On the 28th of July 2010, a Pakistani airliner on approach to Islamabad flew off course and crashed into a hill outside the city, killing all 152 people on board. At the time, Pakistan was experiencing record rainfall and catastrophic flooding; as a result, many wondered if the weather could have contributed to the crash. But the investigation by Pakistani authorities found that the real cause was much stranger. Throughout the flight, the captain violated one rule after another, flying the plane as though he owned the skies. He spent an hour criticizing his first officer’s competence, then tried to select a new heading without pressing the proverbial enter button. As the plane flew straight toward a mountain, the first officer begged the captain to change course. Alarms blared, warning of imminent disaster, but for more than a minute the captain plowed stubbornly onward into the driving rain. In the shocking final moments of the flight, the first officer pleaded for action as the captain flailed helplessly in the face of certain death. How on earth could a supposedly trained pilot act in this manner? The official inquiry failed to answer this critical question. Just as the crew illustrated how not to fly an airplane, Pakistani authorities demonstrated how not to conduct an investigation. In fact, some of the industry’s most serious problems would not be revealed until nearly 10 years later, when a series of even more colossal piloting mistakes again sent a Pakistani airliner crashing to earth.
In 2003, former Pakistani Prime Minister Shahad Khaqan Abbasi decided to pursue a very different career as an airline chairman. And so he founded Airblue, a new domestic carrier to compete with the state-funded Pakistan International Airlines. The airline grew quickly thanks to its low prices, and it soon offered flights to most major cities in Pakistan and several destinations in the Gulf, all using a modern all-Airbus fleet.
One of Airblue’s core routes was the regular service from Karachi, Pakistan’s largest city, to Islamabad, the national capital. Operating this route on the 28th of July 2010 was an Airbus A321, a stretched version of the ubiquitous A320, piloted by Captain Pervez Iqbal Chaudhry and First Officer Muntajib Chughtai. The 61-year-old Chaudhry was one of the most experienced captains at Airblue, with over 25,000 flight hours under his belt. 34-year-old First Officer Chughtai, by contrast, had just over 1,800. Also joining the pilots on the morning flight were four flight attendants and 146 passengers, totaling 152 people on board.
At 7:41 a.m. local time, flight 202 to Islamabad departed Karachi without incident, climbed to its cruising altitude, and proceeded northward toward its destination. Although the passengers thought everything was normal, this was far from the case. Inside the cockpit, Captain Chaudhry was testing his much younger first officer on his knowledge of the aircraft, and he was clearly unsatisfied with the results. Chaudhry humiliated Chughtai, harshly criticizing his aptitude, while flaunting his own evident superiority. This one-sided lesson continued for a full hour after takeoff, by which point First Officer Chughtai had long since lost his last desperate shreds of self-confidence. Despite his supposedly superior flying ability, Chaudhry soon made what would be the first of many inexplicable blunders: while programming the flight management system with the waypoints for their approach to Islamabad, he temporarily confused the Islamabad and Karachi airports, as though he had forgotten where he was going. Although the mistake was swiftly corrected and had no bearing on the rest of the flight, it was the second of several major red flags to be raised by Chaudhry’s behavior.
The wind at Islamabad Airport that day favored an approach to runway 12 from the northwest. However, the weather at the airport was abysmal; in fact, much of Pakistan had been drenched with heavy rainfall for days, leading to nationwide flooding that would eventually claim over 1,700 lives. Today was no different, with a low cloud ceiling over Islamabad and periodic heavy rain. This was a problem because runway 12 lacked an instrument landing system (ILS), a set of equipment which helps pilots align with the runway and descend toward it smoothly using only their instruments. In bad weather, the procedure for landing on runway 12 was to use the ILS for runway 30 (the same runway in the opposite direction), descend in line with runway 30 down to 2,500 feet, and then circle around the airport and land visually on runway 12. In order to perform this so-called circling approach, the pilots must keep their eyes on the airport at all times; if they lose sight of it, the approach must be abandoned.
Islamabad’s Benazir Bhutto International Airport lies in a valley with mountains to the north and east. Therefore, the minimum altitude for the circling approach — 2,500 feet — only provides clearance from terrain within a limited distance away from the airport. This envelope of protection extends for 8 kilometers surrounding the runway, and approaching airplanes must stay within this “envelope” while performing a circling approach to runway 12. To facilitate this, the official procedure specifies a maximum speed for the approach, and gives detailed timing instructions for each leg of the circle. Upon breaking off from the approach to runway 30, the aircraft shall turn 45 degrees to the right and maintain this heading for 30 seconds; turn left to parallel the runway; wait 20 seconds after passing abeam the threshold of runway 12; turn left 90 degrees onto the “base leg;” and then make another left turn to visually align with the runway (see diagram above).
But for some reason, Captain Chaudhry didn’t want to follow the prescribed procedure. To understand what he did instead requires a brief explanation of the Airbus A321’s flight management system (FMS). For lateral navigation, the system has two types of guidance: “selected” and “managed.” In either of the two “selected” modes, the pilot navigates the aircraft by using a knob to select the desired heading, which the autopilot will then maintain until a new input is made. This is the type of guidance normally used during a circling approach. In contrast, in the managed lateral mode (known as “NAV” mode), pilots can pre-program a route consisting of up to 20 waypoints into the flight management system, and the autopilot will fly the plane along the entire route without further input from the pilots. It is this latter mode that Captain Chaudhry decided to use when planning his approach, even though this was contrary to established procedures.
When Chaudhry selected runway 12 in the flight management system, the computer recognized that there was no pre-existing NAV mode approach data for this runway, so it began by automatically creating a waypoint located 9.3 kilometers from the runway threshold on the extended runway centerline. This point, known as the “course fix,” is where the plane must align with the runway and begin its final approach; its exact location is not important and can be altered by the pilots. In this case, the pilots needed to move the course fix closer to the runway, because it was generated outside the 8-kilometer envelope of protection for the circling approach. But Chaudhry never altered it. Instead, he used the FMS to create several unauthorized waypoints leading up to the course fix, thus establishing a route which the airplane would fly automatically once NAV mode was engaged. Instead of using timed legs while circling the airport, he told First Officer Chughtai that they would fly to a made up “point #11,” which was approximately abeam the course fix. At that point — which was well outside the protected area — they would make the left turn onto the base leg. First Officer Chughtai didn’t protest this dangerous deviation from standard procedures.
At 8:58 a.m., flight 202 began its descent into Islamabad, where the cloud ceiling was fluctuating around the minimum descent altitude. The plane locked on to the instrument landing system for runway 30, and the crew discussed when they would break off to circle the airport. Captain Chaudhry wanted to go down to 2,000 feet, but First Officer Chughtai reminded him that the minimum was 2,500. Minutes later, a Pakistan International Airlines flight announced that it had successfully landed in Islamabad — an event which probably put pressure on Captain Chaudhry to do the same, since PIA was Airblue’s main competitor. Meanwhile, a China Southern flight, unable to spot the runway, made the more prudent decision to abandon the approach and return to China.
After arriving at 2,500 feet, the pilots found that the runway was not yet visible through the clouds. They flew onward at 2,500 feet for a short while longer, but at 9:37, Chaudhry commanded the autopilot to begin the initial right turn without having spotted the runway. At the same time, he instructed the autopilot to descend to 2,300 feet, deliberately violating the minimum descent altitude in order to get a better view of the ground. At this point the controller suggested that they enter a holding pattern and wait for the weather to improve. But Captain Chaudhry laughed him off. “Let him say what he wants to say,” he said to a bewildered First Officer Chughtai.
At 9:38, Captain Chaudhry announced that he was going to engage NAV mode on the FMS and have the autopilot fly them as far as the course fix. “Okay, but are you visual?” Chughtai asked. Chaudhry dismissed his concerns out of hand. He apparently didn’t think it would be necessary to spot the airport if he could line up with the runway using NAV mode.
Despite his stated intentions, Chaudhry merely armed the NAV mode, but did not yet engage it. Instead, he used the heading knob to command a left turn to 300 degrees, parallel to the runway. Had they been following the standard procedure, they should have turned onto the base leg by now. But in fact they were already more than 9 kilometers from the runway, outside the protected zone, flying below the MDA, and only just now making the second prescribed turn.
At 9:39, Chaudhry engaged NAV mode, and the autopilot began to steer the plane toward the beginning of the pre-programmed track at point #11. This point was located 13 kilometers north-northwest of the runway and almost dead ahead of the aircraft. Neither pilot knew that if they attempted to fly to point #11 at their current altitude of 2,300 feet, they would collide with the hills north of the airport before reaching it.
15 seconds after Captain Chaudhry engaged NAV mode, the plane’s Enhanced Ground Proximity Warning System (EGPWS) detected rising terrain approximately one minute ahead of the aircraft. As an automated voice began to repeat, “TERRAIN AHEAD,” First Officer Chughtai said to Captain Chaudhry, “This — sir, higher ground has reached! Sir, there is terrain ahead — sir, turn left!”
Chaudhry insisted that they carry on toward point #11, but he sounded anxious and jittery as uncertainty began to seep into his mental picture of the situation. About 10 seconds later, the controller, seeing that the plane was straying outside the protected zone, asked the crew if they could see the runway. “What should I tell him, sir?” Chughtai asked. The question indicated that they couldn’t see the runway, and he was asking whether or not he should lie.
After a few seconds, the controller asked again, and both pilots replied, “Airblue 202 is visual with the ground.”
But immediately after this exchange, Chughtai again warned Chaudhry, “Sir, terrain ahead is coming!”
Now Chaudhry finally relented. “Yes, we are turning left,” he replied, and he reached for the heading knob to enter a westerly heading.
Here he made his single most critical mistake: he forgot that they were still in NAV mode. The heading knob is used to enter a heading while in heading mode (HDG), not NAV mode. To disengage NAV mode and engage HDG mode, all he needed to do was pull the knob outward after selecting his desired heading. But because he forgot this essential step, his selected heading just sat there on the screen, waiting to be fed to the autopilot. Various mode indicators all stated that they were still in NAV mode, but he evidently didn’t look at them. As a result, the plane kept flying straight toward point #11, while Captain Chaudhry rotated the heading knob farther and farther to the left, wondering why they weren’t turning.
It wasn’t until 9:40 and 28 seconds that Chaudhry apparently realized that the computer was not in HDG mode, at which point he finally pulled the heading knob. But in his frantic attempts to get the plane to turn left, he had turned the knob so far that it had looped all the way back around to the right — specifically, to a heading of 86 degrees (almost due east). As a result, the autopilot began to turn the plane to the right, deeper into the hills, instead of to the left. The “TERRAIN AHEAD” warnings suddenly transitioned to the much more dire exhortation, “TERRAIN! TERRAIN! PULL UP!”
Immediately, First Officer Chughtai exclaimed, “Sir, turn left! Pull up, sir! Sir, pull up!”
Three seconds later, Captain Chaudhry made a half-hearted attempt to comply, setting the throttles to max climb and instructing the autopilot to ascend to 3,700 feet. Moments later, he reduced these parameters to standard climb thrust and 3,100 feet respectively. This fell well short of the proper response to a terrain alarm, which was to take manual control, accelerate to go-around power, and pull up as steeply as possible.
This clearly didn’t satisfy Chughtai. “Sir, pull up sir!” he exhorted. Meanwhile, Chaudhry continued to turn the heading knob to the left, but because he was only reducing the selected heading toward zero degrees, the autopilot continued to turn the plane to the right.
“Why is the aircraft not turning left?” Chaudhry wondered aloud. At that moment, he disconnected the autopilot and began to turn left manually as the plane climbed through 2,770 feet. On the ground, witnesses in the Margalla Hills pointed and stared in alarm as the A321 flew straight over them at a shockingly low altitude.
The plane’s altitude peaked at 3,110 feet, at which point Captain Chaudhry appeared to lose all control of the plane. He made a massive leftward input using the sidestick, rolling the plane a terrifying 52 degrees to the left, while simultaneously pushing the nose down. The EGPWS again called out, “TERRAIN! TERRAIN!”
“Terrain, sir!” Chughtai shouted.
Chaudhry quickly reversed his pitch down and began to pull up, but it was far too late. “Sir, we are going down!” Chughtai screamed. “Sir, we are going d — “ The first officer’s last, desperate cry was cut short as flight 202 slammed headlong into a mountainside in the Margalla Hills, sending burning chunks of the plane tearing through the forest and down into a ravine. The brutal impact obliterated the A321, slicing a smoking streak of pure hell across the face of the mountain and instantly killing all 152 passengers and crew. And for a moment, all was silent.
Emergency crews who rushed to the scene were confronted with a hopeless field of destruction. Spot fires burned throughout the mangled wreckage, and it was obvious that no one could have survived. But the response to the crash was itself an unmitigated disaster: for most of the day, first responders were seen standing around the edges of the wreckage field, seemingly unsure what to do. Aviation experts warned that their failure to establish a security perimeter could allow critical evidence to be stolen, but their warnings fell on deaf ears. The body recovery was subsequently botched as well, with numerous mix-ups involving mislabeled remains, and no one ever managed to conduct an autopsy on either of the deceased pilots, as required by international guidelines.
The government of Pakistan soon dispatched investigators from the Civil Aviation Authority (CAA) to determine the cause of the crash. But the investigators lacked the qualifications demanded of them by international aviation rules, which immediately threw the outcome of their investigation into doubt. Already, it seemed like the authorities couldn’t do anything right.
In November 2011, the CAA released its final report on the accident. To anyone familiar with investigating major air crashes, the report was plainly inadequate. Coming in at a mere 38 pages, it was (and remains) one of the shortest reports ever issued on a major crash in the 21st century. It barely outlined the facts of the flight, established the probable cause to be the pilots’ “failure to display superior judgment and professional skills,” and left it at that. Families of the victims were outraged — was that really all the CAA had to say?
The basic sequence of events was nevertheless conveyed in the report. The situation leading to the crash began when Captain Chaudhry decided to fly the circling approach to runway 12 in NAV mode instead of a selected mode. Most likely, he saw the use of NAV mode as a loophole which would allow him to complete the circling approach even if visibility did not permit him to see the airport. But the series of custom waypoints that he entered were all well outside the 8-kilometer envelope of protection conferred by the minimum descent altitude of 2,500 feet, and one of them (point #11) was quite close to the crash site in the Margalla Hills, where it was clearly unsafe to fly at that altitude (the elevation of the crash site was 2,858 feet). Therefore, as soon as Chaudhry activated NAV mode, he put the plane on a collision course with the high terrain.
Chaudhry’s initial attempts to turn left short of point #11 were thwarted by his own failure to switch the lateral guidance to heading mode. The report did not attempt to analyze why he forgot that he was in NAV mode and kept trying to use the heading knob to turn the plane. By the time he engaged heading mode, he had entered an easterly heading which caused the plane to turn right, plunging him into seemingly helpless confusion. During the critical 70 seconds before the crash, he ignored no less than 21 EGPWS terrain warnings and nearly a dozen requests from First Officer Chughtai to turn left or pull up. He seemed to be fixated on turning left throughout the final minute of the flight — so much so that he eventually banked to 52 degrees with no regard for his vertical pitch. If he had pitched up during the escape maneuver instead of trying to turn the plane sideways, they might have just barely missed the hill. But the report did not attempt to explain why he made this bizarre series of inputs.
The one aspect to which the report did dedicate a brief analysis was the coordination between the crewmembers. The cockpit atmosphere could only be described as toxic: Captain Chaudhry spent the first half of the flight gratuitously belittling First Officer Chughtai, leaving him a nervous wreck by the time they began the approach to Islamabad. It was clear that Chughtai lacked any vestige of confidence and was scared of his captain, as he failed to correct most of Chaudhry’s mistakes, addressed him as “sir” to the point of obsession, and never attempted to take control of the plane despite Chaudhry’s lack of a response to a full minute of EGPWS warnings. Although the report simply stated that Chughtai “failed to display required [crew resource management] skills,” the blame for that failure lay with Chaudhry, and the crew resource management would be better described as some of the worst ever seen in recent aviation history.
Another aspect that the report failed to address was in fact already known to the news media: Captain Chaudhry’s health. According to multiple news reports, the 61-year-old Chaudhry had been admitted to the hospital with diabetes, hypertension, and cardiac problems less than two months before the crash. Pakistani regulations explicitly barred pilots from flying if they were being treated for diabetes. But just days later, Chaudhry passed his annual medical examination and was cleared to fly. The report only stated that Chaudhry passed the exam without mentioning the fact that he had diabetes and other serious health issues. That raised the question: how could he possibly have passed the medical by legitimate means? Especially given his age, these diseases should have presented major red flags. In fact, Chaudhry was older than the retirement age for most airline pilots around the world. His previous airline, PIA, had forced him to retire at 60; in order to keep working, he moved to Airblue, where the retirement age was 65 (the average male life expectancy in Pakistan in 2010 was 64). However, the question of whether Chaudhry was medically fit to fly was never adequately answered. To this day it is not known how he passed his physical, or whether he might have been suffering from a medical issue which affected his ability to fly. If he was, it might explain some of his weirder mistakes.
After blundering its way through the analysis section, the official report finished off with a few brief, ill-defined recommendations that were not addressed to any particular entity. Analysts at the time expressed the belief that the report would be unlikely to lead to any noteworthy improvement in aviation safety in Pakistan, mostly because it failed to address almost all of the underlying causes of the crash. Why was the pilots’ crew resource management so terrible? Was it common practice at Airblue to fly circling approaches in NAV mode? These are but a small sampling of the numerous questions which the report should have answered, but did not.
On the 10th anniversary of the crash of flight 202, Express Tribune journalist Belal Aftab wrote, “Since [the Airblue crash], what has Pakistan done to ensure such a tragedy never happens again? The answer, in short: not much.” His evidence: another tragic accident in Pakistan, this time involving PIA. By the time Pakistan International Airlines flight 8303 took off from Lahore on the 22nd of May 2020, two more Pakistani airliners had already crashed, one in 2012 and another in 2016. Pakistan was already one of the most dangerous places to fly, but flight 8303 was about to make that fact public knowledge around the world.
As flight 8303, an Airbus A320, came in to land at Jinnah International Airport in Karachi, the plane was nearly three times as high as it should have been with only a few kilometers left before the runway. But instead of circling around to try again, the pilots pressed blindly onward, forcing the plane into a terrifying descent which at its peak exceeded -7,000 feet per minute. The pilots extended the landing gear, but then inexplicably retracted it again, leading to a cascade of landing gear warnings as the plane careened toward the runway. Incredibly, neither pilot reacted. The plane touched down with its landing gear stowed, causing the engines to scrape the runway. Then the pilots made an even more inexplicable decision: they accelerated to full power and took off again. Within minutes, the damage to the undersides of the engines caused them to fail, and the powerless plane crashed into a busy street in Karachi’s Model Colony, killing 97 of the 99 people on board and one on the ground.
So far, the investigation into the crash is still ongoing. Little is known about how the pilots made such a series of errors, except that they were possibly distracted by a conversation about the COVID-19 pandemic throughout much of the descent. But the crash did prompt scrutiny of pilot training which led to a shocking discovery: approximately one in three pilots in Pakistan were not properly certified, most of them because they had bribed others to sit in for them during their certification exams. Aviation authorities around the world swiftly banned Pakistani airlines from landing at their airports, and Pakistan faced a moment of reckoning: were hundreds of its pilots actually frauds? This discovery finally seems to shed some light on why aviation in Pakistan is so unsafe, something which the report on Airblue flight 202 failed to do. “Pakistan’s aviation sector, and its pilots in particular, have become a global joke,” wrote Aftab. “Those who have lost loved ones are not laughing.”
Aviation safety is indeed not a joke, and Pakistan’s safety problems are a serious matter. Many obvious lessons of the Airblue crash were evidently not heeded: despite the outlandish display of cockpit ineptitude on flight 202, the absurdity of flight 8303 clearly exceeded even this already gross example of negligence. “What will we say 10 years from now, when we look back on 2020?” Aftab continued. “The answer is up to us and how much we hold the airline industry and government leadership to a better standard.” Whether Pakistan’s leadership chooses to see the writing on the wall remains unknown, and it will not be known for several more years. Until then, I would advise readers to avoid flying with any Pakistani airline if other options are available. But while the best time to start tackling the problem was 10 years ago, the saying holds true: the second best time is now.
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