• As per the medical investigation / analysis, the Captain was fit to undertake the mishap scheduled flight.

• Captain was issued ATPL (A) # 948 initially on 26 March 1996 which was renewed and valid up to January 2013.

• Captain possessed valid medical Class 1 till 30 September 2012. He possessed valid IRA-ME on Boeing 737/100-200 aircraft till January 2013.

• FO possessed a valid CPL # 2934 renewed up to July 2012.

• The mishap Bhoja Air Flight BHO-213 was the first evening inaugural scheduled flight from Karachi to Islamabad.

• The mishap flight took off at 17:05:30 hrs for destination and climbed to FL310 en-route to Islamabad.

• The unfortunate flight remained uneventful from departure till it contacted Islamabad approach radar.

• The FDR data was available for last 26 hours however, CVR recording was available for last about 30 minutes.

• The aircraft systems and sub-systems along with both engines response, was consistent with the design performance parameters till the ground impact of mishap aircraft.

• The cockpit crew monitored the Lahore ATIS broadcast and were well aware of the overall weather picture.

• At 18:08:05.6 hrs, Captain came on PA system and announced that the present weather at BBIAP, Islamabad was cloudy along with thundery activity.

• At 18:09:15.1 hrs, Captain astonishingly questioned the runway 18L in use at Lahore and FO informed him that wind is from 2300. The Captain on hearing this said that the winds are from the wrong side 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 18:10:32.5 hrs, Captain and FO discussed Lahore as first alternate and Peshawar as second alternate.

• At 18:15:01.8 hrs, Captain told 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.

• 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 18:18:17.9 hrs, FO asked the Captain that should he take the Peshawar weather and he was told that no, God would help them.

• At 18:19:41.9 hrs, Captain analysed the weather picture and said it was all covered by squall line.

• At many instances it was observed that FO was asking or sharing various with Captain, but he was found not registering the contents probably due to his pre-occupation as a result of adverse / bad weather conditions.

• At 18:20:38.4 hrs, Lahore Approach issued descent clearance to Bhoja 213 for flight level 200.

• At 18:21:12.1 hrs, FO told Captain that he had put the seat belt sign “ON”

• Flight attendant made the announcement in Urdu and English about the seat belt sign “ON” due to the possibility of turbulence.

• The flight commenced descent with Engine Pressure Ratios (EPRs) to approximately 1.0 which is consistent with flight idle setting.

• At 18:23:54.6 hrs, Captain appeared worried about prevalent weather towards BBIAP, Islamabad area.

• At 18:23:56.9 hrs, FO and Captain discussed the weather picture and concluded that it appeared to be slightly ahead of destination. It was observed that Captain had made up his mind for landing at BBIAP Islamabad regardless of prevalent weather conditions as it was the Bhoja Air evening inaugural flight on Karachi – Islamabad sector.

• At 18:23:59.3 hrs, Captain and FO were again found discussing the weather picture.

• It was observed that Captain was trying to justify his decision to continue and land at BBIAP, Islamabad as correct and FO was also observed participating actively in the interpretation of changing weather picture / conditions. At 18:24:27.7 hrs, Captain continued to brief FO about the presence of squall line and appeared worried about the severity of weather in front.

• At 18:24:58 hrs, Captain increased the speed of aircraft to 280 kts as it was the recommended speed for flying through turbulent weather conditions.

• At 18:25:49.6 hrs, FO shared his analysis of weather picture with Captain and said that they were likely to enter the squall line / bad weather area.

• At 18:25:57.5 hrs, Captain had also realized the severity of the weather / presence of squall line and wanted to avoid entering the bad weather area but intended to continue for destination.

• At 18:26:23.2 hrs, FO was observed coordinating with Lahore Approach and at 18:26:40.5 hrs with Islamabad Approach while approaching INDEK.

• At 18:26:54.1 hrs, Islamabad Approach identified Bhoja flight BHO-213 and cleared it to Islamabad via POMAR ONE FOXTROT arrival and informed to expect vector ILS runway 30. The flight was also cleared to descend to 9500 ft on QNH 1009 when ready.

• At 18:27:21.4 hrs, Islamabad Approach asked Captain that if he could give weather brief on Islamabad.

.

• At 18:27:28.8 hrs, Captain briefed Islamabad Approach that there was a squall line present throughout and no gap was observed to come inside and requested Islamabad radar if they could be permitted to approach from the west.

• At 18:28:02.6 hrs, Islamabad Approach apprised Captain that radar was not observing any gap towards west, however a gap was observed on approach radar between radial 160 to radial 220.
• From the abovementioned discussion between radar controller and captain it was evident that they both considered the prevalent weather covering BBIAP, Islamabad and there was apparently small gap for mishap flight BHO-213 to penetrate the squall line.

• At 18:28:22.5 hrs, Captain told Islamabad Approach that the gap was very small one and would try on that one.
• As per Bhoja Air Operational Manual (approved by CAA Pakistan), the aircraft would avoid thunderstorm / active weather cell by 5 to 10 nm. Captain was observed intentionally continuing for destination while disregarding and violating the documented operator Ops Manual, despite knowing the fact that the gap between the adjacent active weather cells was very small.

• At 18:28:35.7 hrs, FO suggested to Captain that they should ask for radar vectoring.

• At 18:28:39.8 hrs, Captain asked Islamabad Approach to turn right on heading 040 as he observed some gap there.

• At 18:28:53.2 hrs, Islamabad Approach did not clear Captain for right turn due to the close proximity of Tilla Firing Range, however they were cleared for right turn after reaching INDEK position.

• At 18:29:28.9 hrs, Islamabad Approach asked the Captain if he was picking any weather towards southeast of Islamabad at a distance of about 10 to 15 miles.

• At 18:29:41.1 hrs, Captain replied to Islamabad Approach in negative and added that till 40 miles there was no weather at all.

• At 18:29:52.7 hrs, Captain informed Islamabad Approach that the prevalent weather was all towards the northern side.

• At 18:30:19.1 hrs, Captain and FO discussed their clearance to descent 6500 ft by Islamabad Approach.

• At 18:30:34.9 hrs, Captain told FO to tell the cabin crew to brief passengers to occupy their seats. The cockpit crew probably were experiencing lot of turbulence at this particular moment and that is why Captain told FO to ask the cabin crew to brief passengers to occupy their seats.

• At 18:31:08.1 hrs, FO suggested to Captain that they should go towards the right. However, Captain said that no, they would not go there as they had to land at BBIAP, Islamabad.

•  It was 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 appreciated Islamabad Approach and said it was very nice whatever you told me and subsequently they exchanged greetings.

• At 18:31:45.6 hrs, Captain told Islamabad Approach that by the grace of God everything was ok and actually he was planning to go far away to avoid weather.

• At 18:31:52.0 hrs, Islamabad Approach radar controller briefed Captain and said that he was looking for the gap and this was the only slightly clear area but even on that heading after about 30 miles cockpit crew might experience little bit of precipitation till intercepting the localizer.

• At 18:32:20.2 hrs, the mishap flight was crossing 10,000 ft of altitude during descent.

• At 18:32:31.0 hrs, Captain shared his apprehension about severe weather conditions with FO and said that the weather kept them under pressure whereas actually they were afraid for nothing.

• A third person was occupying the jump seat in the cockpit. He 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 18:33:37.7 hrs, Captain briefed FO about the prevalent weather that it was in the north and they were observing lightening.

• Till now the mishap Flight BHO-213 had encountered turbulence but not entered the active bad weather cell.

• At 18:33:56.2 hrs, Islamabad Approach cleared the flight to continue descent to 5500 ft and the instructions were acknowledged by FO.

• At 18:34:49.4 hrs, Captain told FO “ILS my side, ILS number one” and FO acknowledged it by saying “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.

• At 18:35:00 hrs, the aircraft levelled off at 5,500 feet altitude and glide slope deviation A became active.

• The altitude of 5,500 feet was maintained for 80 seconds and during this time both aircraft 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 issued clearance to Flight BHO-213 for further descent to 3900 ft and the said clearance was acknowledged by FO which indicates that Captain was pilot flying (PF) and FO was pilot not flying (PNF) and everything appeared just normal in the cockpit

• At 18:35:39.6 hrs, Islamabad Approach gave weather update of BBIAP, Islamabad and said that surface wind at Islamabad was varying between 1800 to 2700,10 kts and sometimes gusting to 20 kts and runway condition was wet, light drizzle was going on and braking action was not known. Captain acknowledged it by saying “thank you very much, sir”.

• At 18:36:36.0 hrs, Captain commented on weather and told FO it was not likely to open anymore and probably FO did not understand due to which Captain repeated again.

• At 18:36:38.5 hrs, FO told Captain about his understanding of weather that the problem was in between 10 & 15 miles and they still had 14 miles to go. It is considered that at this particular moment squall line was 10 to 15 miles away from aircraft and the aircraft was at 14 DME from BBIAP, Islamabad.

• At 18:36:45.8 hrs, Captain confirmed to FO that the squall line is exactly overhead BBIAP, Islamabad.

• At 18:36:50.2 hrs, FO shared with Captain that they were likely to get very close to it. It can be deduced from the cockpit crew discussion 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 18:36:58.0 hrs, Captain told FO that it would hit them at that time. Probably at that particular time, they experienced precipitation which alarmed the Captain.

• 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 by saying when we turn then it would get slightly intense.

• At 18:37:18.8 hrs, Captain suddenly said that it had become dark. Now by this time, cockpit crew is very clear that they were actually entering the squall line / bad weather conditions but did not take any action / decision to discontinue the approach to the destination.

• At 18:37:25.2 hrs, radio altimeter alarm was heard. At that time the aircraft was passing through 2500 ft above ground level (AGL).

•  At 18:37:28.9 hrs, Captain said “airspeed reaching 210 kts, flaps one” and it was acknowledged by FO.

• At 18:38:07.5 hrs, Islamabad Approach advised mishap flight to turn left on heading 340, cleared the aircraft for ILS runway 30 and asked to report established on final approach. This 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.

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 18:38:13 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. The aircraft maintained an approximate 20 degrees angle of bank 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 18:38:24.7 hrs, FO told Captain that the speed of aircraft was 220 kts and immediately Captain responded in surprise by saying “what?”.

• At 18:38:27.4 hrs, FO again repeated his information of 220 kts of airspeed. It is important to note that 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 which indicates that the aircraft was already in the weather conditions where wind shear was probably present.

• At 18:38:24.7 hrs, Captain in highly surprised tone asked FO, “220 kts, oh shit what has happened”. Captain realized that with auto-throttle engaged the speed of aircraft should not have increased to 220 kts.

• At 18:38:31 hrs, the thrust was observed increasing as the aircraft began to level off at the target altitude (~ 3600 feet above sea  level altitude) and simultaneously autopilot transitioned to Altitude Hold mode.

• At 18:38:34.0 hrs, FO informed Captain that they had been cleared for left turn to 3400 and ILS runway 30. The aircraft turned left to intercept the localizer with flaps at position 1 and landing gears down. In this configuration the aircraft was exposed to limited manoeuvrability due to higher drag component.

• 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 CVR recording / aircraft ground impact. At this particular moment, the aircraft had actually entered the active weather cell.

• At 18:38:39.3 hrs, FO asked Captain that should he give him both on ILS. It appeared that the FO is unaware and ignorant of the severity of weather and its implications, instead of recommending to discontinue the approach, he was busy in carrying out the cockpit checks.

• At 18:38:41.3 hrs, Captain told FO that there was something wrong and why it had 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 told FO to give him the ILS in a highly low energy tone and apparently with pre-occupied mind.

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 18:38:45.8 hrs, the cockpit crew had already the autopilot and auto-throttle engaged and the glide slope deviation B became active and tracked similarly with glide slope deviation A until the end of the recorded data.

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 18:38:49 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.

• 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. At the same time, the aircraft approached the glide slope beam from below, and the glide slope deviation began to move towards zero

• At 18:39:09 hrs, autopilot command B was also engaged which is consistent with a dual autopilot approach.

For the event flight, Flare Arm did not engage during the final approach prior to both autopilot channels disengaging at 18:39:33 hrs.

The Flare Arm gets engaged 23 seconds after the following conditions are satisfied:

• VOR/LOC Engage
• G/S Engage
• Radio altitude < 1500 feet. 

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 0 to 9 degrees and till the end of the FDR data, the aircraft remained in approximately 5 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 Ops Manual, with G/S captured, the aircraft should have been in landing configuration (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 18:39:27 hrs, calculated vertical winds show 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 thrust was increased during this time but was not sufficient to counter the airspeed loss.

• 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 noseup to 12 degrees noseup. During this time the computed airspeed decreased from 180 kts to 173 kts.

• At 18:39:26.2 hrs, EGPWS Alarm “Wind shear – Wind shear – Wind shear” was recorded. Both the cockpit crew did not take any remedial action as per Boeing recommended FCOM and QRH procedures, the auto-throttle and autopilot remained engaged. It is evident that the cockpit crew were confused and not clear about the recommended procedures to be followed after encountering wind shear.
• The mishap aircraft was equipped with Terrain Awareness Warning System (TAWS), Sandel Avionics ST3400 and Enhanced Ground Proximity Warning System (EGPWS) MK-VII made by Honeywell. TAWS and EGPWS had the capability to provide various terrain awareness warnings and reactive wind shear warning respectively. The onboard reactive wind shear warning functioned as designed, but the flight crew did not respond with the appropriate recovery manoeuvres; autopilot and auto throttle off, full throttle applied. The inappropriate response is attributable to the lack of training and familiarity with the non-normal condition.
• It was observed that during the recurrent simulator training sessions of Captain, he was not exposed to wind shear training / exercises whereas FO never underwent the simulator training for this variant of Boeing 737-236A.

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 18:39:28.6 hrs, Captain was heard yelling in extreme anxiety and desperation “no …no” but was observed not taking 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 observed by the Captain or the FO (PF and PNF) of initiating a go around and taking over the controls of aircraft.
• 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 knowledge and formal training.
•  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 spikes were observed in FDR recorded data regarding longitudinal acceleration and normal load factor.
• 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.
• Probably the autopilot channels got disconnected due to the aircraft excessive deviation in severe weather; however, the explanation for the autopilot disconnect cannot be identified with certainty.
• 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 engaged.
• During this period of control inactivity, the aircraft deviated below the glide slope, and the pressure altitude and pitch attitude decreased while on average approximately 160 knots computed airspeed was maintained.

• At 18:39:37.1 hrs, Islamabad Approach cleared flight BHO-213 to contact BBIAP, ATC Tower which was acknowledged by FO on the reminder of Captain.
• FO appeared to be highly pre-occupied due to extremely bad weather conditions / severe precipitation and the aircraft encountering wind shear along with complete confusion in the cockpit to recover out of unsafe set of conditions.
• The last recorded communication of Captain with FO was 21 seconds prior to the aircraft ground impact at 18:40:00.3 hrs.

• At 18:37:38.6 hrs, Islamabad Approach asked Bhoja Air Flight BHO-213 to continue descent to 3600 ft and standby for the final turn. This clearance was acknowledged by FO

• At 18:37:52.4 hrs, sound of three wailer was heard which was similar to auto pilot disconnect.

• At 18:37:53.2 hrs, Captain suddenly said twice that what had he done and then laughed. Probably Captain said this due to his selection of manual flying mode / disengagement of autopilot and then he engaged the auto pilot again.

• At 18:38:00.0 hrs, Captain (in a worried tone) told Islamabad Approach “it is exactly on top”. At this particular time, the flight had actually ended up in the active bad weather cell.

• In IAS Speed mode, the auto throttle modulates thrust to maintain the 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 18:39:41.9 hrs, 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 for this TAW alarm.

• At 18:39:42 hrs, the pitch attitude decreased from approximately 5 degree noseup to around 0 degree.

• At 18:39:42.9 hrs, FO informed BBIAP ATC Tower that they were maintaining ATC Tower frequency.
• FO appeared to be ignorant of the dangerous set of conditions as the aircraft was encountering wind shear and TAWS alarms. The FO was busy giving calls to the BBIAP tower instead of assisting Captain or taking over controls of the aircraft. It is evident that the FO was not proficient enough to handle the prevalent abnormal situation.

• During this period thrust also decreased since the auto-throttle was still engaged in IAS Speed mode 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. The rate of descent increased rapidly, however after encountering this second downdraft also, cockpit crew again did not take required remedial actions which confirmed their ignorance of recovery procedures.

• At around 18:39:43.0 hrs, a ground proximity warning annunciation “(Whoop) Pull up, (Whoop, Whoop) Pull up” was recorded. The Captain responded with a nose-up column input. However, pressure 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 come out of TAWS warning, aggravated the existing unsafe / dangerous conditions.

• At 18:39:45 hrs, the power on both engines power 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, BBIAP ATC Tower cleared the mishap flight for landing.
• The cockpit crew never acknowledged this call.

 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 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.
• Captain lowered the nose of aircraft 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.
• Captain had taken the aircraft to a critical unusual attitude by lowering the nose of aircraft to 12 degrees so close to the ground in order to recover out of stall.
• The above sea level altitude continued to decrease while thrust remained at a lowlevel (~ 40-45 percent engine N1) in order to maintain the computed airspeed, however, the speed increased due to the steep dive of 12 degrees.

• At 18:39:48.3 hrs, sound of wailer tones similar to auto pilot disconnect was recorded on CVR which continued till end of recording.
• Due to the lack of automation knowledge and experience, Captain was unable to silence the continuous wailer tone by pressing the autopilot disconnect switch on the control column. 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 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.
• It was evident that Captain was making desperate control column input for survival without adopting / following Boeing recommended procedures and the FO was of no help at all in the cockpit, as he himself lacked the system knowledge, procedures and automation experience.

• 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 and the FO was only shouting and not taking over the controls of aircraft in order to initiate a go around.

• At 18:39:54.4 hrs, the audio ground proximity warning again came on “pull up (whoop, whoop), pull up (whoop, whoop), pull up  (whoop whoop) pull…” and it remained till the end of the recorded data.

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 procedures / actions due to their lack of knowledge, training and experience to handle this type of abnormal situation and resulted in the unfortunate flight to impact the ground.

• The aircraft appeared to pitch up to at least 0 degree at the end of the data while flying 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, at a distance of 4.24 nm from runway 30 threshold, just to the right of the extended runway centreline.

• The CVR last recorded data finished at 18:40:00.3 hrs.