Pakistan’s Aircraft Accident Investigation Board (AAIB) has published the preliminary investigation report related to the May 22nd crash of Pakistan International Airlines’ Airbus A320 (AP-BLD), flight PK8303 with 8 crew members (1 Captain, 1 First Officer, 6 flight attendants) and 91 passengers on-board. The full report is available here
On 22 May 2020 at 13:05 hrs PST, the Pakistan International Airlines aircraft Airbus A320-214, registration number AP-BLD, took off from Lahore (Allama Iqbal International Airport – AIIAP) Pakistan to perform a regular commercial passenger flight (PK8303) to Karachi (Jinnah International Airport – JIAP) Pakistan, with 8 crew members (01 Captain, 01 First Officer, and 06 flight attendants) and 91 passengers on board. At 14:35 hrs the aircraft performed an ILS approach for runway 25L and touched down without landing gears, resting on the engines. Both engines scrubbed the runway at high speed. Flight crew initiated a go-around and informed “Karachi Approach” that they intend to make a second approach. About four minutes later, during downwind leg, at an altitude of around 2000 ft, flight crew declared an emergency and stated that both engines had failed. The aircraft started losing altitude. It crashed in a populated area, short of runway 25L by about 1340 meters. An immediate subsequent post impact fire initiated. Out of 99 souls on-board, 97 were fatally injured and 02 passengers miraculously survived.
According to the report, the crash site is located in a residential area northeast of JIAP. The wreckage lies approximately 1340 m from the runway 25L threshold close to the extended runway centerline. The aircraft parts were spread out over 75 m in a single street, with some parts on the roof tops of adjoining houses.
The investigation so far into the available evidences, ie FDR / CVR readouts (preliminary assessment), footages from CCTV / Security Cameras at JIAP, and “Karachi Approach” radar data etc, following has been revealed and validated as the preliminary findings: -
• The reported weather at origin, en-route and at destination airfields was fit to undertake the flight.
• The report also talks about the cockpit crew not following the defined procedures from the beginning of the flight. On 22 May 2020 PIA flight PK8303 took off from AIIAP Lahore at 13:05 hrs (as per the Lahore ATC recording / transcript). Departure from Lahore and cruising flight were uneventful. The crew did not follow standard callouts and did not observe CRM aspects during most parts of flight which is one of the violations they did during the flight.
• The flight was cleared at pilot’s discretion to report direct MAKLI (a waypoint 15 nautical miles from Karachi VOR) and was told to expect an ILS approach for runway 25L.
• The aircraft changed over to “Karachi Approach” and was cleared to descend down further to 3000 ft, by the time it reaches MAKLI. However the aircraft ended up higher than the required descend profile and at MAKLI the aircraft was at 9780 ft instead of 3,000 ft and at about 245 knots.
• Karachi Approach” inquired “confirm track mile comfortable for descend” and later advised to take an orbit(to do a 360 or make a circle), so that the aircraft can be adjusted on the required descend profile. No orbit was executed and the effort to intercept the glide slope and localiser (of ILS) was continued. This was one of the other error made by the pilots because had they executed an orbit at that point, the aircraft would’ve lost altitude and speed and would’ve made a normal approach. The FDR indicated action of lowering of the landing gears at 7221 ft at around 10.5 Nautical Miles from Runway 25L.
• “Karachi Approach” advised repeatedly (twice to discontinue the approach and once cautioned) about excessive height. Here the cockpit crew made an another error by ignoring the advice of the ATC and decided against discontinuing the approach.
• The FDR shows action of raising of the landing gears at 1740 ft followed by retraction of the speed brakes (at a distance slightly less than 05 nautical miles from the runway 25L). At this time, the aircraft had intercepted the localizer as well as the glide slope. Flaps 1 were selected at 243 knots IAS, the landing gears and speed brakes were retracted. Over-speed and EGPWS warnings were then triggered. According to aviation experts, this was an another illogical action taken by the cockpit crew probably either due to misunderstanding the situation or due to panic because keeping the landing gears down would’ve assisted the crew by helping in keeping the speed in control and at the same time it would’ve increased the rate of descent as it increases drag. Normally pilots lower the landing gears earlier whenever they’re higher than the required altitude so that they can decrease their altitude at a higher rate. Also as per the experts, the point about the aircraft catching the glide slope at 5 nautical miles clearly shows that aircraft’s approach was unsteady.
• Besides pointing out the negligence shown by the cockpit crew while following the procedures, the report has also blamed the Air Traffic Control’s actions and unprofessionalism at the time of the crash. As per the report, the approach to land was continued, “Karachi Approach” instead of changing over the aircraft to “Aerodrome Control”, sought telephonic landing clearance from the “Aerodrome Control”. The “Aerodrome Control” conveyed a landing clearance of the aircraft (without observing the abnormality that the landing gears were not extended) to “Karachi Approach”. Subsequently “Karachi Approach” cleared the aircraft to land. The proper procedure here should be been that the “Karachi Approach” should’ve handed over the aircraft to “Karachi Tower” which it failed to do so.
• At 500 ft, the FDR indicates: landing gear retracted, slat/flap configuration 3, airspeed 220 knots IAS, descent rate 2000 ft/min. According to the FDR and CVR recordings several warnings and alerts such as over-speed, landing gear not down and ground proximity alerts were disregarded which was an another error on the part of the cockpit crew. The landing was undertaken with landing gears retracted. The aircraft touched the runway surface on its engines. Flight crew applied reverse engine power and initiated a braking action. Both engines scrubbed the runway at various locations causing damage to both of them. Figures hereunder show selected screenshots of security / CCTV cameras footages of the aircraft engines touching the runway and showing sparks due to scrubbing, along with marks on the runway. Aviation experts here expressed their disbelief and shock at these events due to them being extremely unusual.
• The report once again points out an another major error by the ATC where “Aerodrome Control” observed the scrubbing of engines with the runway but did not covey this abnormality to the aircraft. It was conveyed to the “Karachi Approach” on telephone. Subsequently “Karachi Approach” also did not relay this abnormality to the aircraft.
• The landing was discontinued and a go-around was executed. FDR recording indicates a brief action of selection of landing gear lever to down position, which was immediately followed by its movement to up position. Intention to undertake another ILS approach for landing on runway 25L was conveyed, however shortly after the go-around both engines failed one by one. Ram Air Turbine (RAT) was deployed to power the essential systems. The cockpit crew here once again deployed the landing gears which according to aviation experts was an another error because at a time when the engines had failed, the aircraft started loosing speed and lowering the gears caused the speed to decrease further. As per experts, this action should’ve been delayed instead of deploying them too early on the second approach. The aircraft was unable to maintain required height due to the loss of speed and power. The aircrew declared the emergency situation that both engines were lost, and transmitted a “Mayday Call”. The aircraft crashed about 1340 meters short from runway 25L. It was a slow speed impact with high angle of attack, with aircraft configuration indicating landing gears extended, slats at step / position 1, and flaps retracted.
• The report also states that the aircraft involved was reportedly serviceable for the said flight; necessary scrutiny of the aircraft maintenance records / documents is under way. Captain and First Officer were adequately qualified and experienced to undertake the said flight; necessary scrutiny of the aircrew records / documents is under way.
• The report concludes by saying that further course of investigation process may include (but not limited to) advance analysis of FDR and CVR, related advanced technical analysis of aircraft / engine components, exploration for reasons and causes of the anomalies discovered so far, and also of any further shortcomings that may be revealed during later part of the investigation.
Earlier Today, Minister for Aviation Ghulam Sarwar Khan presented some of the Preliminary Report’s findings in the National Assembly and according to him the Final report is expected to be presented within a year, most likely this year.