- 8 hours ago
Air Crash Investigation S26E05 Peril Over Pakistan
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00:02Controllers in Islamabad watch as Air Blue Flight 202 head straight towards a massive hill.
00:09He's not turning.
00:14They issue urgent warnings.
00:17Turn left immediately.
00:18But fail to prevent a disaster.
00:21They're going down!
00:30It's the worst accident in Pakistan's aviation history.
00:36When investigators listen to the CVR, they hear the pilots realise they're in danger.
00:42Terrain, sir!
00:45Took steps to avoid it.
00:47Turning left.
00:49But were unable to save the lives of 152 people.
00:54Why aren't we turning left?
00:56The crew knew what they had to do.
01:00They had reported that they were doing what they were supposed to do.
01:04And yet, the aircraft continued to fly in the wrong direction.
01:10BD! BD!
01:14Oh, fuck!
01:34Air Blue Flight 202 begins its early morning descent towards Islamabad, Pakistan.
01:46There are 146 passengers and 6 crew on board the Airbus A321.
01:57Air Blue 202.
01:59Expect arrival to ILS runway 30.
02:01Followed by circling approach to land runway 12.
02:05Understood.
02:05It'll be ILS down to minima.
02:07And then left downwind.
02:10Okay.
02:13Captain Parvez Chowdhury is one of the airline's most experienced pilots.
02:20Najam Qureshi is a former Air Blue pilot who flew with Captain Chowdhury.
02:26Captain Chowdhury had a lifetime of experience flying with the Pakistan International Airline.
02:31He had a very successful carrier.
02:34And he was pretty much approaching the end of his carrier.
02:37Air Blue 202 clear to 3900 for ILS approach to runway 30.
02:41Followed by circling approach to land on 12.
02:45First officer Syed Ahmed has less commercial experience.
02:49He's a former F-16 fighter pilot and squadron leader in Pakistan's Air Force.
02:56Air Blue 202 clear to 3900 for ILS 230.
03:03Clear to descend to 3900.
03:10He had about 300 hours on the tide.
03:13So just brand new.
03:14Learning the differences between the A4s flying and the commercial flying.
03:20Pakistan's capital, Islamabad, is a city of more than 800,000 people.
03:26It's surrounded by the Himalayan foothills to the north and northeast.
03:34The mountainous terrain means the only approach to Islamabad's runway is from the south.
03:41Due to the wind direction today, planes are landing on runway 12.
03:45They must circle the airport and make a visual approach to the other end of the runway.
03:54It is always safe to land with a headwind as compared to a tailwind.
03:59When the winds change beyond a certain limit, the air traffic controller will switch the runways.
04:05That will ensure the plane lands in a headwind.
04:11Thick clouds envelop the airport, making landings difficult.
04:17China Southern is going around and diverting back to Urumqi.
04:20China Southern confirming, diverting back to Urumqi.
04:25Attention all landing aircraft.
04:27China Southern is diverting due to weather.
04:31If at any point you lose sight of the airfield, you should abandon the approach completely and carry out the
04:39missed approach procedure.
04:44Flight 202 is now less than 10 minutes from landing.
04:54Gear down.
05:00Gear down.
05:01Gear down.
05:04The plane reaches the minimum altitude to which the pilots can descend without the runway in sight.
05:12As soon as you see the runway, you turn right, and then after that you're supposed to keep the runway
05:17in sight.
05:19Commencing right turn, heading 352.
05:25Call it in.
05:28Air Blue 202.
05:30Air Blue 202, maintaining 2500 and turning right, heading 352.
05:35Air Blue 202 confirming at 2500, turning right, heading 352.
05:46Captain Chowdhury initiates the first turn of the circling approach.
05:51Air Blue 202.
05:53Continue on the circle for landing on runway 12.
05:57Caution.
05:58Low clouds and visibility.
05:59Maintain visual with the airport.
06:03Even in the poor weather, it is up to the pilots to decide whether they should continue the approach or
06:09not,
06:09depending whether they have the runway in sight.
06:15The controller expects to see the lights of the Airbus as it flies past the airfield.
06:23And we're going to see the airway.
06:29Radar, I can't see Air Blue 202.
06:31What's his current location, please?
06:33He's approaching the no-fly zone north of the airfield.
06:36Instruct him to turn left immediately.
06:41Flight 202 is much further north than expected,
06:45and needs to turn left for the approach to runway 1-2.
06:50Air Blue 202, turn left heading 180.
06:56Confirm he has visual with the ground.
06:58If not, instruct him to climb and execute a missed approach.
07:02Air Blue 202, confirm you have airfield in sight.
07:07The controllers had radar.
07:09They could see what the aircraft was doing.
07:11They could see that the aircraft was not doing what the procedure said they should be doing.
07:19Ask again.
07:21Air Blue 202, please confirm you have visual with the ground.
07:33Air Blue 202, visual with the ground.
07:37He's confirming visual.
07:41He's not turning.
07:45Controllers can see that Flight 202 is rapidly approaching the hills north of the airport.
07:56In the cockpit, the pilots are struggling to turn their plane away from the mountains ahead.
08:03Air Blue 202, see the air.
08:04Why aren't we turning left?
08:10No!
08:15Why is that turning left?
08:18Air Blue 203, pull up.
08:22Air Blue 202, pull up.
08:27Instruct him to turn left immediately.
08:30the controllers can't believe what they're seeing here's a guy with 25 000 hours and
08:37he's flying directly towards a mountain in the cabin passengers have become aware that something's
08:45not right they're approaching the 5 000 foot magala hills terrain ahead
08:59sir we are going down
09:21flight 202 has crashed into the magala hills seven miles from the airport
09:29the wreckage lies at an altitude of nearly 3 000 feet it will be difficult for rescuers to reach the
09:37site
09:41we couldn't get access to it with a car or a truck even with helicopters there was no place to
09:48set down
09:51so the only way to get to the accident site was with a long slow climb
09:58it takes more than half an hour for rescuers and volunteers to make their way up the steep hill
10:04to the crash site in hopes of finding survivors
10:17when crews do reach the site they find a scene of complete devastation
10:33a hundred and fifty two people died in this accident
10:36it's the worst accident in pakistan's aviation history
10:46why did a modern airplane fly into well-known mountains north of the airport in islamabad
11:00investigators arrive at the accident site to study the wreckage of air blue flight 202
11:09when an aircraft flies into mountains there are really two areas that we're looking at in terms of the root
11:15cause
11:17one is a sudden and unexpected loss of control
11:22the other would be the aircraft has actually stayed in control of the pilots
11:27and still somehow been flown into a mountain
11:34an analysis of the engines shows that they were fully functional at the time of impact
11:39and capable of producing maximum thrust
11:46okay good work everyone start heading back down
11:51right so the stabilizer was set at 3.5 degrees nose up
11:56landing gear was down engines that climb power
12:00so configured for landing but climbing at full power
12:06an examination of the electrical and mechanical components that we could find
12:12there was no obvious damage or mechanical failure
12:16they were trying to land here
12:20but then they slam into the margala hills seven miles north of the runway
12:39they were approaching from the southeast for landing here on runway one two
12:56scattered clouds rain
13:00visibility was at 3.5 kilometers
13:04challenging conditions
13:08could the cloudy conditions have been a factor in the accident
13:14when an aircraft flies into high ground one thing that is almost certainly a factor
13:21is poor visibility uh low cloud fog call it what you will
13:28visibility would have been an issue but you don't need to see the margala hills to know that they're
13:39there everyone knows towards the northeast of the runway there are mountains they're clearly marked
13:44on the maps terrain ahead start going down pull up pull up can the controller explain why the crew
14:00of flight 202 couldn't avoid the mountains radar control informed him he'd be doing the circling
14:07approach to runway one two a blue two zero to expect arrival at ils three zero followed by
14:13circling approach to land runway one two and he understood the approach yes sir he did understood
14:23it'll be airless down to minima and then left downwind and then that's when i assume control
14:33as he began the right turn to the circling approach
14:41the circling approach involves four carefully timed turns the first to the right followed by a left turn
14:50that takes the plane parallel to the runway the two final turns line the plane up for the landing
14:56on runway one two pilots must keep the runway in sight for the duration of this approach
15:07after about a minute i expected to see him fly by
15:13but he never did i asked the crew if they had the runway in sight and they confirmed that they
15:20did
15:21air blue two zero two please confirm you have visual with the ground
15:31but he kept flying further and further away from the airport directly towards the hills
15:40after breaking off from the approach they are supposed to turn after 30 seconds
15:45instead they kept going for almost two minutes we tried to stop him several times
15:54it was too late message from radar turn left immediately
16:08we couldn't prevent
16:13what happened
16:20it's all here on the radar track
16:29crew knew what they had to do
16:32they reported that they were doing what they were supposed to do
16:36and yet the aircraft continued to fly in the wrong direction
16:46how could the pilots have ended up so dangerously off course
16:58investigators look into the background of flight 202's pilots
17:03to determine if the approach into islamabad was mishandled
17:09captain had years of experience with major airlines
17:15captain chowdhury has been flying for more than 40 years
17:20he has accumulated more than 25 000 flying hours throughout his career
17:25but only about 1000 of those were on the airbus
17:33the first officer however is a whole different story
17:38first officer Syed Ahmed had far fewer hours than the captain
17:43the former fighter pilot had recently joined the airline
17:47and had accumulated only 286 hours on airbus a320 airplanes
17:56two very different pilots
17:59one during the end of his career with thousands of hours of experience
18:04and the other just starting off his commercial career
18:07but neither of them had a ton of experience with the airbus a321
18:16did the pilots lack of experience on this type of plane play a role in the accident
18:25experience is generally considered to be an asset
18:28the only potential downside is that of course if you've got a lot of experience of one particular thing
18:36it actually might be more difficult to learn how to operate this new type of aircraft
18:48okay
18:50so they're supposed to perform their approach within this area
18:54anything beyond this is outside the airport's 4.3 mile protection zone
19:00okay let's see his track
19:04investigators examine flight 202's radar track
19:08to see how the pilots set up their approach
19:11all right
19:13so they make their first turn here
19:19and then head straight out of the protection zone
19:24then this left turn takes them directly into the margala hills
19:31the radar track shows that the pilots flew closer and closer to the mountains surrounding islamabad
19:38wouldn't they have gotten a warning that they're approaching the hills
19:48yes sir
19:50it should have sounded 60 seconds before impact
19:56the enhanced ground proximity warning system
20:00looks downward to see the height that you're at above ground
20:05but it also looks ahead to see any terrain that you're flying towards
20:14if they got a warning
20:17why didn't they try to pull up or turn to avoid it
20:25did the pilots of flight 202 get any warning of an impending collision
20:32the crew would have been given pictures on their navigation display of the approaching terrain
20:38and they would have been given
20:40aural warnings so since they flew directly into the terrain
20:46has the enhanced ground proximity warning system completely failed
21:01don't leave me in suspense
21:03did they get any ground proximity warnings
21:08they sure did
21:15the cockpit data shows that in the final minute of the flight
21:19the crew got 21 separate warnings about the rising terrain ahead
21:29okay so that answers that
21:34over 21 times we saw terrain terrain pull up terrain ahead pull up there's no way that
21:41the captain missed that warning the enhanced ground proximity warning system was working properly
21:47terrain if the warning system was operating why would the pilots ignore it and allow the accident
21:56to happen if you hear a full terrain pull up warning from the gpws the reaction should be immediate
22:05it should be to apply full power pull the nose of the aircraft up get it moving away from the
22:10ground
22:11and that should be done before any questions are asked
22:19why didn't the crew of air blue flight 202 act on terrain warnings and steer their
22:26plane away from the mountains
22:27islamabad air blue 202
22:30investigators listen to the cockpit voice recording
22:34what are current conditions please
22:36air blue 202 visibility is now 3.5 kilometers with rain
22:40wind one six knots zero five zero degrees
22:44runway one two currently in use
22:47they focus on how the crew set up for landing
22:51it will be runway one two
22:53yes invisibility is crap
22:58the weather was marginal and marginal weather makes you nervous because you don't know whether
23:04you're going to be able to see anything at all
23:07and the captain clearly was nervous about this approach
23:13did the captain proceed with an approach he wasn't comfortable with
23:18set waypoints for runway one two radial zero two six five miles of beam
23:32mate stop
23:35why is he asking you to input a course to the runway
23:40this is supposed to be a visual approach
23:45it didn't make any sense for the captain to be entering waypoints into the flight management system
23:51the circling approach is by definition a visual approach so there is no way that any pilot would
23:57normally do this
24:01then just two miles from the airport the pilots of air blue flight 202 hear of a flight landing ahead
24:09of them
24:09we advise that a dia 737 has landed on runway 12 safely
24:17commencing right turn heading 352
24:23that could have caused the pilot to say hey if they can get in we can get in too
24:29wait stop stop so he starts his turn later than usual half a mile from the runway
24:42instead of breaking off early they had to continue on because of the low visibility and low ceilings
24:48and they did not break off to the right until the last possible point which was at the end of
24:52the runway
24:54concerned with poor visibility captain chowdhury makes a baffling decision switch into lab mode for
25:03managed approach to runway one two there he goes switching to nav mode he can't be visual
25:11carrying out the circling approach using the autopilot to navigate is a violation of procedures
25:20as soon as you select the nav mode the plane starts to fly the pre-programmed waypoints
25:27and at this point captain chowdhury is normal flying the visual approach okay sir
25:36but are you visual i have a visual
25:44chowdhury insists he can see the runway but investigators are certain he could not
25:51they can't see the airfield any longer because they've just got to the far side of it
25:55there is no airfield inside
25:59so instead of turning left to fly parallel with the runway
26:05he keeps flying in this direction moving further and further from the airport
26:12sir we're reaching higher ground
26:16marine ahead
26:18marine ahead sir there's terrain ahead
26:22sir turn left terrain ahead
26:28it should be turning terrain ahead as the captain struggles to turn away from the hills
26:34the rain in the head controllers become concerned air blue 202 confirm you have airfield in sight
26:42what should i tell him sir
26:45terrain
26:45tell them tell them
26:49the crew doesn't reply straight away
26:52probably because the first officer knows full well that no they don't have visual contact with the
27:03ground
27:04terrain ahead
27:05pull up air blue 202 visual with the ground
27:11in the end the crew tells air traffic control that they are in visual contact with the ground
27:19now that's not untrue but it's not the same thing as being visual with the airfield
27:24it feels more like a reply designed to get air traffic control off their backs
27:28sir we are approaching terrain ahead
27:30yes i know we are turning left
27:33pull up pull up pull up the captain says he's turning left but he keeps flying directly towards the hills
27:47investigators are unable to explain why captain chowdhury could not alter his course
27:53and steer away from the mountains
28:00sir turn left
28:02the final minute of the cvr reveals a picture of chaos
28:07and confusion
28:08pull up sir
28:14they're applying power trying to claim
28:19terrain ahead
28:20sir pull up sir
28:24investigators hear first officer ahmed pleading with his captain to pull up
28:28terrain why aren't we turning left
28:32pull up
28:35terrain ahead pull up terrain sir
28:41terrain ahead
28:42sir we're going down
28:46unless it's from radar turn left immediately
28:50sir we're going down
29:01all they had to do was turn away from those hills
29:09despite reacting to the terrain warnings the pilots could not steer their plane away from the mountains
29:18i think they knew what was happening
29:21i think they knew that they had to turn left
29:23for some reason the aircraft didn't turn left
29:28will flight 202's flight data recorder explain why captain chowdhury didn't or couldn't turn and
29:36avoid the mountains can we see the altitude please
29:41the minimum altitude is 2500 feet
29:47investigators can see that chowdhury dialed in an altitude below what's permitted
29:52there's only one reason it would drop below that
30:07there's no earthly reason for doing it because the minimums are there for a very good reason
30:13the only reason why they ever break the minimums is because they can't see the ground properly and
30:18they want to get closer to it can we see the flight path
30:25you see he's way off course in heavy fog and has clearly lost visual
30:33let's see the autopilot modes
30:38so he asks the automation to take over
30:46more than four miles off course captain chowdhury makes his biggest error by switching modes on his autopilot
30:55the captain switched from heading mode to nav mode and the aircraft turned left to heading of 300
31:08towards the mountain
31:11the airbus now makes a left turn towards a predetermined waypoint
31:16bringing the flight dangerously close to the mountains
31:21he's approaching the no-fly zone north of the airfield
31:26from this point on air traffic control continued to urge the flight to turn left
31:31because they knew they were in the vicinity of the high mountainous terrain terrain
31:35ahead
31:38avlo 202 turn left heading 180
31:41when we're turning left
31:46can we see what he's selecting
31:51he's dialing in a left turn
31:59captain chowdhury uses his heading knob to turn the plane sharply left away from the hills
32:08but the plane it keeps flying in the same direction it's not turning
32:24he's still in nav
32:28investigators realize the captain forgot that his plane was in navigation mode and not heading mode
32:35which is required to turn the aircraft if the aircraft is flying in nav mode it will keep on
32:43flying on its predetermined course whether or not the crew change the heading select
32:50why aren't we turning left
32:55captain chowdhury doesn't realize that his inputs are futile
33:02in order to get from nav mode into heading mode you pull the knob out and that engages heading mode
33:08oh he forgot to pull it out he realizes his error and pulls the knob here at 40 seconds before
33:18impact
33:26ah
33:28when captain chowdhury tries to correct his error he only makes a bad situation worse
33:36sir turn left
33:37oh
33:38why is it turning left
33:45captain chowdhury has dialed in so many left turns
33:49that his last input is now to the plane's right
33:53the airbus takes the shortest route to get to that heading
33:58directly towards the margala hills
34:05is in heading mode for the rest of the flight
34:13the investigation saw that the captain was so reliant on the automation that
34:16he was trying to turn the aircraft to the left
34:20asking why the aircraft wasn't turning to the left
34:22but he didn't even use his side stick and actually turn the aircraft to the left manually
34:27why why aren't we turning left
34:30investigators now know why captain chowdhury was unable to turn left and avoid the mountains
34:37but one question remains
34:40why didn't the first officer recognize the mistakes and do something to correct them
34:45sir we're going down
34:52100 knots
34:54check
34:55investigators find a possible explanation for the first officer's puzzling behavior
35:00v1
35:01at the very start of flight 202
35:05rotate
35:07as it took off for islamabad
35:10the flight starts with the pilots working efficiently as a crew
35:15positive rate
35:18gear up
35:23gear up
35:27the takeoff from karachi is textbook
35:33from initial pushback startup and all the bit to take off everything seemed normal
35:42we are clear to climb to flight explain to me why that is blue
35:47but the other symbols are white
35:50the pilot's cordial relationship soon changes
35:56sir
35:56there on your display why is that symbol blue but the others are white
36:02you should know why that is
36:05i believe it's because the flight plan defers from the current route
36:09oh that's wrong it's because it's the one being navigated towards basic
36:15do you know how to modify this point
36:19from the main menu
36:21oh you don't need to return to the main menu you can do it on the screen
36:26what did they teach you in that so-called training of yours
36:31captain chowdhury is heard quizzing and berating his first officer
36:37this wasn't normal behavior it seems it was only really for the purpose of
36:43putting his first officer in his place making sure he knew who was in charge and to do as he
36:50was
36:50told
36:52what's he doing
36:55if you don't know how to use the flight management system
36:59then what use are you in the cockpit you might as well go back and help the girl's safety
37:07yes
37:09sorry sir
37:18what about maximum thrust available for climb can you at least tell me what that is
37:23this has been going on for nearly an hour now torture
37:30radio ahead to islamabad for the weather
37:34do you know how to use the radio yes
37:40captain chowdhury is a very experienced pilot
37:43he should know that this is not how we behave on the flight deck of an airliner
38:02investigators wonder why captain chowdhury would act so aggressively
38:06towards his first officer he was recently treated for diabetes and hypertension
38:13but deemed fit to fly
38:18anything pilots who flew with him said he was demanding sometimes difficult
38:24but nothing at this level
38:27maybe it had more to do with him
38:31could the first officer's background have affected his captain's attitude towards him
38:41in pakistan there has been a hidden rivalry between air force pilots
38:46and the people who are in the commercial side already they feel that actually force guys they are taking away
38:53their opportunities
38:58investigators believe that the captain's abusive behavior might explain one of the mysteries of this tragedy
39:05why first officer ahmed never took control of the plane
39:12all the first officer had to do was to take manual control of the aircraft and fly it away from
39:17the mountain
39:21investigators scrutinize first officer ahmed's actions leading up to the crash of flight 202
39:26his first officer tells the captain to pull up three times and to turn left
39:33twice but he never says he's taking control
39:41if i was the first officer i'll take over the control pull back on the side stick to create the
39:47max
39:47performance maneuver applied toga thrust and keep climbing till i'm clear of the hills
39:54the team believes the captain's behavior earlier in the flight explains why the first officer allowed him
40:01to mishandle the approach if you don't know how to use the flight management system
40:07then what use are you in the cockpit
40:12we have the captain's behavior which was so overbearing so autocratic so nasty that it served to
40:22completely shatter the self-confidence of the first officer first officer ahmed allows procedures to be set
40:29aside switch into nav mode for marriage approach to runway one two okay sir and then fails to take control
40:42when his captain flies the plane directly towards the mountains he was so worn down by the captain's
40:53the first officer clearly knows that what they're doing is wrong he knows that his captain is disoriented
41:07that the aircraft is on a collision course with a mountain
41:10and yet somehow he doesn't have it in him to intervene
41:16terrain ahead pull up sir we are going down sir we're going down three and a half minutes after
41:24the start of the approach we're going down the airbus slams into the hills
41:40this is one of the most extraordinary accidents i've seen
41:48there were no technical factors in this accident
41:54there was nothing wrong with the aircraft there was nothing wrong with the engines
41:59it was all a matter of human misjudgment and human error
42:10if he doesn't try the approach in nav mode there's no accident
42:16all the warning signs were there telling them what to do
42:22it should have been easy to recover
42:41it's hard to believe that somebody of his experience would make so many errors and mishandling of the
42:51aircraft uh so it i just it justifies logic
42:58the final report into the crash of air blue flight 202 makes several recommendations to pakistani airlines
43:07including better briefings on the circling approach procedures and better crew management training
43:15this accident shows that cockpit management in the atmosphere in the cockpit that's set by the captain
43:21is just as important as an operating aircraft and operating engines
43:25and in 2018 the airport in islamabad is replaced with a more modern airport with two runways that are well
43:34away from the hills that claim the lives of the 152 people on board flight 202
43:44as i learned more i really felt extremely bad
43:50i felt very sad about that loss
43:59it was a preventable accident
44:01it was a preventable accident
44:01it was a preventable accident
44:01it was a preventable accident
44:02it was a preventable accident
44:03it was a preventable accident
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