CAA, Pakistan is to study the following for implementation:
- Devise mechanism for 100 % coverage of aircraft inspections in respect of new inductions / registrations by Flight Standard Inspectors who possess type rating on the specific aircraft.
- The inclusion of wind shear, TAWS (EGPWS) and stall recovery exercises as mandatory items in the Pilot Proficiency Check (PPC) during simulator training sessions.
- Review the Licensing Circular (ASC) –1 / 2000 (issue one) dated 15 October 2000 for inclusion of Boeing 737-236A aircraft variance type training.
- Devise mechanism for strict monitoring / performance evaluation of newly launched operator’s flight crew.
- The inclusion of flight crew scheduler for formal certification to ensure required competence level of scheduler.
- The inclusion, of mandatory serviceability of EGPWS / GPWS / TAWS / Wind shear warning system (predictive or reactive) for all turbine engined aeroplanes of a maximum certified take off mass in excess of 5700 kg or authorized to carry more than nine passengers, in the MEL of all operators.
- The availability and integration of Low Level Wind Shear (LLWS) warning system with Automatic Weather Observation System (AWOS) at all airports.
- Review the existing Certificate of Airworthiness (C of A) issue and validation procedure by competent authority.
- The implementation of automated flight crew scheduling system by all operators.
- The submission of selection and induction procedure / policy of all flight crew by the operators for formal approval by CAA, Pakistan.
- The conduct of regular flight safety meetings and submission of their respective proceedings to CAA Pakistan.
All operators in Pakistan are to ensure the following:
- The procurement of customized applicable aircraft documents for the approval of CAA Pakistan prior to the launch of flying operations.
- The strict implementation of Operational Manual (CAA Pakistan approved) by the flight crew.
- The conduct of aircraft variance type ground and simulator training and submission of compliance report to CAA Pakistan prior to formal start of flying duties by cockpit crew.
- To re-emphasize on cockpit crew the importance of strict compliance to Ops Manual, FCOM and QRH instructions / OEM recommendations.
- To devise mechanism where cockpit crew share their views freely with appropriate supervisory levels for highlighting deficiencies in their training for safe conduct of flights.
- To devise mechanism for close monitoring / tracking of simulator training waivers / extensions of the cockpit crew.
- Safety Investigation Board (SIB), Civil Aviation Authority, Government of Pakistan
- Photo By Maarten Visser from Capelle aan den IJssel, Nederland – ZS-OLB B737-200 BA Comair JHB 140309, CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=26612489
2 thoughts on “Bhoja Air Flight BHO-213 “Allah Malik Hai” (God is Great)”
“Captain Noorullah: total flying experience: 10158:20 hrs; ; Flying Hrs on B737-200: 2027:00 hrs; Flying Hrs on B737-236A: 82:30 hrs
First Officer Javaid Ahmad Malik: total flying experience: 2832:00 hrs; flying hrs on B737-200: 750:00 hrs; flying hrs on B737-236A: 82:00 hrs.
The two pilots had worked together previously and of the 23 flights the captain piloted at Bhoja, Malik had co piloted 16.”
If the Approach Radar had the capability, then the controller should have stayed with the aircraft till touchdown. In atrocious weather, giving a change of frequency for the tower takes the copilot away from his focus which is to monitor the aircraft parameters.
In practice, the approach radar controller could always have cleared the aircraft for a landing and asked for it to contact the tower after touchdown. The aircraft changed to and was with the tower frequency for about 18 secs at a crucial period, and blind in the weather in a storm cell on final approach.
In this turbulent weather, the captain used the autopilot like a crutch against all procedures of flying in turbulence. He engaged the autopilot right after takeoff within 20 seconds and wouldn’t take it off until it disconnected by itself during the violent updrafts and downdrafts during the approach to landing.
Again and again we are reminded that the on board weather radar is for avoidance and not playing with the weather.
The captain gambled with the lives of the passengers when a simple diversion to either Lahore or Peshawar could have easily been effected.
Both the crew members were ex-air force. There was a an air of deference towards the captain by the first officer. He did point out the diversion but was not assertive.
The captain and first officer had a mutual understanding to cover each other’s back. That’s why they flew together, a sign of under confidence in both.
Bhoja Airways crash: CAA report points to pilots, airline’s negligence
By Saad Hasan
Published: January 23, 2014
KARACHI: It was the first evening flight in eleven years since Bhoja Airways suspended operations in 1999. The airline resumed service twelve years later and this flight from Karachi to Islamabad was scheduled for Friday, April 20, 2012. A 78 page report released by the CAA includes a blow by blow account of BHO 213’s final minutes before it crashed on that Friday, ruling out any technical failure in the aircraft.
There was a thunderstorm warning for Islamabad but the flight’s captain, Noorullah Khan was not perturbed – with more than 10,000 hours of flying experience under his belt, this was just another routine flight for the former air force pilot, aged 58. Flight number BHO 213 departed from Karachi at 5.05pm, with 127 people on board, including six crew members. Khan was assisted by 53 year old first officer (FO) Javaid Ahmed Malik, also a former PAF pilot. The two pilots had worked together previously and of the 23 flights the captain piloted at Bhoja, Malik had co piloted 16.
Bhoja Airways, under the leadership of former Managing Director of Shaheen Air International Arshad Jalil, had inducted four Boeing 737s to its fleet. This plane, a 737 236a was manufactured in 1985 and used by British Airways till 1999. The plane served South Africa’s Comair until 2010 when it was grounded. The 737 was purchased by Bhoja in January 2012 and on January 12, Pakistan’s Civil Aviation Authority’s inspectors Shaukat Hameed and Javed Afzal carried out a detailed inspection of the aircraft in Johannesburg. The inspectors noted 28 discrepancies, ranging from peeled off paint to an engine fan blade’s waviness. All defects were removed in following weeks.
The CAA’s report notes there was no cockpit and crew monitoring system within the airline. The CAA’s Flight Standard Directorate is exempted from any responsibility, as the CAA says it was never told by Bhoja that the pilots would be flying an advanced version of the B 737 200 – the aircraft, possessing an advanced automated flight deck system, requires different treatment when encountering adverse weather conditions. Captain Khan was not trained to handle the situation and his FO had not received simulator training for the aircraft’s automated deck.
At 6.09pm, the report notes, the plane flew above Lahore. At 6:18, the FO asked Khan if he should request a weather forecast for Peshawar – every flight has two alternate cities marked in case of diversion and in this case, it was Lahore and Peshawar. The captain said there was no need. A thunderstorm loomed over Islamabad, with wind speeds at 20 and 34 knots. At 6.24, the captain commented to his FO about the bad weather and at 6:31, the FO asked the captain to take a right to avoid the inclement weather. “No, no we don’t have to go there, we have to land here,” replied Captain Khan, determined to make it to Islamabad.
The flight was cleared for descent at 6.33. Four minutes later, the captain commented on the dark weather but by 6.38, the aircraft prepared to land. Flight BHO 123 then entered the last two minutes of its life. At 6.38, the FO informed the captain that the speed was 220 knots – when at this point, it should not exceed 190 knots. By 6.39, the plane was pushed into a downdraft – a rapid downward push of air. Within four seconds the plane fell from 1900 feet to 900 feet. According to a senior pilot, ‘everything must have been flying inside’ the cabin at this point. By 6.39.28, the captain can be heard shouting, “No, no!”, while the FO says, “Go around, go around.” The Terrain Awareness Warning System sounded an alarm and the FO contacted the control tower. At 6:39:54, the FO shouted, “Stall warning, let’s get out.” Three seconds later, he says his last words, “Go around, go around, sir, go around.” The aircraft crashed 4.5 nautical miles from the Islamabad airport near Hussainabad village. There were no survivors.
Published in The Express Tribune, January 23rd, 2014.