Bhoja Air tragedy: Airline, CAA, flight crew responsible for the 127 deaths

Captain’s insistence to fly through a thunderstorm also contributed to the crash

KARACHI:

Bhoja Air’s flight BH-213 crashed in April 2012 due to multiple factors including the airline’s failure to realise that its pilots were improperly trained to fly the specific jet and the regulator’s oversight, a Judicial Commission found after an eight-month enquiry.

All 127 people on board died in the plane crash in rural Islamabad in what was Bhoja’s maiden flight from Karachi.

The commission, which was formed on the orders of the Islamabad High Court after a petition was filed by relatives of the deceased passengers, included Justice (retd) Ghulam Rabbani and a technical member Air Vice Marshal (retd) Faaiz Amir.

A 138-page report was prepared based on multiple interviews of airline officials, Civil Aviation Authority (CAA), law enforcement agencies and an analysis of relevant documents including the official investigation report into the crash.

The report, a copy of which is available with The Express Tribune, also notes that the captain’s insistence to fly through a thunderstorm and “abnormal behaviour” of the airplane also contributed to the crash.

It primarily sought to find answers to seven broad questions including the background in which the airline was issued the licence and fixing responsibility for the incident.

“Commission finds the operator Bhoja Air, the regulator CAA, the flight crew and the airplane falling short on the tasks attributed to them on a number of counts,” the report says.

Multiple discrepancies were found on part of the airline. For instance, two months before the crash, a CAA officer informed superiors that the airline was “physically bankrupt” with a negative equity of Rs8.1 million.

Additionally, the condition to have at least three aircraft on dry lease for a start-up airline was not followed as one of the planes, a DC9-32, was inducted on wet lease, which is normally used as a temporary arrangement.

The commission noted that Arshad Jalil – Shaheen Air’s former chief executive officer – bought majority shares in the airline from Farouk Bhoja who said he was never paid the agreed amount. Farouk was not pressed by the commission as he had nothing to do with the airline affairs.

A major oversight also related to the ill-fated flight’s Captain Noorullah Afridi who was found to be below-par in 55% of the essential exercises during the Flight Simulator Proficiency Check in January 2012.

The commission, like the crash investigation report published by The Express Tribune earlier this year, found that Captain Afridi was not adequately trained to use an automated flight deck that was installed on the Boeing 737-236A — an advanced version of the 737-200 that he was flying.

Bhoja’s management did not even incorporate the Boeing recommended inflight procedures, leaving the crew to follow the procedures of the older variant of the jet.

“The failure on part of the operator Bhoja Air in knowing well the airplanes that it brought to operate in the country resulted in absence of required ground and flight training and documentation for the flight crew,” the commission said.

First Officer Javed Malik was not even sent for the simulator training on B 737-236A. Instead, the CAA gave an extension in the validity of the training period not realising he would be co-piloting a completely new type of plane.

While the weather was fine in Islamabad when the flight took off from Karachi on the evening of April 20, 2012, the Met Department reported a thunderstorm over Benazir Bhutto International Airport an hour later.

This should have been communicated to the flight crew by Bhoja Air’s dispatch service, which keeps track of weather at destination and alternative airports, the commission says.

Transcript of the Cockpit Voice Recorder (CVR) revealed that the captain took a casual approach towards adverse weather condition and was bent upon landing in Islamabad. The commission notes this was the most important factor contributing to the accident.

Analysis of the last three minutes of the flight when it encountered windshear, an adverse weather condition, reflects unfamiliarity of the crew with automated flight deck of the aircraft as it did not follow standard procedure.

Published in The Express Tribune, October 1^st, 2014.