JS Air Flight 201

The aircraft was chartered to fly 17 personnel of Italian oil and gas company Eni from Jinnah International Airport in Karachi to the Bhit Shah gas field. Three crew members and one airport security guard were also on board.[5][6] At 01:55 UTC, the flight 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]

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 the feathering function of both engines is to be checked simultaneously. However, the cockpit crew in this case only checked No 2 engine's feathering mechanism serviceability manually, contrary to the documented procedures.[7]

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

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, but contrary to the documented procedures of no remedial action below 400 ft above ground level. 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 and lack of situational awareness on part of the captain.[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. 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 102 knots with increasing pitch attitude and right angle of bank.[7]

Then, further reduction in engine sound was observed. Bank angle was 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. At this stage the aircraft was flying at an airspeed 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. The captain was heard saying several holy verses from the Quran and "Bismillah (In the name of God)". The ground proximity warning "whoop, whoop" sounded until end of recording.[7]

The aircraft involved was a twin-turboprop Beechcraft 1900C-1, with Pakistani registration AP-BJD. It was built in 1991 and at the time of the accident had accumulated around 18,000 flight hours.[8]

On board the aircraft were 17 passengers, 2 pilots, 1 technician and 1 security guard.[9][10]

The captain was a Pakistani national born in 1957. He was described as quite religious. He joined the 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 in June 2006. The captain had accumulated a total flying experience of 8,114 hours, including 1,820 hours on the Beechcraft-1900.[7]

The first officer was a Pakistani national born in 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 in the United Kingdom in 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 in February 2007. He became a captain in March 2010. The first officer had accumulated a total flying experience of 1,746 hours, with 1,338 of them on the Beechcraft 1900.[7]

An inquiry was ordered into the crash. No evidence was found of a bird strike, pilot incapacitation, sabotage, in-flight structural failure or fire.[11][12]

The investigation started with the examination on the plane's propellers, as evidence from the cockpit voice recorder (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 and 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 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, the 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 a 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 the 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 was mentally preoccupied 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]

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.[7]

In December 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, lacked situational awareness, displayed poor crew resource management, and handled the anomaly unprofessionally.[7]

The crash prompted Eni's chief executive Paolo Scaroni to travel to Pakistan with the head of Eni's exploration and production division, Claudio Descalzi.[13] 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".[14] 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".[11]

• Air Midwest Flight 5481