Make the Airblue crash report public

The cockpit resource management, rule violations, incompetent CAA are ‘contributory’ factors in the accident.

Meekal A Ahmed March 23, 2011

Seven months have gone by since the  Airblue crash, and yet the families of the victims have yet to have closure, primarily because the inquiry report has not been made public. There is much speculation, most of it ill-informed, about the various factors which caused the  Airblue accident. Such speculation fails to come to grips with the reality that while a host of factors may have contributed to the accident, the ultimate responsibility for the safe conduct of the flight rests with the aircraft commander. Bad weather, fatigue, fasting, commercial pressure to land and not divert to another airport, poor air traffic control coordination between the tower and radar, inappropriate crew pairing, a breakdown in cockpit resource management, rule violations, a sloppy and incompetent Civil Aviation Authority (CAA) and so on, are ‘contributory’ factors in the accident. The principal ‘probable cause’ of the accident is almost self-evident: Pilot error. This is not a cruel rush to judgment. This is, sadly, the cause of the majority of air accidents world-wide and the circumstances here forcefully point in that direction.

It is a supreme irony that ‘pilot error’ is the predominant cause of air accidents. Pilots are the most well-trained species on earth, subject to recurrent physical examinations and simulator check-rides. Failing the former can end their careers. The latter can cause even the most bold and brave amongst them, to have nightmares over what is going to be thrown at them by the simulator instructor. Today’s full-motion flight simulators are so realistic that pilots are known to emerge from a session, during which emergencies were practiced, drenched in perspiration. The flight simulator is rightfully labelled ‘The ego-buster’.

The Islamabad accident is a ‘Controlled-Flight-Into-Terrain’ (CFIT) event. A perfectly air-worthy aircraft hits high ground. We know what happened. The question is why? Why did a modern aircraft with the most sophisticated look-ahead, terrain-warning systems on board and a computer-generated voice, blaring repeatedly “pull up!” in a rising crescendo as the terrain was approached, still smash into a hill at high speed and extinguish all lives on board?

Only a full accident report can explain what happened in the last 30 minutes in that cockpit and how the aircraft was behaving. Sadly, Pakistan has no history of publishing any air accident report in the last 62 years. The surviving family members of those who perished at Cairo, Taif, Khatmandu, Multan, the Northern Areas, East Pakistan and now Islamabad are left to grieve with no explanation as to why their loved ones died.

The cause of air safety is not served by concealing the facts of an air accident. Each air accident harbours vital lessons. Remedial measures and safety recommendations are made. If the CFIT accidents at Cairo and Khatmandu had been published, arguably the accident in Islamabad would have never happened. Lessons would have been learnt and procedures modified, including special vigilance and better cockpit resource management and cross-checks when flying near high ground.

The main reason for keeping air accident investigations secret is simple: Money. If negligence is proven (and in the above list only the accident at Taif was not connected to pilot error, since there was an uncontrolled cabin fire), the monetary compensation families obtain can be very large. The  Airblue CEO is a politically well-connected individual. He will do everything in his power to ensure the accident report does not see the light of day. One hears that some compensation has been given. But, without knowing the cause of the accident, it is not possible to establish whether the compensation is fair. It, probably, is far from fair.

Meanwhile, it is heartening to read that the Sindh High Court has taken up the case and has summoned all parties concerned to depose before it. The honourable court instead of starting its own investigation and waste more time should pass a simple order instead: The accident investigation report, along with the read-out from the cockpit voice recorder and digital flight data recorder should be published and put on the CAA’s website. That would not only set a bold precedent, it would be the right thing to do. Only full transparency and the truth will bring closure to the grieving families.

Published in The Express Tribune, March 24th, 2011.


Naveed Nasar Khan | 11 years ago | Reply I highly appreciate the deep involvement of the likes of Mr Meekal Ahmed and Ms Marvi Memon for the resolution of this unfortunate Air Blue Crash. Where are all the others including the Media? I happen to be a close associate of Mr Shamim Sheikh who lost his young son in this tragic accident and very well understand his state of concern and so also of all the other kins of the crash victims.The crash happened and valuable lives were lost. Nothing can bring them back to their loved ones, but what followed afterwards is an extremely shameful story. I totally agree with Mr Meekal, where he says the sole reason for holding back the report is `Money'. How true, it is this aspect that has eaten away the very fabric of our nation. But not to worry, today is different from our past. Today belongs to the people, where nothing can be kept away from them. I am very sure, with continuous pressure on the Government, they will sooner than later make the facts known.
Meekal Ahmed | 11 years ago | Reply @Fahd hassan: What is flying side-seat? Your long-winded comment offers nothing of value. It is confusing and inarticulate. The only thing you added is "complacency" and "over-confidence". I agree that these are great killers in aviation and could very well add to the long list of contributory factors that I enumerated. But that is not the "Probable Cause" of the accident. I have heard the theory about mistaking the road for the runway. Either he is visual and can see to his left and ahead and the Margalla hills are to his RIGHT, or he is not visual. If he is not visual, he needs to get the hell out of there. That is SOP. He did not do that. He continued to execute a visual pattern even though he had lost all visual contact with the ground. That is illegal. He is supposed to have told ATC he could see the Margalla's. Obviously, he could not or he would not have hit them. Was he being less than truthful? Yes, pilots will be that at times when they are anxious to land because of commercial pressure not to divert. The look-ahead terrain-based EGPWS on the A320 gives a long 15 second warning of terrain. You make no mention of this crucial safety feature in modern aircraft. The EGPWS will first give you a "soft" caution: "Terrain Ahead". If you are flying down-wind and parallel to the Margalla's, you should get no warning. That caution should have told the crew they must be in the wrong place, flying the wrong heading, and at the wrong height. All they had to do was look at their Primary Flight Displays and Navigation Display right in front of them. The warnings get more incessant: "Terrain!", "Terrain"! if you keep flying towards high ground. And finally, "PULL-UP"! "PULL-UP"! which stops if you are clear of obstacles but will otherwise repeat itself until impact. These warnings were either disbelieved and/or ignored. Over-confidence and "spatial disorientation" could be factors here. Why listen to a dumb computer-generated voice? YOU know exactly where you are! Right? "You don't fly for the other guy and your tasks are divided"? You must be nuts. Have you never heard of CRM? You use ALL the resources in the cockpit. You NEVER fly on your own. You check and cross-check each other. You fly as a closely-integrated, seamless team. A good captain will tell his co-pilot something like "If you see me doing something unsafe, speak up. Don't just sit there". Or "before you touch anything, tell me what you are doing". That is the heart of CRM. All I can say in conclusion Fahad is I sure as hell would not want to fly with you! Answering Sheik Sb.'s question about very experienced pilots, sad to say, Sir, but the reality is that even the best make mistakes. PIA's inaugural Boeing 720B flight to Cairo was under the command of Capt. A. A. Khan, No 1 in seniority and acknowledged to be a very fine pilot.
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