PK8303 Crash: Uncovering The Tragedy Of Fatal Errors

If someone wanted to write a training book on how to be the worst pilot in the world, this report would be a mandatory read

PK8303 Crash: Uncovering The Tragedy Of Fatal Errors

This is the second part of a two-part series on PIA flight PK8303 crash in May 2020. To read the first part, click here

Phase five 

The fifth phase is from lift-off to engine no.1 spool down (reduction in power or thrust from engine number one). (From 09:34:42 To 09:36:17) 

With power in one engine increasing, the aircraft took off after having skidded half way down the runway. Its engine number one was badly damaged and the aircraft's engines were rumbling. 

At this stage, the aircraft was being flown by Captain Sajjad Gul and dual input commands on sidestick stopped. Engine number one of the aircraft was running at 94% while engine number two was in the start phase. 

Karachi Tower called Karachi Approach on the landline and informed them that the aircraft had skidded on the runway without any landing gear. Ultimately, the aircraft took off, flying over the end of the runway. 

Karachi Approach asked the tower about the latest position of the aircraft. Karachi Tower informed Karachi Approach that the aircraft was crossing the stopway, the end of the runway. 

At this stage, the aircraft's engines were in full blast mode, resulting in a loud noise. Further warnings also blew up in the cockpit. But the aircraft was once again airborne.

At that moment the captain first lowered the landing gear, but quickly raised it back, but the plane's system did not record the phase of the gears being lowered and then raised becaues it required the canopy of the landing gear to open and this did not happen because the action was withdrawn as soon as possible. Otherwise, the plane may have crashed earlier. 

This shows that the captain was making every effort to get out of the pit he had fallen into without following the process and procedures. But instead of getting out, he was falling further into it. 

At 09:35:00, the captain called Karachi Approach and said: "Going Around". 

Given the information Karachi Tower had, it declared a full-scale emergency at the airport.

The 'go-around' call came from Captain Sajjad Gul, who had exclaimed a few moments ago to disregarded the instructions and advice of the air traffic controller to go around but now he was going to do exactly what the traffic controller had told him when this messy situation had begun.

But now the captain was in much worse position with his engines damaged, leaking oil and lubricants, while his cockpit was screaming with alarms. 

At this stage, both the engines of the aircraft were running at 94% but the oil content in both engines was low. Oil quantity of Engine No. 1 had dropped from 16 Quarts (QT) to 4 QTs in just 64s while the quantity of oil in Engine No.2 dropped from 15 QT to 5 QT in 64s. This suggested that both engines had lost around three-quarters of engine oil because of the friction the plane's engine had with the runway.

Soon enough, the low oil pressure warning was issued. 

This resulted in two Master Warnings, which were manually turned off by the captain on both occasions. 

The air traffic controller then cleared the aircraft to land on Runway 25L again, which meant that the aircraft had to circle along the runway and land back at the same location from where it had previously attempted to land unsuccessfully. The aircraft banked left and gained an altitude of 3,000 feet. It is important to mention here that the aircraft could have made it to the closely located Faisal Airbase, given the circumstances and the distance it had covered before its eventual crash.

In fact, at one point, there was a call out for the location of Faisal Base. 

At 09:36, engine number one began to slow down, and eventually, its generator stopped powering the aircraft. This means that the plane was now effectively being powered by only one engine rather than two. 

But at that moment, the voice of the first officer was recorded as saying, "Stop thrust lever number two, stop number two (engine)". As one of the engines almost shut down, the first officer had basically told the captain to shut down the remaining engine, which was powering the aircraft. The captain, who was already in a closed tunnel, proceeded to follow instructions from the first officer. He immediately stopped the thrust levers of engine number two while engine number one, which was already in dire straits and had its generator shut down, saw its thrust levers pushed for top flight. Thus, the power from engine number one decreased from 82% to 46%, and the power of engine number two decreased from 82% to 71%. 

As a result, the next moment the flight data recorder stopped recording because the engine number one's generator stopped powering the aircraft while the engine number two's generator had already stopped powering the aircraft. 

At 9:36:26, the Karachi Tower asked the Karachi approach if the landing gear of the plane was down. 

Phase six 

The sixth phase is from engine No.1 spool down (reduction in power or thrust from the engine) to the end of flight and end of cockpit voice recording (CVR). (From 09:36:17 To 09:40:18)

The cockpit voice recorder restarted after remaining shut for six seconds. This was due to the power generators shutting down on both engines. At that moment, the ram air turbine was activated, which is a fan under the wing of the aircraft that powers the aircraft in emergency situations. 

After that, the aircraft sounds two stall warnings (when the aircraft stops or slows down due to lack of speed) and two Dual Input sounds. While the plane was at a height of 1,900 feet at that time. At this point, the Karachi approach controller contacts the aircraft and says that the plane has to come down from a height of 2,000 feet. At this, the captain seeks permission to come down, which was granted to him. 

For eight seconds from 09:37:13, there was a conversation between the captain and the first officer about the condition of engine number two and it is confirmed that engine number two was working. During this time multiple systems warnings were issued twice and the captain asked to shut them down. 

Meanwhile, power in engine number 2 had increased from 40% to 76%. Karachi approach asked if the radar was showing that they had reached 1,800 feet and were descending further. "Cupid, we're maintaining altitude, trying to hold," said the captain. 

The captain said, "You selected engine #2 to IDLE, while engine #1 went," to which the first officer replied, "Yes." 

The sound of the engine stalling was then recorded as playing in the cockpit, to which the captain asked what the sounds were. The first officer simply replied, "Slow down". As speed was reduced, the engine speed decreased from 65% to 42%, shortly after which a single stall warning was heard, followed by a master warning. After the stall warning rang out, the first officer asked the captain to increase speed, and after some time, the first officer again told him to continue to increase speed. To which the captain replied, "How can I increase the speed?" 

A few moments later, the first officer asked the controller, "Do we have Faisal Airbase here?" 

His inquiry suggested that they could land the plane at the Faisal military airbase in an emergency. Karachi's approach then told the flight crew: "Looks like you are turning left", to which the first officer replied, "We will continue direct descent. We have lost both engines". 

By stating this, the aircraft informed Karachi Air Traffic Control that both engines had stopped powering the flight and that the plane was gliding. If it stalled, it would drop out of the sky like a rock.

At this point, Karachi Approach made another call in this whole malady of errors, which put the final nail in the coffin of this flight. The controller asked, "Confirm that you are doing a belly landing?" meaning that the plane would be landing without any landing gear. The first officer replied in the negative. 

This exchange struck the captain, who asked the first officer if the landing gear had been pulled out. In response, the first officer replied that the landing gear had not been lowered. 

In response, a sound similar to the aircraft's landing gear being lowered was heard, and it can be seen on video that the aircraft's landing gear was then lowered. Three seconds after lowering the landing gear, the captain said to the first officer, "Ask the cabin crew to sit down." Two seconds later, the first officer addressed the cabin crew and said, "Cabin crew, proceed to your station for landing. At that moment, the aircraft was still at a height of 700 feet and was turning to the left, i.e. towards the runway. 

Two seconds later, the captain made an emergency call in aviation parlance, "Mayday, mayday, mayday." Moments later, the first officer also called mayday. At the same time, stall warnings could be heard on the plane. Karachi Approach Controller called the aircraft and said both runways were available to it for landing. 

Eight seconds later, the captain's voice is heard saying, "Don't take the flaps, don't take the flaps," after which the plane's altitude drops to 400 feet.

Twenty-four seconds after that, a sound is recorded in the cockpit of the plane as it crashes. The recording stops after that and the instruments fall silent. The plane crashed a few hundred metres away from the runway above a populated area of Karachi. 

Of the 99 passengers on board, two of them miraculously survived, while 87 passengers lost their lives in the accident. There were eight crew members, including the captain and first officer, in the plane. As a result of the accident, one person died on the ground. 

What did the AAIB find? 

The Aircraft Accident and Investigation Board (AAIB) found that the aircraft being flown was serviceable and airworthy on the day of the accident.

It found that of all the chaos and everything that was not supposed to happen, it was the flight controls which functioned as expected. It noted that the emergency handling of the aircraft by the flight crew and their role in the entire process became a limiting factor in the flight. 

Even though the aircraft landed once on its belly, the aircraft's landing gears had functioned as expected.

It found that both of the aircraft's engines were affected by friction with the runway and were damaged, causing engine oil leaks and reduced engine lubrication, resulting in a crash. First engine number one and then engine number two shut down. The plane's emergency locator transmitter was not linked to Suparco. 

Flight crew and pilots 

Per the report, the captain and first officer were licensed pilots, qualified and medically fit to fly. The captain had over 17,000 flight hours and had been flying this particular Airbus model for at least five years. The first officer had considerable flight time on the smaller ATR twin turboprop aircraft but had relatively fewer flying hours on the Airbus.

No social/psychological problems were reported/documented about both.

However, if someone wanted to write a training book on how to be the worst pilot in the world, this report would be a mandatory read. 

Flight operations 

The captain and first officer of the aircraft did not follow the sterile cockpit rule during the flight. This means restricting flight crew member activity that is practically necessary during busy phases of flight and the rule that "at no time should the flight crew be disturbed, except in matters critical to the safe operation of the aircraft." 

Moreover, for a pilot who was appointed as a standards inspector for this particular aircraft, he appeared clueless about every standard included in the manual.

"The captain and first officer did not conduct an approach briefing prior to landing. As this critical step was not scheduled, the captain or first officer did not feed the flight path into the flight management system, so the aircraft did this on its own. The reason for this was that the plane went into the holding position while landing, on which the captain shouted, "Get out of the hold, get out of the hold".

Similarly, the captain and the first officer did not do any cross-checks during the entire flight. Critically, the captain or first officer did not communicate when the landing gear was lowered or raised. Even when the traffic controller reminded them, the captain nor the crew made any attempt to plan or determine how to land the flight. As a result, both were giving opposing directions to the plane when attempting to land it. 

On approach from the runway, the first officer asked the captain if they should circle around. Moreover, it was the first officer who had previously raised the landing gear, indicating he intended to circle again. But the captain refused to go around. This conflict of intent is mainly revealed when the captain wants to allow the plane to belly-land, causing the plane to skip on the runway four times while the first officer asks for a go-around. But the captain then pushes the thrust levers, takes off for a go-around and attempts to land again. Even then, neither the captain nor the first officer talk about the situation that the plane landed on the runway without landing gear and or how they wanted to attempt the second landing. 

It should be noted that the flight history of this crew in the 12 months prior to flight PK8303 included several occasions when he flew at high speeds, and landed further down the runway with a high rate of descent with low ground clearance warnings. There were several times in their history when there were no go-arounds, and many times the unstable approach was continued. 

Fasting likely influenced the decisions of the flight captain and first officer. However, its effects on the flight crew's performance could not be determined with certainty.

Pakistan International Airlines' role 

At the time of the accident, PIA's data analysis rate from flights was at 5%. Till the time of the accident, only one full-time flight data analyst was available in PIA's safety department. 

This meant that data from unstable and sometimes dangerous flights was not analysed at PIA. In the absence of the analysis, there was no question of any action being taken based on its data. However, since July 2020, all flight data at PIA is reviewed by a dedicated analyst. 

PIA's Operations Manual contains detailed guidelines on the health and nutrition of pilots. But the minimum duration of flight crew meal opportunities and the period during which meals should be taken regularly were not mentioned in the manual. 

The national flag carrier, which is currently up for sale and has attracted interest from eight parties, most of which are domestic, did not have available staff engagement records, including psychological assessments, prior to 2002. The flight crew were not breath-checked before the flight, and there were no pre-flight undertaking certificates for psychoactive substances. Neither were the flight crew's certificates of non-intoxication or drug abuse. It does not necessarily have to be intoxicating substances but can also be drugs that treat psychological or mental disorders or physical ailments such as migraines, headaches, backaches or bowel disorders. 

Air traffic controller 

The air traffic controllers on duty were quite qualified, rated, medically fit and held valid licences. After transfer from Karachi Area Control, the aircraft remained with Karachi Approach Control till the accident. The Karachi approach allowed the aircraft to land for the first time by taking clearance from the Karachi Tower Controller. Karachi's tower controller could not determine whether the landing gear was out or not due to the plane's pitch down. 

While the tower had observed sparks and fireballs generated as a result of the aircraft landing for the first time without the landing gear extended, it did not report this to the flight crew immediately. Moreover, the approach controller did not discuss the second take-off of the aircraft with the flight crew. 

Causes of the accident 

The aircraft landed on the runway without any landing gears, resulting in massive damage to both engines, causing lubricants and oils to leak, which ultimately resulted in the destruction of both engines. 

During the flight, especially in the last half hour, the pilot and the first officer did not follow the SOPs and ignored the instructions and suggestions of the air traffic controller. 

Lack of discussion or communication between the air traffic controller and the captain and first officer regarding the landing without gears, especially when the aircraft had skidded on the runway. 

This is the second part of a two-part series on PIA flight PK8303 crash in May 2020. To read the first part, click here