AirBlue crash report: An expected waste

Published: May 4, 2012

Why would a highly experienced pilot with over 25,000 flying hours under his belt behave as irrationally as the report suggests? PHOTO: FILE

We love to be experts, be it speculation behind the reasons for an avalanche or an aviation disaster. But unfortunately some of our experts fail quite miserably. Their reflection on events and their opinions are not only shallow but unworthy of being called an ‘expert opinion’.

The Civil Aviation Authority (CAA) has recently released the investigation report of the AirBlue crash. Now I must proclaim that my expertise in aviation accident investigation does not go beyond watching National Geographic’s investigations of air disasters. However, having watched multiple seasons of that series, I understand that the purpose of an investigation report is twofold.

The first is to pin the responsibility of the disaster. Secondly, and more importantly, it is to investigate the underlying factors that caused the responsible person or machine to behave in that particular way. This helps in mitigating that particular risk in the future.

The recently released report on AirBlue crash was no better than an earlier investigation report prepared by a policeman consisting of only “gawahon kay biyanat” (statement of the witnesses).

It was simply a statement of facts, lacked qualification for most of its observations and was meaningless when it came to its principal purpose, which is:

Will this investigative report help us understand the reasons behind the disaster and aid in making future air travel safer?

I am sorry to say that it does not serve that purpose.

Now I am not sure if we can even call them experts. Apparently, all these CAA ‘experts’ did was listen to the cockpit voice recorder (CVR) and analyse the data in the flight data recorder (FDR) to create a story of the flight’s final moments. Bravo! Investigation complete, culprit found – who is also dead, so he can’t even retaliate.

Aircrash investigations start from here. Why would a highly experienced pilot with over 25,000 flying hours under his belt behave so irrationally and unprofessionally? Moreover, why wouldn’t a first officer stop him from acting in this illegal and unprofessional manner and rather choose to become his accomplice?

The report is totally silent on this account. Is it because the pilot is dead and therefore can be blamed, but further investigation may end up focusing on someone who is alive?  

The report does not explain or assure why another pilot would not behave in a similar manner in the future. The recommendations of the report are downright funny; construct the new Islamabad Airport ASAP (as soon as possible). So the fault was with the airport and not the pilot? But the report stated that it was the pilot’s fault!

Meanwhile the same investigators have another horrific crash on their hands, the Bhoja Air crash, which apparently happened due to an undetected weather phenomenon called microburst.

Federal Aviation Administration (FAA) of USA mandates that all the planes are supposed to be equipped with Doppler radars which detect microburst and help the pilot in avoiding it. A similar crash was covered in an episode of  “National Geographic Air Crash Investigations” (Season five, episode four: Slammed to the Ground)

That crash happened way back in 1985 and subsequent investigations and research helped aviation get safer by understanding the microburst phenomenon and its deadly nature. The last statement of the episode says that microburst related air crashes are now a thing of the past.

Unfortunately, we in Pakistan have a tendency to repeat the past ad nauseum. I suspect that once again the CAA investigators will blame the unprofessional behaviour of the pilot as the cause – because he chose to fly through a microburst (while every pilot knows that flying through a microburst while landing is an almost certain crash). And if the plane did not have a  microburst detecting equipment installed (which is a standard worldwide), why was it issued with an airworthiness certificate?

Coming back to the tragic AirBlue disaster, all the loved ones of the crash victims who have read the report must be cursing the pilot. Even the first officer’s family must be cursing the pilot who foolishly caused the crash and caused everyone to die.

My question remains the same. Why would such an experienced pilot behave in this manner?

The investigators should dig deeper into the history of the captain; they must reconstruct the details of his last few days and his flying habits by interviewing people who had worked with him over the last 36 years.

Some things are in the air and have to be felt. A pilot at the end of his career may know that if some hidden metric of performance exists in the airline to judge his productivity in this manner, he may see the axe fall on his job the next year. The investigation must not stop here but should be continued. The Bhoja Air tragedy has merely made it more imperative.

The same question must be asked about the first officer. Why didn’t he choose to take over? Was it because he was an ex-air force pilot where seniors have to be obeyed to death?

The Hofstede power distance can be one factor which created a status generalisation issue (as reported by Milanovich and Driskel in their study of Status and Cockpit Dynamics). However, airlines are aware of these cultural issues in cockpit communications and many measures have been implemented in the training regime to offset this problem. Still this issue reared its ugly head.

The report must find out the reasons behind the first officer’s behaviour. At the moment it has been written in a manner which has  exonerated the first officer and implicated the pilot only.

There is a conflict of interets here. Investigation needs to be  carried out by an independent investigator because the fault can lie with anybody in the entire spectrum; pilot, airline, regulator or controller. For this reason, the US agency for aircraft investigations, National Transportation Safety Board (NTSB)is a body independent of FAA (US aviation regulator).

However in Pakistan, regulator (which is ground controller as well) becomes investigator. Naturally they want to avoid blaming themselves and pin all the blame on the pilot or at maximum, the airline. The higher ups of the Ministry of Defence need to take notice and create an independent investigation body which should investigate further and try to make future air travel safer.

This report, for sure, is nothing more than a waste of money and effort.

Read more by Farhan here.                                                                                                                                                                                                                              

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Farhan Shahid Khan

A professional engineer currently pursuing masters in project management at University of Melbourne.

The views expressed by the writer and the reader comments do not necessarily reflect the views and policies of The Express Tribune.

  • Lone

    You are absoutely right in saying that “Now I must proclaim that my expertise in aviation accident investigation does not go beyond watching National Geographic’s investigations of air disasters.” Even more accurate is your first line that “We love to be experts, be it speculation behind the reasons for an avalanche or an aviation disaster.” How can you say that the report “lacked qualification” when the blame has been pinned on the Captain ?

    Another observation, “Now I am not sure if we can even call them experts. Apparently, all these CAA ‘experts’ did was listen to the cockpit voice recorder (CVR) and analyse the data in the flight data recorder (FDR) to create a story of the flight’s final moments. Bravo! Investigation complete, culprit found – who is also dead, so he can’t even retaliate.” What else do you see in NatGeos “Air Crash Investigation” ? Its pretty much a re-creation of the events as they happened, exactly the same way the CAA report has been devised.

    Dude you are no expert here thats why you are unable to comprehend the technicalities of the report. Thats how its done. What were you expecting to read that a prithvi missile came across the Indian border and hit the plane or one of the air hostesses was a suicide bomber?Recommend

  • Parvez

    I think you have raised good valid points that need attention.
    Institutions like the airlines, railways, merchant marine depend heavily on professional competence to run, manage and importantly regulate. When the structure that makes them work is diluted for political, personal, monetary or any other reason, the structure starts crumbling and that is what we are seeing today. Recommend

  • T

    A very good analysis. If only someone would pay heed to it. Sigh.Recommend

  • HZ

    I wonder firstly people were blaming CAA for hiding Pilots fault and now its a waste ? If we demanded for the reasons behind the crash then we should not judge their credibility. And Mr. Author 80% of the crashes takes place due to pilots fault worldwide.

    P.S I lost a loved one in Bhoja Air Crash :'( Nobody can ever feel what I am going through. Recommend

  • SZ

    you certainly are not qualified to analyze the report….
    you are correct in saying that they should have dug deeper into the pilot’s past to understand his behaviour
    The report might have been lacking in that department, but it leaves no doubt that the pilot was at fault.Yes, people might be cursing the pilot, that should be expected. People make mistakes and the pilot made one which had enormous consequences.
    You can’t dismiss the pilot’s error by saying that he is dead and can’t answer for himself.
    Pilot’s unprofessional behaviour with the First officer at the beginning of the flight was the cause of inaction by the FO at the critical moments of the flight.
    The case Korean Air Cargo Flight 8509 (Mayday S11E7) of is interesting in this regard.Recommend

  • SM

    what a c* article – a waste of precious reading time – if you read the whole report it is quite clear that the pilot seemed to be confused (towards the end of the flight) and adopted a rude manner towards the first officer (so even if he wanted to say something he would have just kept quiet). Plus the report also mentions what the correct route was and what the pilot should have done – indeed the captain could have gone back if he wasnt sure where he was and asked for help but he didnt.

    Get you facts right…….Recommend

  • Hafeez

    Great insight. You are right that even if the blame is squarely put on pilot, there is a need to investigate why did he behave in that manner? And certainly it should be a very detailed and deep investigation. Besides that, in order to avoid the conflict of interest, the investigative agency must be an independent 3rd party, not the CAA.Recommend

  • murassa sanaullah

    If according to the report the pilot’s behaviour was irrational then there should be a compltet physical and phsyclogical analysis of the pilots.The pilots and other crew members should not be over worked.But Icannot understand about one thingthe Air Blue incinence was not the first incidence Ihave not seen or read about any report of crashes which occured in the past but our media kept quiet.The other thing I can not under stand is whom does our people specially media want to blame.Recommend

  • ad

    Excellent Article bro nice analysis as a viewer Just chill ppl will always criticize just for the sake of criticismRecommend

  • Ahmed

    I agree with the author completely. Aircrash investigative report is not just to pin blame. It is an effort to understand the underlying cause beneath the blame, so that future air travel can be made safer. This report just pins the blame but no moreRecommend

  • Farhan

    There is an anecdote in flyers
    “There are old pilots and there are bold pilots but no old bold pilots”. This report fails to answer the question that how come captain pervez iqbal ch became an old bold pilot? What were the pressures on him which caused him to act in this manner? If he was habitual of it, then how come he flew for so long without getting noticed? is it common to violate procedures in aviation in Pakistan? All these questions need to be answered to formulate actionable recommendations. As the investigators did not do that, their recommendations were not very good like the one mentioned about Islamabad AirportRecommend

  • Yaser

    AirBlue crash was a pilot error straight and simple. However I agree that underlying cause of this crash are not as simple and the real effort would be to locate them so that in future such causes can be controlled. This report is rightly called “First Investigation Report” by the author (misspelled in the document)Recommend

  • Arsalan

    Agreed! Good analysis indeedRecommend

  • Mansoor

    I agree with Lone here.

    You say your expertise does not gobeyond watching Air Crash Inverstigations on Natgeo. Well then I am pretty sure you are aware of Korean Air Flight 801 and KLM Flight 4805? Both ended in disaster. Why?
    The former was due to the First Officer’s inability to question the Captains decisions during critical moments of flight, while the latter was due to the Captains snobbishness and acting too hastely while making descisions. Put both of them together and you have Air Blue Flight 202.
    It has, unfortunately become a ‘custom’ for Pakistanis (including myself) to name and shame. We have forgotten the meaning of patience. We do not understand the time and efforts that are put into investigating air crashes and the amount of expertise required. All we want is to find the culprit, most preferably alive, so that we can punish them ourselves; hence the anguish and retaliation against this report. On one hand, we complain and protest against America’s or Europe’s involvement in any Pakistani matters, and on the other hand we complain when our own Pakistani authorities investigate the matter themselves. Make up your mind; who’s investigation do you want? Pakistan or foreign, more experienced authorities with more resources?
    Lets face the facts here. Pakistan does not have the resources to decode and ather information from the Flight Data / Cockpit Voice Recorders. So, they are sent away (France in the case of Airblue as the aircraft was an Airbus, whose HQ’s are in Toulouse). If they have been sent away, why not let them conduct the entire investigation? Wait, Mullah’s going to complain Western interference right? Then be happy with what you got. This greed is killing our country!Recommend

  • Farhan

    Thanks for the feedback. I just have raised few questions and not suggested answers. I am aware of both crashes mentioned by you and you must be aware that after Korean Air Flight 801, cockpit status generalization issue was debated and controls put in place for First Officer to take over, once Captain seems not in control. This report does not tell us whether those controls were implemented in Air Blue or Pakistani Aviation? Why should an air accident happen in Pakistan which has already happened in past, properly analyzed and controls put in place. Clearly the failure lies beyond Pilot/ Co-pilot as well.
    Secondly, As I said before that air crash investigation is not like traffic accident report which is just to pin responsibility. A pilot is no ordinary driver, he is a highly trained and experienced professional. It is true that most of the aircrashes happen due to pilot error but mostly are due to mistake on behalf of pilot and not violating the air traffic controller. Questions to be raised is that whether these violations are a norm in Pakistani Air Space? A report needs to go further.
    Hope it clarifiesRecommend