Bhoja Air crash: Revelations from the CAA report

Published: January 23, 2014
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Onlookers are seen at the site of the Bhoja Air Boeing 737 crash in the outskirts of Islamabad on April 25, 2012.  PHOTO: AFP

Onlookers are seen at the site of the Bhoja Air Boeing 737 crash in the outskirts of Islamabad on April 25, 2012. PHOTO: AFP

KARACHI: The evening flight was a routine affair for Captain Noorullah Khan, 58, even if there was a thunderstorm warning for the city where the plane headed. A former Pakistan Air Force (PAF) pilot, he had 10,158 hours of flying experience behind him.  

It was a Friday on April 20, 2012. The Bhoja Air flight BHO-213 took off from Karachi for Islamabad at 5:05pm with 127 people onboard including six crew members.

It was the first evening flight in 11 years since Bhoja suspended operations in 1999. The airline had resumed service a couple of months back under the new ownership of Arshad Jalil, a former Managing Director of Shaheen Air International.

The plane was one of the four Boeing 737 inducted in the fleet. It was a 737-236a – an advanced version of the 737-200 – manufactured in 1985 and purchased by British Airways, which used it till 1999. Then it served in South Africa’s Comair till the end of 2010 when it was grounded as the airline switched to another model.

All relevant checks and approvals were obtained when Bhoja bought it in January 2012. On the 12th of that month, Pakistan’s Civil Aviation Authority’s inspectors Shaukat Hameed and Javed Afzal undertook a detailed inspection of the aircraft at Johannesburg.

They pointed out 28 discrepancies, which ranged from peeled-off paint to a fan blade of one engine sporting a cut. They also examined the waviness of the blade. All defects were removed in following weeks.

And so at 6:09pm the plane was in the air somewhere above Lahore. Inside the cockpit, Khan was assisted by 53-year-old first officer (FO) Javaid Ahmed Malik who was also ex-PAF pilot.

The two men were considered very close. They had worked in Shaheen and then moved to Bhoja together. As a matter fact, out of 23 flights the Captain took at Bhoja, the FO was his co-pilot in 16 of them.

Khan was a fatherly figure for Malik, who had performed very well in PAF as a cadet. But during his initial flying experience, he suffered airsickness, which scarred his confidence for the rest of his career.

The captain left Shaheen after he was dropped from a ground training programme for B 737-400 aircrafts as the management felt he won’t be able to manage the automated flight deck system efficiently.

The automated flight deck system is slightly more advanced than the semi-automated ones and needs different treatment, especially when the aircraft encounters adverse weather condition.

Captain Khan was not properly trained to handle the situation on such systems whereas his first officer never received simulator training for the B 737-236a variant, which has an automated deck.

At 6:17pm, the captain sang a few lines of traditional Punjabi song ‘Sanoo nahar wali pul tay bula kay’  while the FO laughed.

Exactly at 6:18:17, the FO asked Khan if he should take the weather forecast for Peshawar. The captain said there was no need. Every flight has two alternate cities marked in case the plane needs a diversion. In this instance, they were Lahore and Peshawar. But the pilot seemed to have made up his mind to land at Islamabad.

There was thunderstorm activity over Islamabad with wind speeds between 20 and 34 knots. The environment was rife for downburst and wind-shear, which causes drastic changes in wind speed and direction over a short distance and altitude.

The captain realised how bad the weather was at 6:19. At 6:24, the captain explains to the FO about the squall line, which basically means bad weather. Over the next few minutes the cabin crew discussed the situation outside.

The radar controller told them at 6:28 that there was a gap between radials 160 to 220. That meant there was small space for the aircraft to pass through the stormy clouds.

At 6:31:08, the FO asked the captain to take a right to avoid the bad weather. “No, no we don’t have to go there, we have to land here,” replies Captain Khan who was determined to land.

After that the crew became relaxed for a while.

The tower clears the flight to descend at 6:33. Autopilot and auto throttle are engaged at 6:35. At 6:37 the captain commented on the darkness. They knew they were near bad weather but did not change course, which they should had done as per the flying manual.

By 6:38:10, the landing gear was down and the aircraft was arranging itself with the localiser, an imaginary line which helps guide it towards runway.

Flight BHO-123 had entered the last two minutes of its life.

At 6:38:24pm, the FO told the captain that the speed is 220 knots.

“What?” the captain shouted. The information is repeated. “220…oh shit what has happened?”

The captain knows that the auto throttle speed should not have exceeded 190 knots. He couldn’t correlate this variation with the presence of wind shear.

Precipitation, rain or hail lashing the aircraft frame, started at 6:38:37pm. The aircraft was taking the final approach.

By 6:39:16pm, a descending air mass had pushed the plane in downdraft, a rapid downward push of air. The speed being maintained by auto throttle was not enough to get out of the situation. In this situation pilots are trained to do just one thing: apply full throttle manually and get out.

“Wind shear- wind shear-wind shear,” said the Ground Proximity Warning System at 6:39:25. Within four seconds the plane fell from 1900 feet to 900 feet.

According to a senior pilot this is the time when passengers were exposed to havoc. “Everything must be flying inside.”

It was 6:39:28 when Captain Khan was yelling, “No, no.”

A second later the FO shouted, “Go around, go around.”

From then onwards the plane was flown manually but auto throttle still controlled the thurst.

The Terrain Awareness Warning System blared ‘whoop’ sounds. The FO was busy contacting the control tower. That is when he should have taken over control from the Captain as they are trained to do under Crew Resource Management courses.

At 6:39:54pm FO Malik shouted in desperation, “Stall warning, let’s get out.”

Three seconds later he said his last words: “Go around, go around sir, go around.”

The Bhoja aircraft crashed 4.5 nautical miles from the Islamabad airport near Hussainabad village. No one survived.

The cockpit crew conversation and findings are part of a 78-page investigation report which was spearheaded by CAA. It ruled out any sort of technical failure in the aircraft. Possibility of sabotage or bird hit was also discounted.

The radar controller has also been declared innocent. It has been found there was no way he could have known that there was wind shear.

One reason for the cockpit crew’s failure was the wrong induction of pilots for B 737-236a aircraft, it said. Bhoja’ management did not have a cockpit crew monitoring system at all.

The most astonishing part of the report is how CAA exempted its Flight Standard Directorate from any responsibility. CAA never objected to the pilots because it was never told by Bhoja that they would be flying advance version of B 737-200.

How these two inspectors overlooked what kind of an aircraft it was before clearing it remains a mystery.

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Reader Comments (22)

  • Muhammad Mubeen
    Jan 23, 2014 - 4:31PM

    Tragic Incident …. May Allah Bless All of Them!Recommend

  • khawar shafi advocate
    Jan 23, 2014 - 4:44PM

    To Allah belongs what ever is in the universes and to Him all shall return. My heartfelt condolences to the bereaved. The reporter has highlight fair objection on appointment of CAA as supervising the investigation when it ought to have been made subject to interrogation.Recommend

  • Saad D
    Jan 23, 2014 - 6:04PM

    Brilliantly written Saad! What a gripping account. It’s a tragic story and towards the end, I felt my heart sank as if I was in that cockpit.

    Recommend

  • Adeel
    Jan 23, 2014 - 7:13PM

    yup CAA well done.. always blame deceased Captains.. and never question your own performance. A 3rd world country already grounded the plane for reasons that it was a piece of crap. a pilot of 10k+ hours of flight experience wouldn’t know that auto throttle was still controlling? Crap report.

    Recommend

  • Captain Azim Ansari
    Jan 23, 2014 - 8:01PM

    As a former pilot, I am stunned at the FO’s subdued response to the Captain’s decision not to divert due to bad weather and then his inability to take control. If the co pilot had applied full power at the time of the windshear warning even he could have saved his aircraft. The simulator scenario teaches pilots to immediately throttle out of such a scenario. I think the pilots in pakistan need major refresher courses and should be trained in Dubai not in Pakistan.Recommend

  • Azam
    Jan 23, 2014 - 8:10PM

    Very nicely narrated….!!!
    The Black Box if properly decoded, can provide all the conversation that took place inside the plane.

    The flight operations of Bhoja Airline should also had taken into consideration the capability of both the pilot and the co-pilot before deputing them on this newly acquired plane and that too, resuming operation as first flight after a gap of several years.

    The pilot was not properly trained to handle the situation on such systems whereas his first officer never received simulator training for the B 737-236a variant, which has an automated deck.Recommend

  • Anonymous
    Jan 23, 2014 - 8:25PM

    I lost a very close friend in that plane. This is the first I’m hearing of the details, thanks for reporting. Recommend

  • nasir
    Jan 23, 2014 - 8:54PM

    Air Force Pilots Bad For BusinessRecommend

  • Wajahat Khan
    Jan 23, 2014 - 9:55PM

    @Captain Azim Ansari:

    Even PIA pilots are not properly trained with state of the art technology and all Pakistani pilots are a major pain to international air traffic controllers due to their poor English language skills which makes it difficult to communicate with them. All Pakistani pilots should not only be trained and certified on new planes but also should be taught how to communicate in English always, regardless of whether they fly in pakistani airspace or international airspace.Recommend

  • Haris Lodhi
    Jan 23, 2014 - 10:48PM

    I can understand the pain of victim families.I had lost my mother in Air Blue Crash and my father also passed away last month.Recommend

  • A. Khan
    Jan 23, 2014 - 10:53PM

    I thought Pakistani CAA had a requirement that European/US aircraft could not be more than 20 years old, for all these start up airlines. Where along the way was this rule changed ? Bhoja flight BHO-213 was using A Boeing 737-236 A (Construction Number (MSN) 23167) with flight flight in 1984. At the time of crash, the plane was over 27 years old.

    Did it have all the checks done ? Also, I find the factoid that the pilots did not have experience with the “newer” flight controls hard to digest. The aircraft was 27 years old. What was the most recent experience for the pilots ?

    Sure, the pilots are to blame but Bhoja Air management AND the CAA are equally culpable. The pilots are no longer with us but management of both Bhoja and CAA certainly are.Recommend

  • Yasir
    Jan 24, 2014 - 12:25AM

    @Haris Lodhi:

    I lost my mother last year as well. No one can understand how much it hurts to lose a parent, especially a mother. I wish both our mothers get granted Jannah. Ameen.

    Recommend

  • Mazhar Hussain Malik
    Jan 24, 2014 - 12:45PM

    Whatever happened on those fateful moments was predestined. We as human beings are helpless against the forces of nature. Nevertheless it is a bitter reality that sometimes over confidence becomes the reason for disaster. Poor judgement on the part of the pilot took the lives of so many innocent souls in this case. But again I will say that the sequence of events that took place in the dying moments of that fateful flight were very tragic and also point towards the fragility of human life.

    Recommend

  • Ashah
    Jan 25, 2014 - 6:27AM

    As weekend Pilot and a flying enthusiast I am just amazed at the english used in the narrative by the CAA. This is a highly unprofessional report would not pass a 10th grade english class the Pilot is dead ! So ! How do they know what he was “thinking” when the report continues to harp on the fact ” He was determined to Land ” ???? We pilots are taught safety first ! there is no shame in going around when you don’t have a stablized approach WX is one of the bigest causes for un-for- told crashes and I am pretty sure a Pilot with over 10,000 of flying time knew better than to land in that WX ? un less he reported wrong! that he had the” runway in sight” on his Localizer ? to the Controller I have not read the full report but this write-up in this paper is nonsense !

    Recommend

  • Usman Ali
    Jan 25, 2014 - 7:41PM

    This unfortunate flight was the 36th aircraft to crash in Pakistan since 1947, raising the total deaths caused by aircraft crashes to 1199. Surprisingly’ has anyone ever had noticed that, why no one from CAA is ever held responsible, why all the time its pilot’s error (because they are dead already), why air-worthiness responsibility of CAA is ignored all the time ?
    (Source: http://www.opfblog.com/11102/major-pakistan-air-crashes/)

    Recommend

  • saleem hatoum
    Jan 27, 2014 - 4:46AM

    I think the panic came into the cockpit when 220 kts was called by the F/O.

    Recommend

  • Asad Ahmed
    Jan 27, 2014 - 12:59PM

    It is the quality of training what matters, not the place/city where the pilots get trained. All airlines either have their own facility, or use other company’s training aids. PIA has pilot training facilities/simulator for B 777, A 310, B 747 in Pakistan, but use training facilities for B 737 & ATR abroad. So do the other airlines in Pakistan. It is the “quality” of training and standards and the adherence to company policies(diversions) and SOP’s which makes the difference.Recommend

  • Syed Ata ur Rehman
    Jan 28, 2014 - 12:39AM

    I think we should respect each other’s sentiments. It’s a good account on the narration of events. The details of conversation in the cockpit seems to be real. We all pilots are required to be bold enough to take over the controls if the senior is making any mistake. Total number of hours do not matter when we are tunnel visioned. CRM must come into action. Almost same had happened in air blue crash. May Allah bless the departed souls but we must draw the valid lessons keeping our emotions aside. Wishing happy landings for all of us.

    Recommend

  • Waqar
    Feb 2, 2014 - 11:34AM

    After reading this report the first thing I did was check on PCAA s website for the official report, but there was none. Thus unless the proper report is filed the complete picture cannot be ascertained. Even then the role of PCAA as both the report development/issuance body and under which such a large number of crashes have occurred is being questioned. In my view Boeing ‘s own report should also be published and made available so that such accidents are avoided and this does not relegate to only being a blame shifting exercise.

    Recommend

  • Asad Ahmed
    Feb 4, 2014 - 5:58AM

    Mr Khan
    I believe that either you are ill informed or totally unaware of the fact that since quite some time now, it is a CAA(Pak) requirement that a pilot has to pass IELTS (English language proficiency test) for their professional licence. It has never been reported in the newspapers or to the CAA regarding Pakistani pilots lack of communication skills. Maybe it is someone’s figment of imagination or one might call it inferiority complex, after all English is not a first language for Pakistanis. Maybe you might ask these international controllers regarding some other major pains like the Chinese, Japanese, Koreans, Italians, French, Spanish (long list). So please be realistic & do your research and homework properly before airing your ill gotten information. Thanks @Wajahat Khan:Recommend

  • Nadz
    Feb 19, 2014 - 5:11AM

    Goosebumped………… Miss you Dad.

    Recommend

  • Kaiser
    May 31, 2014 - 8:59PM

    @Captain Azim Ansari:
    I wonder why do retired officials whether diplomats, generals and scientists come and try to belittle their own kind? Why do we forget that the dead pilot has a lot of flying experience and that every pilot faces a crisis situation at some point of time during his career. The ones who make it alive through such a situation blame others because by doing so they get another chance to prove that they were the best. Why do we forget the causes of crashes such as the missing Fokker in the Himalayas,in which there were five pilots and the plane was not being flown by the designated pilot.The Jumbo which landed at Islamabad without deployed landing gears. The Multan incident where the pilots feathered the wrong engine and the plane glided powerless till it struck wires and crashed.The Cairo crash where neither of the pilots had the controls.The Peshawar crash in which a student pilot who was facing suspension, made such a steep turn that the Fokker suffered a severe loss of lift, literally sank and its tail struck the ground.
    Captain Sahib please call it a day and be thankful enough to destiny which escorted you safely to retirement.I am sure you must have encountered several incidents during your career and some of which would have gone unreported.
    The easiest thing in the world is to blame a dead man. It would have been more graceful to have said a few words in Prayer for those who lost their lives in the incident.
    Regards,
    A former Pilot.

    Recommend

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