2010 Karachi Beechcraft 1900 crash

2010 Karachi Beechcraft 1900 crash

The aircraft involved in the crash registered as AP-BJD, seen here in 7 July 2007
Accident
Date	5 November 2010
Summary	Pilot error in response to engine failure
Site	Karachi, Pakistan 24°51′36″N 67°00′36″E / 24.86000°N 67.01000°E / 24.86000; 67.01000Coordinates: 24°51′36″N 67°00′36″E / 24.86000°N 67.01000°E / 24.86000; 67.01000
Aircraft
Aircraft type	Beechcraft 1900C-1
Operator	Jahangir Siddiqui Air
Registration	AP-BJD
Flight origin	Karachi-Jinnah International Airport
Destination	Bhit gas field, Jamshoro district, Sindh[1]
Passengers	17[2]
Crew	4
Fatalities	21 (all)[3]
Injuries	0
Survivors	0

The 2010 Karachi Beechcraft 1900 crash occurred on 5 November 2010, when a Jahangir Siddiqui Air Beechcraft 1900C-1 crashed near Jinnah International Airport in Karachi, Pakistan, killing all 21 aboard. The aircraft and the bodies were burnt beyond recognition.^[3] The pilot had reported trouble with the engine of the aircraft shortly before the accident.^[4][5][6]

The final report published by Pakistan's Civil Aviation Authority, concluded that pilot error was the cause of the accident. After takeoff the aircraft experienced an abnormality and the cockpit crew decided to land back at Karachi after calling right hand downwind for runway 25R. The pilots later lost control of the plane, stalled, and crashed onto terrain. With 21 fatalities, the accident was the second worst accident involving a Beechcraft 1900C-1 tied up with the 2003 crash of Air Midwest Flight 5481 in Charlotte-Douglas International Airport in North Carolina. Currently, it was the 16th deadliest plane crash in Pakistan.

Accident

Jinnah International Airport in Karachi, the place of the accident

The aircraft was scheduled to fly chartered flight from Jinnah International Airport, Karachi to Bhit Shah Oil Fields to convey 17 employees of Eni company including one foreign national from Italy. The flight was registered as Jahangir Siddiqui Air Flight 201 (JS201). At the time of the accident, the plane was operating its first flight. At 01:55 UTC the cockpit crew contacted Karachi Ground for take off. The Karachi Ground Controller said “copied JS-201 start up approved runway two five left” which was acknowledged by cockpit crew. The captain cleared the area towards left side and started the Engine No 1.^[7]

Sequence of a propeller at idle speed, feather, and unfeather

The cockpit crew then requested Karachi Ground for the taxi instruction. After the instruction from Karachi Ground, they conducted a pre-take off checklist. At this point, right engine propeller feathering was checked in manual position. As per procedure run up checks are supposed to be carried out and feathering function of both engines is to be checked simultaneously, however, cockpit crew in this case only checked No 2 engine feathering mechanism serviceability manually contrary to the documented procedures.^[7]

At 02:03 UTC, the plane was cleared for take off. Soon after take off, the right engine went out, and the speed started to decrease slightly. The first officer then put the engine into feathering position. At this stage, it is considered that probably the first officer may have observed partial feathering due to which he wanted to feather the propeller of engine No 2 which was approved by the captain contrary to the documented procedures of no remedial action below 400 ft above ground level. It is important to note that the actual problem being discussed among the cockpit crew was related to No 2 engine, whereas at this stage the captain advised the first officer to inform ATC tower that they had problem with engine No 1 which indicates the confused state of mind, pre occupation and lack of situational awareness on part of the captain.^[7]

The first officer later on reported a problem on engine No 1 (as based on his captain's advice), which in reality based on the first officer's observation, he realized that the engine with abnormality occurred in engine no 2, but somehow followed his captain's advice to report to the tower that they had problem with engine no 1.^[7]

The ATC cleared the aircraft for an emergency landing in Karachi. The cockpit crews later acknowledged. This was the last transmission from the aircraft to the tower. The captain later noticed that the first officer was moving the engine No 2 feather control lever and asked him "What are you doing?". The first officer then told the captain that the engine was not feathering. At this point, the speed of the aircraft was at 102 knots with increasing pitch attitude as well as right angle of bank and first time it is observed that the captain told the first officer to wait and hold his ongoing actions.^[7]

Then, further reduction in engine sound was observed. At this stage, it was evident that right bank was continuously also increasing due to full power on serviceable engine No 1 and as the power on engine No 1 was reduced indicated by reduction in engine noise, the right angle of bank started to decrease subsequently. It is important to note that the aircraft at this stage was flying at very low airspeed which was close to the stalling speed with landing gears down and at maximum all up weight.^[7]

An increase in engine sound occurred and a stall warning sounded until the end of the recording. At this stage, the captain was sure that the aircraft would be either forced landing on unprepared surface or impact the ground due to stalled state of aircraft, as in the Cockpit Voice Recorder (CVR), it was heard that he was saying several holy verses from the qur'an and saying "Bismillah (In the name of God)". Ground proximity warning “whoop, whoop” sounded till end of recording. The aircraft later hit the ground.^[7]

The accident aircraft was a privately chartered plane carrying people to a nearby facility managed by Eni, an Italian oil and gas company.^[8][9]

Nationalities of passengers

17 ENI passengers, 2 pilots, 1 technician and 1 security guard^[10]

Nationality	Fatalities		Total
	Passengers	Crew
Italy	1	0	1[11]
Pakistan	16	4	20
Total	17	4	21

The captain was a Pakistani national born on 14 August 1957 at Karachi. He was described as quite religious. He joined Pakistan Air Force (PAF) Academy in Risalpur in 1977 as trainee pilot. During his service career he flew various training / fighter and light communication aircraft including MFI-17, T-37, FT-5, FT-6, Piper (Seneca-II), Beech Baron, Y-12, Super King (B-200), Cessna-172 and Cessna-402 aircraft. He retired at the rank of squadron leader from PAF in 2003 while accumulating 6,279 hours. He started to fly as first officer in JS Air on 13 June 2006. The captain had accumulated a total flying experience of 8,114 hours.^[7]

The first officer was a Pakistani national born on 16 February 1977. He was given multi-engine aircraft rating on Cessna-402 aircraft on 23 December 2004 after completing all requirements / formalities by CAA Pakistan. He joined JS Air and underwent his Beechcraft-1900 ground and simulator training at Farnborough Learning Centre, United Kingdom from 30 October 2006 till 10 November 2006 and successfully accomplished his training. After completing his flying training at JS Air, he was cleared by CAA Pakistan to fly as Co-pilot under supervision on 13 February 2007. The first officer had accumulated a total flying experience of 1,746 hours.^[7]

Investigation

An inquiry has been ordered into the crash. There were several things that investigator probed as the probable cause of the accident, which are bird strike, in-flight structural failure, sabotage, in-flight fire, pilot incapacitation, mechanical failure, or pilot error. However, there were no evidence indicating a bird strike, pilot incapacitation, sabotage and an in-flight structural failure. All of them were ruled out. Investigators later ruled out in-flight fire as the cause of the accident, as the fire occurred on the flight was due to post-impact rather than a pre-impact fire.^[12][13]

The investigation started with the examination on the plane's propellers, as evidence found by investigators (from the CVR) suggested that an engine failure occurred in mid-flight. Investigators retrieved the propeller from the wreckage and stated that the beta valve in the aircraft may have malfunctioned in mid flight. There are two possibilities of beta valve malfunction; mis-rigging after some maintenance work or fair wear & tear during routine service. Unfortunately, the beta system’s integrity and rigging status could not be verified because the propeller governor had been completely consumed in the post ground impact fire. However, it was confirmed from the documented history and the engineering staff that there was neither any reported defect related to the beta system nor was there any scheduled or unscheduled maintenance performed in the recent past. Therefore, the only probable cause of occurrence could be fair wear and tear of the beta valve.^[7]

However, investigators stated that even if a mid-air engine failure occurred, the pilots still could have returned to the airport safely. If an aircraft had a mid air engine failure in one of its engine, the plane still could fly. All twin engine aircraft are designed to sustain a safe flight even if one of the engines has failed or is switched off due to any abnormality provided the emergency handling procedures are correctly followed. Similarly, Beechcraft 1900C also had the capability to sustain safe flight with single engine operation. This suggests that pilot error maybe the main cause of the accident.^[7]

Investigators reviewed the CVR data and stated that the pilot may have lacked situational awareness. After experiencing the abnormal engine No 2 operation, at one stage the cockpit crew indicated confusion about the engine No 1 or 2 and subsequently transmitted incorrect information to the ATC Tower that they were experiencing abnormal operation of engine No 1. The first officer was exposed to serious level of stress and anxiety when he observed the propeller feathering of No 2 (right) engine. The situation was aggravated due to the fact that the auto feathering was selected to “Off” which entailed the cockpit crew to manually manage feathering of Propeller in case of any anomaly. He did communicate to the captain correct information, however, the captain did not register engine No 2 and told him to inform ATC Tower that they were experiencing problem with engine No 1 and FO communicated the same without questioning the captain or correcting himself. He got mentally pre-occupied to a level where he could not perform the recommended remedial action. Thus, he did not effectively contribute towards handling of abnormal set of conditions.^[7]

Investigators checking the captain's flight history discovered that his performance during simulator training check flights remained consistently below acceptable levels. He was not able to safely handle training scenarios during critical phases of takeoff and post-takeoff, and was only able to achieve satisfactory performance levels with coaching during these mandatory exercises. The final report stated that the captain suffered from "lack of confidence" and also revealed that the captain lacked the required proficiency and skills to independently handle aircraft operations with a single functioning engine during critical phases of flight.^[7]

Even though the captain made the most serious mistakes, the first officer was also noted by the CAA in his failure to raise the landing gear during an in-flight emergency. Investigators concluded that the cockpit crew neither discussed nor raised the landing gear after takeoff. The wreckage also confirmed the landing gear were in the extended position at the time of ground impact. The Beechcraft-1900C aircraft has a very low rate of climb with landing gear in extended position due to increased drag while operating with a single engine. Any banking of the aircraft would aggravate the situation and the marginal rate of climb would degrade into a rate of descent, which happened in this particular case. The first officer was a qualified captain on Beechcraft-1900C aircraft, however his actions and the assistance available to him was not at an acceptable level. He failed to retract the landing gears after takeoff and undertook remedial actions well below the defined minimum safe altitude, contrary to recommended procedure, which indicated his preoccupation, anxiety and stress in handling the abnormal situation. As a result, the aircraft failed to achieve stable flight, despite having a serviceable engine.^[7]

On December 18, 2015 Pakistan's Safety Investigation Board released their final report stating that the accident was caused by the inability of the captain to handle the abnormal operation of engine No 2 just after takeoff, failure of the cockpit crew to raise the landing gear after experiencing the engine anomaly, and execution of remedial actions by the first officer before the attainment of minimum safe altitude. The crew did not follow standard procedures, did not take proper actions, lacked situational awareness, experienced Crew Resource Management failure, and handled the anomaly unprofessionally.^[7]

Aftermath

The crash prompted Eni Chief Executive Paolo Scaroni to head to Pakistan with the head of Eni's exploration and production division, Claudio Descalzi.^[14]Dawn reported that the crash was "a reminder of the need to constantly review and enforce air safety protocols in Pakistan", though noted that while the country "has generally had a good air safety record" that this crash happened "while memories of the catastrophic Air Blue crash – the worst aviation disaster in the country's history – are still fresh".^[15] The Express Tribune also said the crash evoked memories of the previous crash, noting that the coverage was "reminiscent of that of the Airblue crash" because "soon after the crash, images of the site splashed onto TV screens, with bulletin after bulletin giving detailed coverage, implicit with the promise that this tragedy will be investigated and justice will be done".^[12]

See also

• Kegworth air disaster
• TransAsia Airways Flight 235

References

External links

• Final report (Archive) - Pakistan Civil Aviation Authority