WHAT Happens when the Captain goes TOO FAR? Airblue flight 202

have you ever been really humiliated by someone you work with do you remember how that felt and how that made you act in the minutes and hours after it happened now imagine that you have that feeling but instead of sitting in an office you are operating a heavy commercial aircraft in marginal weather flying a really complicated maneuver around mountainous terrain and suddenly things are starting to go really really wrong stay tuned a huge thank you to curiositystream for sponsoring this video in the morning of the 28th of july 2010 air blue flight 202 was a scheduled domestic passenger service between karachi and islamabad in pakistan the aircraft being flown was a four-year-old airbus a321 which is the slightly stretched version of the very common airbus a320 family the flight was scheduled to carry 146 passengers four cabin crew and two pilots the weather in the morning was really miserable with heavy rains low clouds and reasonably poor visibility and the weather has been like that for the previous two weeks prior to the flight in fact the weather had been so bad in pakistan that it had triggered several floodings all over the country and it was forecasted to be equally bad when the flight was due to land in islamabad later in the morning now in normal circumstances rain and moderately bad visibility is not a problem but the pilots were looking at their pre-flight briefing material and they realized that the surface wind was 070 degrees at 16 knots and it was forecasted to become even stronger later on the runways available in islamabad is runway 3-0 and runway 1-2 but the problem here is that there's only an instrument approach procedure into runway 3-0 this is because to the north of the runway there is a lot of mountainous terrain which makes it impossible to construct an approach procedure from that direction and with this wind there was a possibility that the runway in use was going to be runway one two because they couldn't land without much tailwind the only way to actually land on runway one two would be for the pilots to execute a approach procedure into runway three zero and then providing if the weather was good enough they would have to do a visual circling maneuver to runway one two a visual circling maneuver can be quite complicated for the crews to fly it's something that we don't do very often and it involves a lot of track keeping timings and also it is a visual maneuver which means that you need to have quite good visibility quite good weather in order to do it and the way that air blue instructed their crews to fly the circling procedure was to establish themselves on the inbound approach procedure in this case an islamabad that was going to be the ilf with gear down and flap 3 selected then had to descend down to their minimum descent altitude which was going to be 2 500 feet and providing that they had the runway environment inside they could then start breaking to the right they couldn't break to the left because islamabad city was there and it was not approved to fly over that so they had to break to the right 45 degrees they have to do that using the selected heading mode on the autopilot and then time for about 30 seconds outbound once those 30 seconds were out they needed to turn downwind fly to a beam the threshold all the time keeping the runway environment in sight start the timing once you beam the threshold fly for 20 seconds outbound and then turn left select flaps full and then hopefully establish themselves at the latest 400 feet above the runway and land on runway 1 2. the reason that these timings are so important is because a you need to keep yourself fairly tight close to the runway in order to see the runway if the visibility is bad but more importantly the mda the minimum descent altitude is calculated to give the crew a clearance area that stretches from about 4.2 nautical miles from each runway threshold and within that area you can maneuver and have at least 394 feet of clearance above the terrain right so it's really really important when you do a visual circuit maneuver like this that you stay within those 4.2 miles and this is going to be really important very soon the pilots would have been aware that there was a very real possibility that this was the type of procedure they were gonna have to do once they reached islamabad and even though the minimum visibility to do the circling was only 2400 meters in reality you need better visibility than that and if you at any time during the circuit maneuver lose contact with the runway you're gonna have to execute a go around and a missed approach and the misapproach procedure you need to follow is the procedure from the approach that you flew before you broke off for the circling this makes the missed approach procedure potentially also quite demanding so the pilots would have been very aware that unless the weather became much better when they arrived there was a very real possibility that this flight might end up in a diversion the pilots that were scheduled to operate together on this flight had vastly different experience levels the captain was a 61 year old with close to 25 500 hours which is a lot he had around 1 000 hours of experience on the airbus a320 family and he had previously just a few years earlier worked for a different airline but that airline had a mandatory retirement age of 60 years and that's why he had switched over to air blue the first officer on the other hand was 34 years old and had around 1 900 hours of total experience with only slightly less than 300 hours on the airbus a320 because of this they decided during the pre-flights that the captain was going to be pilot flying for the flight because of the complexity of the potential circling later on this by the way makes perfect sense because they had to break right for a left-hand circling and that would mean that the runway would be outside of the captain's window making it easier for him to see it after the pilots had completed their planning they briefed their cabin crew and they made their way out to the aircraft where they checked the technical status of the aircraft which they found to be in perfect working order at time city 241 that's 7 41 local time so quite early in the morning air blue flight two cir2 took off from karachi and started flying down towards islamabad about 11 minutes into the flight the cabin crew came in and served the pilots a couple of croissants and some tea and the captain apparently found that this was the perfect opportunity to start testing the technical and operational knowledge of the first officer and remember this was not a training flight according to the final report the captain did so in a very snobbish degrading and humiliating way and apparently he wasn't very happy with the answers he was getting from his much more junior first officer so this grilling continued on and off for about one hour of the flight and throughout this ordeal the first officer became more and more quiet less and less involved in the conversation as everyone can kind of understand i want to take a moment here to really explain how potentially devastating behavior like this can be for the crew resource management inside of a cockpit remember this first officer was not on the trainee so he would not have been prepared to be grilled by his colleague while he was operating the aircraft and even if this would have been a training flight we in the training department our job is to try to build up our colleagues the people that we are training so indeed we might be asking the occasional questions just to probe the knowledge level of the ones that we're training but if we find that there are deficiencies we just note that down so they can be debriefed later on in order for them to increase their knowledge level never ever ever should you put yourself in a position where you make the other person feel smaller feel worthless and lose their self-confidence because if you do you might find yourself in a situation where they could potentially help you you are making mistakes something is happening in the flight but because they have lost all their confidence they're not going to do that and we are going to see a terrifying example of that very soon once the captain was finally done grilling the first officer he told him to take the weather for islamabad first officer went on to the 80s frequency and received the weather and as expected it was just as bad as when they left it did confirm that runway 1 2 was going to be the landing runway and that the wind was indeed favoring that runway visibility was about three and a half kilometers with some low clouds around this clearly made the captain quite nervous because he could be heard on the cockpit voice recorder confusing the arrival airport and holding patterns around with a completely different airport but anyway he started setting up the cockpit for the arrival procedure but curiously he didn't prepare for the company approved circling procedure instead he started setting up his flight management computer with waypoints that he created himself for a right-hand circling pattern rather than the left turn circling pattern that was approved now this doesn't make much sense because the approach plate clearly states that there is a prohibited area just to the west of the airfield and that you're not allowed to overfly the city but on top of that he's sitting in the left seat and if he would break left for a right hand circling it would mean that the airport would be on the first officer's side rather than his anyway the captain continues to set up the cockpit for an approach in this way the first officer sees this happening but he doesn't say anything and the captain starts creating these pbd fmc waypoints now pbd stands for point bearing distance and basically the way that you do this if you want to make your own waypoints is that you find a fixed point and then you set a bearing and a distance from that point in order to create a new point the captain is doing this because he is now trying to create a route that will bring him in towards a final for runway one two without having to fly this really complicated company stipulated circling procedure now one of the problems with doing it this way is that when the fmc doesn't have an approach procedure for one runway it will create a default point called a cf point okay center fix this center fixed point is by default five nautical miles away on the final for the runway that you want to come into so when the captain is creating this right hand pattern in for with one two he uses the threshold point and it creates a couple of points with bearing from the threshold then he connects these points into the cf points and then to the runway but like i said the cf point is five nautical miles away which means that all of these other points that he's creating are also more than five miles away remember what i said about the protected area in case we're circling that's 4.2 miles so that means that this whole circuit that he's creating is actually outside of the protected area and the cf point by the way the default point that the fmc has created doesn't take any kind of terrain or anything into account it's just a default point now before we go any further it's really important that you guys understand how the pilots operate the autopilot in the airbus so the autopilot is controlled from something called a mode control panel on the glare shield up there the pilots can choose to either have the aircraft flying according to what we call a managed mode this is what you think about when you think about an autopilot it's the aircraft basically flying a pre-programmed route and the pre-programmed profile that is optimal or they might want to fly it in a selected mode this is where the pilot actually tells the aircraft exactly what they wanted to do for example they wanted to fly a specific heading or track or maybe they want to fly a specific vertical speed or something like that there are many reasons why pilots might want to go from a managed mode to selected mode it could be that they want to divert around a thunderstorm cell for example or like what we're talking about today fly a circling maneuver now if the pilot wants to go out from a managed nav mode into a selected heading mode what they do is they set the heading that they want and mod control panel and then they pull out the heading selector when they do so the autopilot will understand that okay the pilots now want me to turn on to that heading and it's going to turn in the shortest possible direction towards whatever heading that the pilots have selected if the pilot is then after the aircraft has to turn they want to go back in to manage mode well then they are going to have to put it onto an intercept heading to the track and then push the heading selector back in again that is going to tell the autopilot that okay now the pilots want me to intercept the route that we were flying and then follow the route onwards in order to understand what's about to happen in the story it's really important for you to understand the difference between those two modes and how the pilots are supposed to be manipulating the autopilot when the captain was finally done with his briefing he told his first officer to ask for descent and at times 03 48 and 17 seconds the aircraft received its first descent clearance from its cruise altitude of 33 000 feet down towards islamabad about six minutes later the air traffic controller came back and said that they could expect radar vectors for an ils approach from with 3-0 with a circuit to land runway 1-2 this was read back by the first officer who once again asked if it would be possible for them to do a right-hand circling instead of a left-hand circling air traffic control came back and said that no that is not possible due to local restrictions expect a right hand turn for a left hand circling this meant that all of the waypoints that the captain had created during his setup which was reliant on a left-hand turn to circle on the west side of the airport was now not going to be usable so after descending in now the captain told the first officer to create similar waypoint to the east of the airport instead first officer didn't seem to mind to do this he went in and he created these pbd waypoints based on the runway threshold and the cf point they were called pbd 10 11 and then to the cf point kind of creating a pattern like root but like i mentioned before these waypoints and this root that was now being created look nothing like the circling that they were supposed to fly and in fact if they would have looked closed onto it they would have noticed that this root would take them deep inside of the margala hills where the terrain was actually much higher than the minimum descent altitude that they were about to descend down to now before we get into the approach and the final part of this story i just want to share this short message from my sponsor who makes it possible for me to make these kind of videos whenever i travel somewhere like last week when me and my family went to dubai the way that i use curiosity stream myself is i try to find a documentary on there about the place i'm going to so for example we checked out the burj khalifa dubai's vertical city and that just made the experience of going up into the burj khalifa so much more rewarding it is a high quality subscription streaming service with thousands of documentaries and non-fictional stories from some of the best filmmakers in the world if that sounds interesting to you and i bet that it does then go down and click on the link in the video description here below which is curiositystream.commentorpilot and use the coupon code mentor pilot so they know that you're coming from my video that will give you a whopping 25 off the annual fee which is only 14.99 dollars per year which is insane value for money so after this video go down and check it out at time zero 434 air blue flight 202 received their final vector and the descent clearance to 3 900 feet to intercept the ils approach runway 3-0 the crew read this back they started selecting some flaps to slow the aircraft down and once they were established on the ils they were transferred over to islamabad tower now it's important to point out here that islamabad tower did not have their own radar screen so the previous sector could see the aircraft on the radar but the tower could not as the aircraft was descending down the glide slope the crew once again asked the tower for the weather conditions on the right hand downwind for runway one two the tower once again pointed out that the right hand downwind was not going to be available they would have to turn right for a left hand downwind the pilots had set their altitude selector to 2500 feet which is the minimum descent altitude for the circling but during the descent on the glide slope the captain suddenly reached over and sat 2000 feet instead this was actually picked up by the first officer who said no the mda is 2500 feet like we briefed and the altitude selector was set back up again but this indicates already here that the captain was willing to descend lower than the mda possibly because the lower down the glide slope you could come the more of a chance you have to actually see the runway because you're getting closer to runway but that would also mean that he would have less descent clearance during the actual circling maneuver and it shows a bit of a mindset of the captain at times zero forward 37 and three seconds the aircraft levels off at 2500 feet without having made visual contact with the runway the captain engages the selected heading mode and they continue flying straight ahead towards the romeo november vr beacon which is the missed approach point that's the latest point at which they have to be able to see the runway in order to break for the circling if they haven't seen anything by then they need to execute a go-around during the short flight towards the vor the tower controller comes in and tells the crew that another aircraft has just managed to land on runway 1-2 it's likely that that information would have been fed into the minds of the pilots making them think that well if they could land then definitely so can we as well maybe the weather is better than we think it is what the tower did not tell them was that that aircraft has managed to land on romwe 1 2 on its third attempt and another aircraft that tried it just prior to them diverted due to the bad weather anyway just as the aircraft is about to reach the romy november beacon the pilot can see the runway ahead of them and the captain in selected heading mode turns the aircraft right onto a track of 352 degrees the tower controller who can also see the aircraft at this point calls them up and tells them to call him on downwind so that he can issue the landing clearance for runway one two the tower controller also tells them to consider doing a bad weather circuit possibly referring to making the circuit as tight as possible because of the bad visibility but in response to that the captain inside of the cockpit just mutters to the first officer let him say whatever he wants to say possibly indicating that he has some plans of his own soon after this the captain also reaches over and reduces the altitude selector from 2500 feet to 2 300 feet the first officer doesn't speak up this time and the aircraft starts descending this is now violating the minimum descent altitude during the circling and reducing the available terrain clearance for the aircraft the next thing that happens is that the captain now tells the first officer that he intends to go into the managed nav mode following the route that the first officer created before but it doesn't actually engage the nav mode instead he continues in the selected heading mode going outbound on heading of 352 degrees the first officer says okay sir but are you visual and the captain responds visualize okay and the aircraft continues to fly outbound further and further away from the airport and the captain explains to the first officer that he wants to fly to the pbd 11 point where he's going to select flaps 3 and then flaps full as they're turning in towards the cf point this is clearly showing that the captain is fully intending to fly this programmed route that they have created and not the company specified circling procedure that they're supposed to fly they're now also so far away from the airport that it's impossible that the captain has the runway inside further violating the procedure at times 04 39 and 32 seconds the captain turned the heading bog to 300 degrees this makes the aircraft parallel the landing runway and it's now heading straight towards their created waypoint pbd11 as he's doing so he also pushes in the heading selector this engages the managed nav mode so from this point onward the aircraft is going to try to follow whatever route is in the fmc they're now at about three and a half miles away from the runway and they're out of sight from tower and quickly becoming closer to the outer limit of the 4.2 nautical mile protected circling area as this is happening the radar controller has been looking at the aircraft on his radar screen and he realizes that it's not where it's supposed to be it's actually getting very close to a restricted area called op277 but because the tower controller doesn't have his own radar screen he's not aware of this so the radar controller calls up the tower and asks him what the aircraft is doing this prompts the tower controller to call up the aircraft and tell him to immediately turn left to avoid flying into the restricted area and from this point onwards things are going to start happening very very quickly within a few seconds from this call the first terrain ahead warning is issued in the cockpit this warning is issued by the enhanced ground proximity warning system and that system uses a global terrain database together with the aircraft gps position its attitude and its flight path to predict closure rates to terrain this warning is issued when the aircraft is about 60 seconds from a potential collision with terrain and it is definitely not something that you should ever hear during normal circumstances if you hear this warning the correct thing to do is to immediately change your flight path either by turning or by climbing and definitely verify your own position because under no circumstances should you be in a position where a train warning like this would occur as this first warning is heard the first officer speaks up and he says sir the higher ground has reached sir there is terrain ahead sir turn left the captain can now be heard on the cockpit voice recorder becoming jittery and stressed this was clearly not something that he had anticipated and it's likely that this increased stress levels that is now hitting him further degrades his situational awareness because the aircraft just continues flying towards the waypoint the tower controller now calls up the aircraft and asks the pilots to please confirm that they're still visual with the runway and the first officer doesn't know what to respond to this so he just turns over to the captain and asks what should i tell him and when the tower controller repeats the same question again both pilot goes on to the frequency at the same time and said a firm air blue flight 202 we're visual with the terrain which is not the same as being visual with the runway the first officer is now becoming more and more anxious which frankly anyone can understand and he calls sir the terrain head is is coming that is further accompanied by two more egpws warnings and to that the captain finally responds yes we're turning and he's starting to turn the heading bug to the left but this is where the captain makes one of the biggest mistakes so far because remember the aircraft is now flying in the managed nav mode towards the waypoints that they have created the captain turns the heading bug but that doesn't really do anything because the autopilot still thinks that they want to continue with the route in order for the autopilot to understand that the captain now wants to turn he would have had to pull the heading selector out to switch it from the managed to the selected mode but he doesn't do this and in the stress that captain is now likely feeling he just keeps turning the bug more and more to the left until it actually ends up on a heading of 086 degrees this is where the captain finally pulls out the heading selector switching it over to the selected mode instead but remember the heading is now set to 086 degrees the aircraft is on a heading of 300 degrees this means that the quickest way for the aircraft to turn to the selected heading is not left like the captain wants it to do it is right and that's what the aircraft is doing it starts turning to the right bringing the aircraft further into the margala hills further in towards the higher terrain now more and more terrain ahead egpws warnings can be heard in the cockpit and they subsequently turn into terrain ahead pull up whenever you have an oral pull-up warning in any cockpit there's only one thing that you should be doing as a pilot and that is the terrain escape maneuver in the airbus that means disconnecting the autopilot pitching up to max aft side stick adding full toga trust taking down any speed brake if you're using them and also rolling wings level if that procedure would have been followed there is a possibility that they might have been able to clear the terrain ahead but unfortunately none of this is being done the first officer can now be heard pleading sir turn left sir pull up sir pull up but it doesn't go as far as to actually take controls from the clearly confused and bewildered captain and execute the terrain escape maneuver himself at time 0 4 40 and 33 seconds there is some indications that the captain is doing a meager effort to try to comply with the terrain warning he moves the truss levers into the flex detent which is not toga but it increases the thrust and it also disconnects the outer throttle he also sets 3700 feet in the altitude selector and this causes the aircraft to start climbing but only seconds later he reduces the altitude back down to 3100 feet and he brings the thrust levers back into climb thrust again which once again re-engages the outer thrusts on the hills below a couple of eyewitnesses could see the aircraft screaming above them at a shockingly low altitude in the cockpit the first officer continues to plead with the captain sir pull up but the captain seems to still be in the mindset to get this aircraft down on the ground he continues to turn the heading bog more and more to the left ending up at the value of 025 degrees but since that's still in the mind of the autopilot indicating a right-hand turn that's what the aircraft continues to do at times 0 4 40 and 46 seconds the captain finally decides to take matters into his own hands he disconnects the autopilot and he induces full left side stick together with some left rudder and those two actions together causes a rapid roll to the left up to a maximum value of 52 degrees at that time the aircraft was actually climbing at 2770 feet and it reached as high as 3110 feet before the combination of the high bank angle and the captain now inputting forward side stick causing the aircraft to start descend and the descent reaches 3 000 feet per minute with a negative attitude of 4.6 degrees since the outer thrust was now re-engaged the fact that the aircraft is now pitching forward causes the engines to spool back in order to try to maintain the airspeed causing further pitch down this increasing descent rate together with the roll and the already low terrain clearance now made this accident unavoidable and the last thing that was recorded on the cockpit voice recorder was the first officer miki speaking up saying sir we're going down so we are going down and then the recording stops at time city for 41 and 8 seconds the aircraft crashes into the margala hills 9.6 miles away from the airport at an altitude of 2858 feet all 146 passengers and six crew members perish in the accident the final report that came out of this investigation is one of the shortest and least complete ones that i've ever seen in connection to a modern aviation accident it lacks the normal root cause analysis that is so important in order for us to learn something from an accident like this what it is is basically a chronological description of what happened during this flight based on the cockpit voice recorder and they lay the blame of this accident almost squarely on the captain and his lack of crm primarily during the initial part of the flight where he completely obliterates the self-confidence of the first officer and then obviously during the actual circling maneuver and his lack of discipline and not following standard operating procedures but they also mentioned that the first officer was overly passive and that he should have taken controls and done something about the situation when he recognized the danger that they were facing the problem though is that the fund report never goes into whether or not this was a cultural issue that existed within the airline whether or not this captain had had previous problems with the crm or whether other pilots within the company was used to doing this on orthodox procedure of trying to fly a circling maneuver in a managed nav mode rather than in the described heading mode that they were supposed to do it so we never really get to learn anything from this the recommendations include the things like building of a new airport in islamabad and more emphasis on crm training and checking within the airline but it's very vague and it doesn't really help despite the very limited value that we got from this final report i just want to use this accident as an example of how important your leadership skills and your team building and crew resource management skills are if you're in any type of leadership position be it in a cockpit or in an office somewhere you have to continuously be building your team members up making sure that they're all helping you to pull in the same direction and crucially making sure that they are willing and feel that they can speak up no matter what the situation is if they don't feel that and if you don't build up your team members you might find yourself in a situation like the captain did in this accident where something is going wrong you're losing control of the situation and where your team members should be there to give you a helping hand in this case the first officer taking over control and executing the terrain escape maneuver they won't be there for you when you need them the most i have actually started doing leadership and decision making courses based on examples like this and if that's something that you are interested in well then go to mentorpilot.com and put your email down on my emailing list so i can let you know when my next course is due now check out this video next it's a fascinating story that i think you're going to enjoy and if you want to support the work that i do then consider becoming part of my awesome patreon crew it's a great gang or get yourself some merch have an absolutely fantastic day and i'll see you next time bye [Music]

Channel: Mentour Pilot

Views: 505,549

Keywords: captain, mentour pilot, mentor pilot, crash investigation, full epsiodes, aviation, pilot, crash, air crash investigation, final report, boeing, airbus, piper, cessna, disaster, fatal crash, air incident, air disasters 2022, pakistan, airblue, airblue 202, islamabad, karachi, a321, humiliated, pbd, waypoints

Id: kamyxB-yKrc

Length: 31min 9sec (1869 seconds)

Published: Sun May 08 2022