Bhoja Air Flight 213
The aircraft involved in the accident while still in operation with British Airways Comair in 2009
|Date||20 April 2012|
|Summary||Microburst induced windshear countered by pilot error|
|Aircraft type||Boeing 737-236A|
|Flight origin||Jinnah International Airport, Karachi|
|Destination||Benazir Bhutto International Airport
Bhoja Air Flight 213 (B4 213/BHO213) was a domestic scheduled passenger flight operated by the Pakistani airline Bhoja Air. On 20 April 2012, the Boeing 737–236 aircraft, flying from Jinnah International Airport, Karachi, crashed in bad weather during its approach to Benazir Bhutto International Airport, Islamabad. All 121 passengers and 6 crew members aboard were killed in the crash. This was the inaugural flight of Bhoja Air's second daily service on this route.
It was the second-deadliest aviation accident in Pakistan, the deadliest one being the 2010 crash of Airblue Flight 202 that killed all 152 on board, and is the fourth deadliest accident involving the Boeing 737-200 series.
The aircraft was a Boeing 737–236, registered AP-BKC, Built as msn 23167, it first flew on 13 December 1984 and was delivered to British Airways on 7 January 1985 (registration G-BKYI), it was subsequently acquired by codeshare operation Comair (registered as ZS-OLB) in June 1999. The aircraft operated South African domestic routes until late 2010 when Comair retired its 737-200 fleet and it was sold to Bhoja Air in January 2012.
The aircraft was operating a domestic scheduled flight from Jinnah International Airport, Karachi, to Benazir Bhutto International Airport, Islamabad, which was the airline's first evening flight in almost 12 years. (Bhoja Air was earlier closed down amidst financial difficulties in the year 2000, but restarted operations in March 2012). There were six crew and 121 passengers on board. The flight departed from Karachi at 17:00 PST (12:00 UTC) and was due to land at Islamabad at 18:50 (13:50 UTC). At 18:40 PKT, the aircraft crashed 3 nautical miles (5.6 km) short of its destination, near the village of Hussainabad, Rawalpindi. All 127 people on board were killed. The landing was attempted during heavy rain and a thunderstorm.[Note 1]. Initial reports suggested that as the pilots attempted to land amidst rain and strong winds, the aircraft may have flown into an unexpected wind shear, which smashed it onto the ground below. However, eyewitnesses stated that the aircraft may have been struck by lightning prior to the crash, describing it as a "ball of fire." A following Airblue flight landed safely five minutes after the accident occurred.
The airport was closed for three hours after the accident due to a lack of fire cover. The emergency crews based at the airport went to the crash site to assist in the firefighting operations there. Flights affected by the closure were diverted to Allama Iqbal International Airport, Lahore. Despite the fact that the crash occurred in a residential area, there were no casualties on the ground.
Sequence of events
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Flight 213 was on approach to Benazir Bhutto International Airport piloted by Captain Noor Afridin and First Officer Javid Malik. Airport AFIS told the crew of Flight 213 that the weather in the area was thundery with heavy precipitation. The crews acknowledged the report and continued the approach. Flight 213 had only experienced some turbulence while approaching therefore it continued the approach. The Flight crew was still at normal mood condition, as Captain Noor's jokes and laugh were heard in the CVR. But a few minutes later, the flight finally encountered bad weather conditions. The flight crew entered bad weather, but still continued the approach, even though Bhoja Air's operational manual told crews to discontinue approach if bad weather was encountered. They continued the approach until finally they realized that they had entered an active cell. At this time, Captain Noor was worried about the condition, but continued the approach. Autopilot was later disengaged by flight crews. Islamabad Tower then told Flight 213 to land on Runway 30. The landing checklist was completed and done. Flight crews followed the landing procedure on ILS approach. The autopilot later engaged again.
The plane continued to approach the airport and leveled off with landing gear retracted. At this time, Captain Noor had been in extreme anxiety, as the plane was in an active bad weather cell. However, First Officer Javid seemed to be ignorant and unaware of the extreme precipitation and bad weather, and did not recommend the Captain to discontinue the approach. As the plane continued the approach, Captain Noor became pre-occupied with anxiety, as he saw erroneous readings in flight parameters on some instruments from the effect of bad weather. At this point, the approach was still normal as usual.
The plane was descending and followed the approved glide path. At this point the plane was on final approach and began descent on the glide path. Flaps then retracted to 5, which was actually incorrect as the flaps should be at 30. Suddenly, the plane encountered an increasing downdraft (in other word; microburst), as it continued the approach. The pitch angle increased as it encountered the descending air mass. Computed airspeed decreased significantly as the autopilot tried to maintain the glide slope beam.
The aircraft had to pitch up and consequently, lost airspeed as the result. These are the indications that a downdraft had occurred.
The computed airspeed remained decreased. A few seconds later the wind shear alarm occurred. Surprisingly, neither pilot took any remedial action to recover it as per Boeing procedures with auto-throttle and autopilot engaged. At this point, Captain Noor could be heard yelling "no..no.." in extreme anxiety and desperation. Despite getting specific warning about the wind shear condition, the flight crew still did not take any recovery action to recover from the unsafe condition.
Flight Officer Javid later also heard in extreme desperation, shouted "go around..go around" to Captain Noor. However, there was no go-around action initiated by Captain Noor. First Officer Javid also did not take over the control of the aircraft to initiate a go around. Suddenly the downdraft dissipated, and a sudden change of angle of attack of the plane occurred. A longitudinal acceleration spike was also observed at this point, along with the normal load factor. The autopilot disengaged, and a nose-down column was commanded. The pitch angle decreased for the next few seconds. The auto-throttle remained engaged.
After the disengagement of the autopilot, there was no control activity of the aircraft wheel for six seconds and the column activity for eight seconds. Captain Noor and First Officer Javid were both in state of confusion and unsure of remedial actions to be taken to get out of the unsafe condition. The aircraft pressure altitude and pitch angle were decreased while 160 knots computed airspeed remained maintained.
Islamabad tower later contacted the flight crews. First Officer Javid later acknowledged it on the reminder of Captain Noor. Flight Officer Javid was extremely pre-occupied by severe weather condition and seemed to be in state of confusion to recover the aircraft from the unsafe condition, as the plane encountered wind shear before. This was the last communication by the Flight Officer and the Captain. The Terrain Awareness System Alarm sounded. The alarm, "Whoop Whoop Whoop" could be heard in the CVR. The crew were still in state of confusion and did not take any recovery action as they were supposed to according to the Boeing Manual. The pitch later decreased from 5° nose up to 0° with airspeed also decreasing.
The plane suddenly encountered another downdraft. This one was more severe than before and gradually increased for 15 seconds, causing the plane to descend rapidly. Even though the crew had encountered the same problem before, surprisingly, they did not take any recovery action again to get out from the unsafe condition, which confirmed their ignorance on recovery procedures. The TAWS warning, "Whoop Whoop Pull up!" was heard on the CVR. The Captain responded by making a nose up. However, pressure altitude remained decreasing as well as the thrust, as auto-throttle remained engaged.
Suddenly the downdraft dissipated rapidly from 50 fps to 0 fps in four seconds, this cause a rapid increase in the angle of attack and, as the result, the stick shaker was activated for approximately two seconds. It appeared that the Captain desperately tried to get out from the TAWS pull up warning, as he maintained a nose up input. Thus, the plane stalled. He heard the stick shaker warning and, to get out of it, he later maintained a nose down input. This input continued for the next few seconds. However, proper and complete Boeing stall recovery action remained not carried out.
The pitch rapidly changed from 2° nose up to a maximum 12° nose down for over 8 seconds. The plane remained in maximum nose down even when the plane was at close proximity with the ground. The "Pull up" ceased momentarily until it was activated again until the end of the recording. Islamabad Tower later cleared Flight 213 for landing. Flight 213 never acknowledged the call as the cockpit was in total chaos. Wind shear alarm later activated again once more. Captain Noor wants to get out from the "Pull up" warning, but exceeding the critical angle of attack. This caused both stick shakers to activate again. First Officer Javid shouted in extreme anxiety "Stall warning let's get out!". The Captain did not make any evasive action as he was so focused to get out from the condition, aggravated by the First Officer's action to not take control of the aircraft. The TAWS warning, " Whoop Whoop Pull Up!" activated again and remained so until the end of the recording.
The plane later banked to the right and returned to the centerline of the runway with pitch angle of 0° and travelling in 215 knots. First Officer Javid shouted his last words on the flight to the Captain, he shouted "Go around Sir, Go around!" The plane then impacted the ground and exploded, killing all 127 people on board.
Passengers and crew
On board were six crew, 110 adult passengers, six children and five infants.
A statement on Bhoja Air's website offered condolences to the affected families and said that it would fulfil its legal obligations under the Pakistani law applicable at the time of the accident.
President Asif Ali Zardari cut short his trip to cities in Punjab and returned to the capital, and he and Prime Minister Yousuf Raza Gillani sent condolences to the families of those who died in the accident. The Civil Aviation Authority issued an office order at 9 a.m. the next day, requiring all airlines to transport the bodies of the victims free of cost. Those families who had already paid for the transportation before the order was released were refunded the amount.
On 30 April, Bhoja Air announced compensation of Rs. 500,000 to the legal heirs of the victims of the Flight 213. However, the compensation is long overdue. The families of the deceased protested outside the office of Bhoja Air in Karachi.
On 28 May 2012, Bhoja Air's license was revoked by the CAA, due to failing a requirement under the Pakistani Civil Aviation laws that a carrier must maintain a minimum fleet of three aircraft. Of Bhoja Air's original fleet of 3, one crashed, another was grounded after it developed a fault, leaving only one operational aircraft.
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Investigations into the crash were opened by the Civil Aviation Authority (CAA) and by the Safety Investigation Board of Pakistan. Boeing is assisting the CAA with the investigation. The aircraft's cockpit voice recorder was recovered from the wreckage on 21 April and passed to the CAA. The flight data recorder was also recovered. Both were sent to the United States for analysis by Boeing.
Pakistani officials promised a full investigation and Farooq Bhoja, the owner of Bhoja Air, was put on the Exit Control List, meaning he may not leave the country while the criminal investigation was underway against him and the airline.
CAA, the regulatory authority for maintaining aviation safety standards in Pakistan, faced harsh criticism in Pakistani media for allegedly compromising on safety standards. The corruption within CAA, due to politically motivated appointments, was alleged to be the prime reason for increase in frequency of technical faults, crash landings and catastrophic air accidents. The CAA, however, maintained that it did not issue any airline license or airworthiness certificate under political pressure, however it did announce that the Bhoja Air engineers were not qualified to issue the air worthiness certificate.
Following the accident, the CAA announced it would re-certify the fleet of all private airlines in the country. The CAA suspended the airworthiness certificates of two Bhoja Air aircraft on 24 April 2012. The CAA announced that the suspension was lifted on 28 April 2012.
Civil Aviation Authority released the final investigation report comprising 78 pages on 21 January 2015. The report found that the primary causes of the accident include the ineffective management by the cockpit crew of the basic flight parameters such as airspeed, altitude, descent rate, attitude, as well as thrust management. The report also found that the ineffective automated flight deck management in extreme adverse weather conditions by the cockpit crew caused the accident.
The investigation found that ineffective flight deck management by the pilots in adverse weather conditions caused the accident. The pilots had inadequate flying experience, training and competence level in the aircraft.
- ^ The METAR in force at the time of the accident was "OPRN 201300Z 23020KT 4000 TS FEW025CB SCT030 BKN100 25/15 Q1009.3/29.80". This translates as "METAR for Benazir Bhutto International Airport, issued on the 20th of the month at 13:00 Zulu Time. Wind from 230° at 20 knots (37 km/h). Visibility 4,000 metres (13,000 ft), thunderstorm occurring on station. Few clouds at 2,500 feet (760 m), cumulonimbus clouds present. Scattered clouds at 3,000 feet (910 m). Broken clouds at 10,000 feet (3,000 m). Temperature 25 °C, dewpoint 15 °C. Altimeter setting 1009.3 hPa / 29.80 inHg".
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