Insanity in the Air: The crash of Pakistan International Airlines flight 8303
On the 22nd of May 2020, a Pakistan International Airlines A320 on approach to Karachi slammed into a residential neighborhood just short of the runway, killing 97 of the 99 people on board and one on the ground. Only two survivors miraculously escaped the burning rubble.
The story that eventually emerged from the wreckage defies rational comprehension: after an approach so steep it bordered on madness, the crew set the plane down on the runway apparently without having extended the landing gear, causing the aircraft to slide on its engines for nearly a kilometer. And then, as if that wasn’t enough, after skidding across the ground for 18 seconds, the crew managed to pull the plane back into the air and climb to 3,000 feet — only for both damaged engines to fail, leaving the aircraft with insufficient power to return to the airport. The annals of aviation history contain few comparable accidents. In fact, the sequence of errors, reckless decisions, and baffling misbehavior that enabled the disaster surpasses all but the most irredeemable blunders of the past, calling into question Pakistan International Airlines’ ability to carry passengers with anything close to an acceptable level of safety. And in order to fix this deep-seated rot, sweeping changes are most likely needed — not only to safety rules and enforcement, but to the culture of patronage and corruption whose tendrils reach into every corner of Pakistan’s troubled flag carrier.
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The state-owned Pakistan International Airlines, or PIA, has been part of the global face of Pakistan since the 1950s, bringing countless travelers to and from the world’s fifth most populous country for well over 70 years. PIA was once among the only respected airlines in the region, so much so in fact that when the United Arab Emirates set up its own flag carrier in 1985 — creating the highly regarded airline now known as Emirates — it was PIA whom they approached for help. Nevertheless, PIA has never had a particularly strong safety record. Between 1970 and 2020, the airline suffered one fatal accident on average every five years, which is particularly poor when considering that its average fleet size during the aforementioned period was only around three dozen aircraft. Advances in aviation safety in recent years have also failed to stem the bloodshed, and in fact PIA has had three fatal crashes in the 21st century so far, more than almost any other flag carrier.
The most recent disaster to mar PIA’s record was also perhaps its most preventable, and most damning.
In May 2020, the world was still in the grip of the Covid-19 pandemic, which resulted in the deaths of millions and reshaped daily life for virtually everyone on earth. In Pakistan, almost all domestic flights were grounded from late March in order to control the spread of the disease, with some scheduled services resuming only on May 16th. At Jinnah International Airport in Karachi, Pakistan’s largest city, the number of daily arrivals had dropped to just 8, from 77 in January and February, and airports and airlines alike were still operating with reduced staff.
Less than a week into this resumption of service, on May 22nd, 91 passengers and 8 crew arrived at Allama Iqbal International Airport in Lahore, Pakistan’s second largest city and the capital of Punjab province, for a regularly scheduled PIA flight to Karachi. The weather that day was clear, the Lahore-Karachi route was a bread-and-butter service familiar to the crew, and the Airbus A320 provided for the trip was in good working order — certainly there was nothing to indicate that risk was above baseline levels for any reason other than the general pandemic disruption.
The flight crew in command of flight 8303 to Karachi that day consisted of 58-year-old Captain Sajjad Gul, who had over 17,000 hours of flying experience including over 4,700 on the A320; and 33-year-old First Officer Usman Azam, who had been flying with PIA for 10 years but had only about 2,100 total hours, mostly on the A320. For the leg to Karachi, First Officer Azam was to be the flying pilot, while Captain Gul would be the pilot monitoring.
Both crewmembers would have had more on their minds than just the pandemic and the flight itself. Notably, the 22nd of May that year fell close to the end of the holy month of Ramadan, in which most Muslims abstain from food and drink between sunrise and sunset, until the holiday of Eid al-Fitr, when the fast is broken. At that time, Eid was scheduled to fall on May 24th, and many of the passengers were traveling to visit family for the occasion. Captain Gul and First Officer Azam had both been fasting for several weeks, including on the day of flight 8303, where they partook in the traditional pre-dawn Sehri (Suhur) meal before forgoing all further intake during the daylight hours. By the time the flight departed Lahore at 13:05 local time, they most likely had not consumed any food or drink, including water, in at least seven hours. The significance of this fact would later be subject to debate.
As the flight reached its cruising altitude of 34,000 feet, the atmosphere in the cockpit was casual. The pilots were engaged in a lengthy and animated discussion of the Covid-19 pandemic — the big topic of the day, to be sure — which continued for some time, interrupted only by radio calls and other routine events. At one point a flight attendant came to the cockpit to ask if the pilots would like a snack, but seeing as they were fasting, they politely declined.
Minutes later, at 13:24, the pilots made contact with Karachi Area Control and were told to expect an instrument landing system (ILS) approach to runway 25L at Jinnah International Airport.
The initial descent and approach phases would start from the Nawabshah beacon, located about 100 nautical miles northeast of the airport, from which the inbound flight would proceed directly to waypoint MAKLI, on the extended centerline of runway 25L at a distance of 15.3 nautical miles from the threshold. At MAKLI, the aircraft would turn to the right to align with the runway before reaching waypoint SABEN, located at 11.4 NM, where the final approach phase would begin. The prescribed crossing altitude for SABEN was 3,000 feet. If it was not possible to descend to this altitude before reaching the waypoint, the approach procedures contained provisions for a holding pattern based off of SABEN in order to increase the number of track miles, providing more time to descend. After crossing SABEN at 3,000 feet, it would then be possible to intercept the glideslope, which would automatically guide the aircraft down to the runway at the correct angle. The intention of the procedure was that the glideslope would be intercepted from below.
Having been told to expect this approach, the pilots had already programmed it into their flight management system, or FMS. With this data entered, the FMS was also able to calculate a vertical descent profile that would bring the aircraft to each approach gate at the correct altitude and speed. The pilots could then set the autoflight system to fly the entire approach essentially by itself, automatically modifying heading, speed, and pitch to maintain the lateral and vertical flight plan stored in the FMS. Considering this technological capability, the lack of any unusual features in the approach procedure, and the perfectly clear weather, the descent and landing ought to have been smooth sailing. Unfortunately, for several frankly boneheaded reasons, events would soon go off the rails anyway.
At 14:15, after crossing Nawabshah, the crew requested clearance to begin their descent, and the Karachi area controller cleared them to descend to 10,000 feet and proceed direct to MAKLI. In response, the flight crew selected 10,000 feet using the flight control unit (FCU) altitude knob, engaging Descent mode.
At this point it would be helpful to provide a refresher of some background information I’ve covered in several previous articles involving the Airbus A320. On the A320, pilots provide instructions to the autopilot by using the FCU to engage various flight modes. Normally, three modes are engaged simultaneously — one to control the airplane’s lateral position, a second to control its vertical position, and a third to control its airspeed. All the possible modes, whether lateral, vertical, or speed-related, fall into two broad categories called “selected” and “managed.”
To engage a selected mode, the pilots use the altitude, airspeed, vertical speed, or heading knobs on the FCU to enter a specific target value, then pull the corresponding knob outward. This will cause the auto-flight systems to maintain the selected value until a new value is entered. For example, if the pilot wants to fly on a heading of 360, they can enter “360” using the heading knob, then pull the knob outward, and the autopilot will steer the plane to 360 degrees and hold it there until the pilot tells it to do something else.
In contrast, if the pilot pushes a knob inward, a managed mode will engage. In a managed mode, the autoflight system will determine the flight path (whether vertical, lateral, or both) based on the information pre-programmed into the FMS. For example, if the pilot wants to instruct the plane to fly along a track between a series of pre-programmed waypoints, they can push in the heading knob to engage the lateral NAV mode, and the autoflight system will continually manage the airplane’s heading in order to follow the track in the FMS no matter how many twists and turns it may have.
In the case of PIA flight 8303, the pilots had already engaged NAV mode in the lateral channel when they selected an altitude of 10,000 feet and pushed in the altitude knob. This engaged the managed Descent mode, in which the aircraft will follow the vertical profile computed by the FMS, as described earlier. At that time, the aircraft was below the computed profile, so the autoflight system kept the airplane in a slow and steady 1,000 feet-per-minute descent until it intercepted the profile from below, at which point pitch and thrust were automatically reduced in order to capture the profile. The aircraft would continue to follow this computed vertical profile until reaching the selected altitude of 10,000 feet, unless the pilots selected another altitude or engaged a different mode.
In this case, the programmed approach to runway 25L by default included the holding pattern at SABEN, described previously. The computed vertical profile thus accounted for the presence of the holding pattern, which added 23 track miles to the approach. This extra distance provided considerably more time in which to descend to 3,000 feet, meaning that a slower rate of descent could be used prior to reaching SABEN. The presence of the holding pattern was indicated on the pilots’ navigation displays by a white curved arrow at SABEN, and the word “HOLD” in the text description of the flight plan on the multi-function control and display unit.
However, the crew of flight 8303 didn’t intend to actually carry out the holding pattern, probably because there were no constraints that would prevent them from descending early enough and fast enough to reach SABEN at 3,000 feet on the first pass. In that case, the crew should have used the multi-function control and display unit to delete the holding pattern from the flight plan, which would cause the FMS to recalculate the descent profile. However, this was not done, nor was the discrepancy detected, because the pilots never broke off their off-topic conversation in order to conduct an approach briefing, which would have included a cross-check of the FMS flight plan.
Unaware of the developing problem, the flight crew accepted an ATC clearance to 5,000 feet at 14:18, still proceeding toward MAKLI. Moments later, Karachi area control instructed the flight to contact Karachi Approach on a frequency of 125.5, which was not acknowledged by the crew. In the cockpit, the pilots were still engaged in non-pertinent conversations, as a result of which Captain Gul mistuned his radio to 126.5 instead of 125.5, apparently without noticing. Karachi area control tried three times to call the flight to confirm the handover without success, at which point the controller instructed another PIA flight to try calling flight 8303. This flight called twice but also failed to make contact. A sixth call was made by Karachi Approach on 125.5, which was also not acknowledged. Only when Karachi Approach called on the emergency Guard frequency of 121.5, which should be tuned in one radio at all times, did they get any response. Contact was finally re-established on the correct frequency at 14:25, nearly two and a half minutes after it was lost. This incident would have no direct impact on the events that followed, but it was nevertheless illustrative of the direction in which things were going.
With two-way communications re-established, Karachi Approach cleared flight 8303 down to 3,000 feet, the target altitude for SABEN. At that time, the aircraft was still at over 15,000 feet, approaching MAKLI.
Shortly before reaching MAKLI, the crew armed the localizer and glideslope modes in order to prepare to intercept the instrument landing system. The ground-based ILS equipment consists of a localizer providing lateral guidance to align with the runway, and a glideslope to provide vertical guidance to achieve the normal 3-degree descent path. When the localizer and glideslope modes are armed in the A320’s FCU, in the lateral and vertical channels respectively, they will lay dormant until the ILS signals are close enough to be detected, at which time the modes will automatically engage and the autoflight system will drop what it was doing before to follow the ILS instead.
Since waypoint MAKLI lay in line with the runway, it also lay along the localizer. Therefore, when the aircraft approached MAKLI with the localizer mode armed, it would pick up the localizer signal, and the lateral mode would change from NAV to LOC in order to follow the localizer instead of the FMS flight plan. This would result in the cancellation of the programmed holding pattern at SABEN. However, the flight had been descending according to a vertical profile that included the holding pattern, so if LOC mode was allowed to engage before the holding pattern was completed, then the plane would align with the runway at a higher altitude than intended. The fact that the flight crew armed the localizer mode before completing the holding pattern proved that they didn’t intend to fly the holding pattern and likely didn’t know it was in the flight plan.
As a result of the above, when flight 8303 was just short of MAKLI, the LOC mode automatically engaged, overriding NAV mode, and the autopilot steered the plane to align with the localizer. However, Descent mode was still engaged in the vertical channel, so the airplane continued to follow the computed vertical profile in the FMS, which included the holding pattern. Seconds later, flight 8303 crossed the MAKLI waypoint at 9,363 feet, with only four nautical miles remaining to SABEN, where they were supposed to be at 3,000 feet. Losing so much altitude in such a short distance was impossible. Recognizing that flight 8303 was improperly positioned for the approach, the Karachi controller called and asked, “Pakistan 8303, confirm track mile comfortable for descent?”
Captain Gul, who was working the radios, immediately replied, “Affirm.” There was no evidence that he was yet aware of the developing problem.
Seconds after his radio call, however, Gul apparently thought to check the FMS, causing him to suddenly realize that something was wrong. “What has happened!?” he exclaimed. “Stop, stop, oh no! Take out the hold, take out the hold, take out the hold, take out the hold!”
First Officer Azam immediately deleted the holding pattern from the flight plan, but this had no effect because the autopilot was now following the localizer, not the flight plan track. “Hold taken out,” he said. “Should we report this happening?”
“No,” said Captain Gul. “This could be due to hold. Tell Karachi approach that [we’re] established on localizer.” He did not articulate any specific plan to correct their excessive altitude, nor did the crew discuss exactly how high they were or what kind of profile would be required to get back on course.
At this point the prudent thing to do would have been to disengage LOC mode and enter the holding pattern at SABEN in order to lose altitude. But someone on the flight deck apparently thought he had a better idea, because at 14:30 and 44 seconds, one of the pilots changed the vertical mode in the FCU to “Open Descent.”
Open Descent is a selected mode in which the autoflight system maintains a selected airspeed by pitching the nose up or down while engine power remains at idle. The plane will descend at whatever vertical rate results from this configuration. This allows for potentially very steep rates of descent, and for that reason the use of Open Descent mode on final approach is prohibited. In fact, several A320 accidents in the early 1990s were attributed to improper use of Open Descent mode while close to the ground. Although Open Descent would potentially allow a descent rate steep enough to get flight 8303 back on profile, it goes without saying that the decision to use it in this case was both inappropriate and dangerous.
Immediately after selecting Open Descent mode, the flight crew extended the speed brakes to increase drag, then entered a target airspeed of 255 knots, ten knots faster than their present speed and above the 250-knot speed limit below 10,000 feet imposed by most countries. Since the thrust levers were pinned at idle in Open Descent mode, the autopilot tried to accelerate to the selected airspeed by pitching the nose down, resulting in a rapid descent, which was presumably the pilots’ intention. At this point they were at about 9,200 feet and the glideslope was 4,500 feet below them, with only 14.1 nautical miles remaining to the runway threshold.
Meanwhile, observing flight 8303 on radar, the Karachi Tower controller, who was responsible for all takeoffs and landings, called the Karachi Approach controller and said, “Sir, it’s too high.”
“Yes,” the Approach controller replied, “It is too high and I am observing it and will give orbit.”
At that moment, flight 8303 crossed the SABEN waypoint at 7,800 feet, now 4,800 feet too high. Seconds later, Karachi Approach called the flight and said, “Pakistan 8303, report level passing.”
“Out of 75 for 3,000,” Gul replied. By “75” he meant 7,500 feet, which was optimistic considering they were still at 7,700 feet at that time.
“75 for 3,000, the present position is 10 miles from touchdown,” the controller said, hinting at the scale of the problem.
In response, Gul blithely transmitted, “No problem sir.”
At that moment, still at an altitude of 7,400 feet, one of the pilots extended the landing gear without any callout or cross check. This action was probably performed in order to increase drag, which would allow them to descend faster with no corresponding increase in airspeed. As a result, the descent rate surpassed 2,900 feet per minute and continued to increase rapidly. Maintaining speed with this additional drag caused the autopilot to pitch the nose down even more, reaching 7.4˚ nose down within 30 seconds.
Moments later, at 14:31 and 41 seconds, the controller radioed the aircraft and said, “Sir, orbit is available if you want,” indicating his belief that flight 8303 should enter a holding pattern.
Speaking to First Officer Azam, Captain Gul said, “Say it’s okay.” It’s unclear why he didn’t make this call himself, since radio calls are the responsibility of the monitoring pilot.
After six seconds, Azam picked up the radio and uttered a line that ought to go down in history for all the wrong reasons: “Negative sir, we are comfortable,” he said. “We can make it, inshallah.”
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Now descending through 5,000 feet, with a descent rate greater than 4,000 feet per minute and increasing, Captain Gul’s mind still appeared to be elsewhere. “Hold was stuck, this was automatically built-in, I forgot,” he said, discussing previous events instead of the rapidly developing situation in front of him. After a few seconds’ pause, he added to Azam, “He will be surprised [by] what we have done,” referring to the air traffic controller. The controller would end up being very surprised indeed, but probably not in the way Gul intended.
At that moment, Karachi Approach called and said, “Pakistan 8303, disregard, turn left heading 180.” This was probably intended as an order to begin a holding pattern, but the use of the word “disregard” made the message ambiguous.
“Sir, we are comfortable now, and we are out of 3,500 for 3,000, established ILS 25L,” flight 8303 replied. Their actual altitude at that time was 3,900 feet, not 3,500.
This time the controller decided to cut the proverbial bullshit. “Negative, turn left heading 180,” he ordered.
Incredibly, the crew ignored this direct instruction. “Sir, we are established on ILS 25L,” flight 8303 repeated, making no attempt to change course.
In the cockpit, the crew reduced the target airspeed to 225 knots, presumably in an attempt to slow down enough to extend the flaps and slats. These high lift devices increase both lift and drag, enabling flight at lower speeds while also assisting the crew in getting the plane down as fast as possible. However, the flaps and slats have a maximum speed in any given configuration, above which extension is not allowed due to increasing risk of damage from aerodynamic forces.
The Airbus A320 has four different flap/slat settings, called configuration (CONF) 1, CONF2, CONF3, and FULL. The maximum speed for CONF1 is 230 knots, which is likely why the crew selected 225 knots in the FCU. However, the actual speed of the airplane at the time the crew selected CONF1 was 242 knots, which resulted in an immediate “overspeed” warning, consisting of a continuous repetitive chime, red master warning light, and red warning message on the Electronic Centralized Aircraft Monitoring (ECAM) display. Neither pilot acknowledged the warnings.
Then, only one second later, the situation escalated further when the autopilot automatically disconnected due to excessive nose down pitch. In order to maintain a selected airspeed in excess of 200 knots with the landing gear, speed brakes, and flaps extended and the thrust levers at idle, the autopilot was continuously applying more and more nose down pitch to keep the plane in the dive and prevent it from decelerating too rapidly. Shortly after the flaps were extended, the pitch angle reached an astonishing 13.7 degrees nose down, which is the maximum that the autopilot can command. Such an attitude should never be reached in normal flight, and in fact an unintentional pitch down greater than 10 degrees is considered an in-flight upset. The A320’s programming logic assumes that if the autopilot has to command a nose down pitch of 13.7 degrees or more, then something is likely wrong with it, and an automatic disengagement occurs.
Uncommanded disconnection of the autopilot will normally result in a cavalry charge alarm, red master warning light, and “A/P disconnect” warning message on the ECAM. In this case, however, the overspeed warning was already sounding and the master warning light was already illuminated. In order to prevent oversaturation of the cockpit aural environment, the A320 has a built-in hierarchy of alarms organized by relative priority, in which “overspeed” outranks “autopilot disconnect.” Therefore, the cavalry charge alarm was suppressed in favor of the overspeed warning, and the main indications that the autopilot had disconnected were the ECAM message and a change of autoflight status indication on both pilots’ primary flight displays. Neither pilot immediately acknowledged the disconnection, and for a considerable period thereafter it was unclear whether anybody was flying the airplane.
Almost simultaneously with the activation of the overspeed warning and the disconnection of the autopilot, Karachi Approach called the flight and said, “Sir, you are five miles from touchdown still passing 3,500.”
Flight 8303 simply replied, “Roger.” In response, the controller again warned that they were too high, and again, the crew blew him off.
Moments later, at an altitude of 2,230 feet, the descent rate reached an unbelievable 7,400 feet per minute as the plane continued to plunge toward the ground with its engines at idle and almost all the high drag devices extended. A normal descent rate at that point, 5.2 NM from the runway, would have been 1,000 feet per minute or less. A vertical speed of 7,400 feet per minute is essentially unheard of outside of emergency descents following cabin depressurization.
As the descent rate peaked, the situation escalated still further as the ground proximity warning system (GPWS) burst to life, calling out “SINK RATE! PULL UP! PULL UP!”
In response, First Officer Azam pulled his side stick about two thirds of the way back, commanding the plane to pitch up. The airplane reacted quickly as the pitch attitude reached zero degrees within seconds, while the descent rate reduced to “only” 2,000 feet per minute. However, their airspeed continued to increase to a maximum of 261 knots, 31 knots over the speed limit for CONF1, and the unceasing chime of the overspeed warning continued to fill the cockpit.
Meanwhile, as Azam pulled back on his stick, someone retracted the speed brakes and the landing gear, without any kind of callout or cross check.
This was a pivotal moment in the sequence of events, but precious little is known about it. Since neither pilot made any mention of the landing gear at this stage, it can’t even be said with complete certainty who was responsible, let alone what they were thinking. However, subsequent events suggest that First Officer Azam was most likely behind it, as will be seen shortly.
In the seconds following the retraction of the gear, the airspeed dropped below the overspeed threshold with the flaps in CONF1, and the alarm ceased. In response, one of the pilots — probably Captain Gul — extended the flaps further, to CONF2 and then CONF3. The maximum speed with the flaps in CONF3 was 189 knots, but the actual speed of the aircraft at that point was still 232 knots, so the overspeed alarm began to blare again, only three seconds after it stopped.
At that same moment, Karachi Approach interjected with clearance to land. Official documents don’t make it clear whether it was common for the Approach controller to issue a landing clearance, which is normally the responsibility of the Tower controller.
Then, 36 seconds after the landing gear was selected up, at a height of 1,100 feet, First Officer Azam asked, “Should we do the orbit?”
“No, no, leave it,” said Captain Gul. He immediately grabbed his own side stick to take control, but Azam continued to make inputs for four more seconds before apparently realizing that Gul was now the pilot flying. Such a transfer of control should be accompanied by a formal handover callout, which was not made.
This exchange lends weight to the assumption that it was Azam who retracted the landing gear and speed brakes. Considering that Captain Gul wanted to continue the approach, it’s very unlikely that he was the one who retracted the landing gear. Furthermore, the combination of Azam’s nose up inputs and retraction of the gear was indicative of a possible desire to break off the descent, which Azam verbalized when he asked to perform an orbit. However, the situation was characterized by confusion, because neither pilot was clear about his intentions and neither was adhering to any procedure. If Azam wanted to entirely abandon the approach and go around, then the proper sequence of actions would have been to engage go-around mode, which would cause thrust to increase; verify that the aircraft was climbing; and only then call for retraction of the landing gear, which should be performed by the monitoring pilot at the flying pilot’s command. But on the other hand, if Azam only wanted to perform an orbit to lose altitude before resuming the approach, then retracting the landing gear was unnecessary. Thus in the end, the exact reason why Azam retracted the gear is not clear from the available evidence and will likely never be known with certainty.
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By this point, flight 8303 was descending through 1,000 feet, which is considered the “stabilization gate” for an ILS approach. That means that in order to continue, the flight crew was required to verify compliance with PIA’s stabilized approach criteria. The exact definition of a stabilized approach varies from country to country and airline to airline, but at PIA an approach was considered stable as long as the airplane is on the correct flight path, with only small inputs required to maintain it; the airspeed is above the landing reference speed but not more than 20 knots above; the airplane is in the landing configuration; the rate of descent is not greater than 1,000 feet per minute; the power setting is appropriate for the configuration; and all checklists have been completed. If any one of these criteria is not met, the crew should execute a go-around and attempt the approach again.
At the moment flight 8303 reached the stabilization gate, it met none of these criteria — not a single one! The aircraft was significantly above the glideslope with large inputs required to intercept it; the airspeed was 75 knots too high; the landing gear wasn’t down; the rate of descent was 1,800 feet per minute and increasing; engine power was at idle; and the landing checklist had not been performed. And yet there was no discussion of a go-around, and in fact “failure to go around at the stabilization gate” feels like a hopelessly academic concept in the face of what was, without doubt, a completely deliberate disregard for the very notion of standard operating procedures.
And so the approach continued, growing wilder with every passing second. Having apparently grown sick of the continuous overspeed chime, Captain Gul now said, “Cancel it,” prompting First Officer Azam to silence the warning using the “emergency cancel” button, which is the only way to cancel the continuous repetitive chime. Since the chime indicates an unsafe condition requiring immediate action, it should not normally be cancelled without rectifying the underlying problem, and in fact the “emergency cancel” button is only intended for use in the event of a false alarm.
However, three seconds later, at a height of 750 feet, and only 1.5 NM from the runway, the plane drew close enough to the ground to trigger the “landing gear not down” warning, which is accompanied by a continuous repetitive chime, red master warning light, a red warning message on the ECAM, and the appearance of a red arrow next to the landing gear lever. Consequently, the continuous repetitive chime immediately started back up again, but the crew made no comment. It’s possible that they believed the chime was again triggered by the still-ongoing overspeed condition, but the ECAM message and the red arrow would have told them that this was not the case. The improper configuration also should have been caught by First Officer Azam, considering that he was the one who had put the gear up less than a minute earlier, but for whatever reason he said nothing. Captain Gul, for his part, seemed to be on another planet entirely.
Then, one second after that, the sound of the chime was joined by the blare of the ground proximity warning system as it repeatedly exclaimed, “SINK RATE! TOO LOW, TERRAIN! PULL UP!” These dire warnings were again ignored by the flight crew.
One side effect of the plane’s extreme flight path was that it remained within the GPWS terrain warning envelope until below 30 feet above the ground, at which point the GPWS is inhibited. The ground proximity warning system is capable of generating a “TOO LOW, GEAR” warning if the landing gear is not extended while near the ground, but this warning has a lower priority than “TOO LOW, TERRAIN” and “PULL UP,” which indicate that the plane is about to crash. As a result, the “TOO LOW, GEAR” warning, which would have otherwise sounded, was never heard. Given their propensity for ignoring dire alarms, it’s not clear whether one more alarm would have stirred the crew to action, but the possibility can’t be excluded.
At 14:34, flight 8303 streaked over the threshold of runway 25L, still descending, with a projected touchdown point somewhere close to half way down the runway. Their airspeed was around 200 knots, at least 75 knots above the landing reference speed, and the gear was, needless to say, still not down. Even excluding this last point, of which he was unaware, it’s unclear why Captain Gul thought he could land from this position, but for whatever reason he tried.
In fact, Gul was so eager to land that he attempted to engage both thrust reversers while the airplane was still 7 feet above the ground. The A320, being a sane aircraft, did not allow him to do this; neither thrust reverser deployed, and the disagreement between the positions of the reverser handles and the actual reversers triggered several more warning messages on the ECAM, which were ignored.
Moments later, at 14:34 and 28 seconds, flight 8303 finally touched down 4,500 feet into the 11,150 ft (3,400 m) runway.* With the landing gear retracted, the first parts of the aircraft to touch the ground were the undersides of its low-slung engines, which began to slide along the asphalt, throwing up twin showers of sparks. The plane bounced slightly back into the air at least three and possibly four times,* barely slowing down, even as Captain Gul instinctively hammered on the brakes that were still stowed in the wheel wells along with the rest of the landing gear. Outside, the bottoms of both engines were being subjected to a powerful abrasive force that was rapidly chewing through critical components of the accessory gearboxes, stripping material away like a 3-D printer operating in reverse, deconstructing the engines layer by layer.
First Officer Azam immediately realized something was wrong, and without announcing any kind of control handover he began pulling back on his side stick to bring the plane off the runway again, even as Captain Gul pushed the nose down in an effort to keep the plane on the ground. Gul again attempted to apply max reverse thrust, and the engines responded by decelerating toward idle, but neither reverser was able to deploy. Instead, the №2 (right) engine fire warning suddenly sounded, accompanied by yet another continuous repetitive chime, ECAM message, and red master warning light. Neither crewmember mentioned the warning, which ceased after 7 to 10 seconds, but after 14 seconds on the ground First Officer Azam did finally exclaim, “Take off, sir, take off!”
Two seconds after that, at a speed of 160 knots, Captain Gul advanced both thrust levers to takeoff/go-around (TOGA) power, and the №1 (left) engine responded by spinning up normally, but the right engine’s power level continued to fall. Nevertheless, after slewing slightly to the right, the badly damaged airplane lifted off again at 14:34:46, after sliding across the ground on its engines for no less than 18 seconds.
*Note: According to the accident report, the plane touched down 4,500 feet past the threshold, where the first set of runway scrape marks was found. However, a diagram in the accident report places the start of the first set of scrape marks at a location corresponding to 5,400 feet, not 4,500. These scrape marks at 5,400 feet are verifiably visible on a video of the runway inspection after the accident, with their position confirmed by cross-referencing runway markings. However, the video appears to show possible scrape marks in the vicinity of 4,500 ft as well. Additionally, an anonymous Pakistan CAA official told Pakistan’s Express Tribune newspaper that the left engine touched down at 4,500 feet and the right engine touched down at 5,500, which does not correspond to the video — which shows marks from both engines in both locations — but is nevertheless the only official mention of the clearly obvious scrape marks in the mid-5,000-foot range. As such I believe that the aircraft most likely did touch down at 4,500 feet, but that it may have touched down five times — including once around 5,400 feet — and not four times as stated in the official report.
In the control tower, the astonished Tower controller watched as flight 8303 slid, spewing sparks, for nearly a kilometer before somehow lurching back into the air. Almost immediately, he called the Approach controller, who didn’t have a direct view of the runway, to report what he had seen: “He did not put the gears down, going up after touching,” he said.
“Where is he now?” the Approach controller asked.
“Now over the threshold, stop way,” said the Tower.
“What do you mean, going up!?” the incredulous Approach controller replied. In the background, one of the pilots could be heard transmitting, “Pakistan 8303, going around!”
On board the aircraft, the situation was fluid and critical. The left engine was propelling the airplane upward into a steady climb, but the right engine remained at idle thrust because damage to accessory components had caused a loss of power to the engine control unit, as a result of which the command for TOGA power could not be transmitted to the engine until backup power automatically kicked in. The damage had also knocked out the №2 engine-powered AC generator, which together with the corresponding №1 generator supplies the airplane’s electrical system. The system automatically reconfigured to run all equipment off the №1 generator alone, but given that the №1 engine had suffered similar damage, its days were also numbered.
As flight 8303 climbed through 59 feet, the GPWS became active again, and briefly issued a “TOO LOW, GEAR” warning. In response, one of the pilots rapidly selected the gear lever down then up, apparently in a moment of confusion about where the gear was positioned. However, neither pilot made any comment about the landing gear at this stage.
By the time the flight reached 442 feet, the №2 engine control unit was back online, and miraculously, the right engine finally spooled up to TOGA power as had been commanded almost 25 seconds earlier. However, a much bigger problem was now developing, which was that the prolonged slide across the runway had worn several gaping holes in various oil lines in both engines. By 14:35 and 15 seconds, the left engine oil quantity had fallen by 75% and the right engine oil quantity by 67% as oil poured out through the breaches. Without lubricating oil, tightly fitted rotating components would contact each other and seize up within minutes. Possibly as a result of this process, both engines recorded elevated vibration levels before the engine vibration parameters became invalid due to possible sensor damage. Furthermore, at 14:35:33, a “№1 engine low oil pressure” warning was received, accompanied — once again — by a continuous repetitive chime and master warning. This time, the crew appeared to notice as someone cancelled the warnings within five seconds, at which time the №2 engine low oil pressure warning also triggered, setting off the continuous chime yet again.
By this time the aircraft had managed to climb back to 2,160 feet, and power in both engines was reduced toward 40% in order to level off and reduce their speed. Having momentarily stabilized the situation, the crew transmitted, “Request heading for Pakistan 8303, we would like to come again for ILS 25L.”
“Roger, turn left heading 110, climb 3,000,” the Approach controller replied.
At the same time, the Approach controller remained on the phone with the Tower controller, trying to get a better sense of the situation. “What happened?” he asked.
“He had not put the landing gears down,” said the Tower. “I have declared full-scale emergency.”
“For the time being…” Approach started to say.
“He touched and there was fire, belly landing type, then went up,” the Tower continued.
“Okay,” said Approach. “I was telling him to discontinue.”
“Ask him whether gears were down or not,” the Tower said. “I saw those were not down.”
“Okay,” said the Approach controller. But he never did ask the crew about the gear-up landing.
Meanwhile, flight 8303, climbing to 3,000 feet as cleared, managed to reach only 2,670 feet before the left engine began to lose power, slowly spooling down from the commanded power setting. Most likely, the engine had seized due to the lack of lubricating oil. But, incredibly, the words that came out of First Officer Azam’s mouth were, “Thrust lever number two idle, move number two idle!”
In response, the crew reduced power on the right engine to idle, even though this engine was working and it was the left engine that had failed. In fairness, the right engine had earlier generated a fire warning and failed to respond to the command for TOGA thrust, but these indications were no longer present.
Seconds later, rotation of the left engine slowed below the threshold required to power its AC generator. Since the №2 generator had already been knocked offline, the loss of the №1 generator caused a complete loss of electrical power, and both flight recorders ceased recording. All critical instruments and fly-by-wire computers were temporarily transferred to battery power. Detecting the loss of both generators, a contingency measure automatically kicked in to deploy the emergency ram air turbine, known as the RAT, which drops from the underside of the fuselage and generates electricity by windmilling in the airstream. Eight seconds after the loss of electrical power, the RAT enabled its partial restoration, causing the critical systems to switch back off battery power. The cockpit voice recorder resumed recording, but the flight data recorder did not, because it was not hooked up to the emergency electrical bus, which was by design due to its high power draw.
Flight 8303 was now half way through its circle back to the runway and in a dire emergency, with no power from either engine. Although the flight data recorder died before the switch could be recorded, the flight controls also presumably entered alternate law — a concept hopefully familiar to some readers — in which many of the Airbus’s flight envelope protections were lost, including stall protection. The A320 normally does not allow inputs that would lead to a stall, actuating the controls as needed to prevent the angle of attack from reaching the stall threshold regardless of what the pilot is doing. However, with the loss of both electrical and engine power, this protection could no longer be maintained. Instead, if the angle of attack approached the stall threshold, an aural “STALL” warning would be triggered, urging the crew to take action.
As the aircraft tried to maintain 3,000 feet with no forward thrust, its speed dropped precipitously, and the angle of attack began to rise toward the stall point, at which the plane would no longer be able to hold itself in the air. In the cockpit, both pilots were manhandling the controls simultaneously, resulting in several aural “DUAL INPUT” warnings, followed seconds later by “STALL! STALL!” In response, the crew pitched down, reducing the angle of attack and silencing the stall warning, but now the plane was in a descent, dropping through 1,900 feet while still miles from the runway. Growing desperate, Captain Gul asked where the runway was located, and First Officer Azam managed to spot it, but they were running out of time.
Noticing the loss of altitude, the Karachi Approach controller called and said, “Pakistan 8303, you are dropping altitude 2,000.”
“Uh, just give me 2,000,” Azam replied.
In the background, a continuous repetitive chime again sounded, the reason for which was not determined due to the absence of flight data. At this point it almost didn’t matter. In any case, after six seconds, Captain Gul said “Close it,” and the warning was cancelled.
At that moment, one of the pilots apparently discovered, upon glancing at the engine parameters, that engine №2 was in fact still running, and had been all along, albeit at idle. A short discussion ensued, after which the №2 thrust lever was advanced — and lo and behold, the engine began to spool up, its high-pitched whine cutting through the background noise on the cockpit voice recording.
Karachi Approach called again, reporting that their altitude was still showing 1,800 feet and descending. “Copied, we are maintaining, trying to maintain,” Azam replied.
Azam must have also been looking at an abnormal checklist, because he now informed Captain Gul that the minimum speed to power the RAT was 140 knots, and that they must maintain at least this speed or they would lose everything. Moving further down the checklist, which presumably related to dual generator failure, he suggested that they turn both generators off and back on again. This would not have solved their problem, which was that the undersides of both generators had been turned into a several-thousand-foot-long smear across runway 25L.
At that moment Captain Gul suddenly realized their earlier mistake. “You had selected №2 to idle, whereas engine №1 was gone,” he said.
“Yes,” said Azam, who had plainly already realized this.
Seconds later, however, their luck ran out. A series of bangs were suddenly heard as the №2 engine began to break down, presumably also due to the lack of lubricating oil. Captain Gul asked what the noises were, to which First Officer Azam said, “Reduce the speed!”
The banging sounds were most likely associated with a compressor stall or surge, which occurs when airflow through the engine is disrupted and air momentarily shoots forward from the highly pressurized combustion chamber. The correct response is to reduce power until the surging stops, which is what Azam was suggesting. Power in engine №2 was subsequently reduced to 65%, and the banging ceased. Nevertheless, the engine was on its last legs, and 30 seconds later it began to spool down, just like the left engine had.
Now without power and with no hope of regaining any, the plane began to descend and decelerate more rapidly than before. Intermittent “STALL” warnings were heard as they flirted with the edge of disaster. Recognizing the alerts, First Officer Azam urged Captain Gul to increase their speed to prevent the stall, but Gul simply replied, “How would I increase speed!?”
With no engine power, the only way to increase speed was to pitch down. If they didn’t pitch down, their speed would steadily drop and the angle of attack would steadily increase until they stalled and fell from the sky.
Looking for any sort of plan B, Azam asked, “Do we have Faisal Base,” referring to a nearby military airfield — but it was already behind them.
Flight 8303 began to turn left for an early base leg to line up with runway 25L, without clearance from air traffic control. “[You] appear to be turning left,” the Approach controller said, observing the deviation.
“We will be proceeding direct sir, we have lost engines,” Azam replied. They were now at 1,500 feet and falling fast.
“Confirm you are carrying out belly landing?” the controller asked.
“Negative sir,” said Azam.
In response to the query, Gul asked whether the landing gear was extended, a question he maybe should have asked several minutes earlier. Azam confirmed that the gear was up, then selected it down. The rumble of the gear extension was heard on the CVR.
“Cabin crew to be seated,” Gul said.
Picking up the public address microphone, Azam said, “Cabin crew to your station for landing.” They were at 700 feet, two thirds of the way through the base turn, with the runway in sight, but their airspeed was still dropping.
Seconds later, stall warnings again began to blare. But this time, they were coming in low over densely populated suburbs of Karachi, and if they pitched down they would strike buildings. Instead, Captain Gul simply shouted, “Mayday, mayday, mayday,” and Azam keyed his microphone and broadcast the same to air traffic control. This would be the last anyone heard from flight 8303.
With the warning blaring continuously, the plane began to stall, descending ever faster toward the city below, its nose pitched high in the air in a desperate but futile attempt to maintain altitude. The approach controller could be heard in the background advising that both runways were available for landing, but the crew did not reply.
“Don’t take flaps, don’t take flaps!” Gul exclaimed, continuing his left turn, coming almost into line with the runway — but it was too late.
At 14:40 and 18 seconds, Pakistan International Airlines flight 8303 began to strike rooftops along a dead-end street in Karachi’s Model Colony neighborhood, just 1,400 meters short of the threshold of runway 25L, and only one block from open terrain. Proceeding down the street, the wings sheared the roofs off several buildings, throwing masonry in every direction, before the left wing plowed into the side of a third floor apartment, triggering a massive explosion. The entire plane pivoted to the left, crashed to the street level, and plowed into numerous cars and buildings, sending burning debris careening through the narrow chasm formed by the tightly packed houses. Within just 100 meters, the remains of the airplane came to an abrupt stop, piling into the terminus of the dead-end street, up against the back wall of a school.
By the time the plane came to a halt, the narrow street was choked with wreckage, smoke, and flames, strewn with the battered remains of cars and piles of toppled masonry. Witnesses rushed from nearby buildings to look for survivors, but most were beaten back by the intensity of the fire. Nevertheless, by some miracle, not everyone aboard the A320 was killed in the violent crash. In the forwardmost section, passenger Muhammad Zubair awoke soon after impact to find himself in smoke-filled darkness, surrounded by screams and shouts from others trapped somewhere in the black. In a stroke of good fortune, he managed to spot a patch of light and hauled himself toward it, then jumped three meters down to the street through bursts of fire before being helped to safety. Simultaneously, another passenger, Zafar Masud — the president of the Bank of Punjab, one of Pakistan’s largest financial institutions — was pulled to safety by bystanders with only moderate injuries, escaping from business class seat 1C. Masud later stated that his seat was ripped from plane, slid across a third floor rooftop, then fell onto a parked car as he was still strapped inside it. Only later would he learn that he and Zubair were the only survivors — all 97 other passengers and crew perished in the impact and the fire that followed.
On the ground, 18 buildings were damaged in the crash, but due to various factors none completely collapsed, which likely saved the lives of many bystanders. In addition, most of the men in the neighborhood were not home, having gathered at a nearby mosque for Friday prayers. Eight people on the ground were taken to hospital with injuries ranging from moderate to severe, mostly women and children, including three teenage sisters who were at work cleaning a top floor apartment when it was struck by the plane. All were burned over more than 50% of their bodies and were found in critical condition. Unfortunately, the youngest of the three, 13-year-old Naheeda Khaskheli, succumbed to her injuries nine days after the crash, bringing the final death toll in the disaster to 98.
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The initial reaction to the crash was marked by confusion as experts and observers struggled to piece together the disparate clues available. Photographs of damage to the bottom of the engines and air traffic control transcripts mentioning a belly landing and engine failure led to early speculation that the plane had landed with its landing gear stowed, followed by a go-around and loss of both engines. This turned out to be broadly correct, although many early discussions assumed that the initial belly landing was intentional, when it was not. The outbreak of a pilot licensing scandal — much more on that later — also led to speculation that the pilots were improperly qualified, but this turned out not to be the case either.
Although investigative updates in the first weeks fleshed out most of the basic outline of the flight, many unanswered questions remained until the Aircraft Accident Investigation Board (AAIB) of Pakistan released its long-awaited final report in February 2024. What the report revealed was a story of negligence on a colossal scale.
The immediate circumstances for the accident were created when the flight crew, distracted by non-pertinent conversations, failed to conduct an approach briefing that would have revealed the presence of a holding pattern in their FMS flight plan. This conversation continued until below 10,000 feet, in violation of the sterile cockpit rule, which prohibits activities not related to the immediate operation of the aircraft below this altitude. This likely contributed to the pilots’ failure to realize that they were not descending fast enough to arrive at the proper altitude by the SABEN approach fix unless the holding pattern was completed. Had the crew recognized this problem earlier, they could have engaged Open Descent mode before reaching MAKLI, which would have allowed them to descend to 3,000 feet and intercept the glideslope from below at SABEN, as the designers of the approach procedure intended.
Instead, the crew demonstrated a lack of situational awareness when they armed the localizer and glideslope modes before ensuring that there were enough track miles remaining to descend safely. Subsequently, the localizer mode engaged and the programmed holding pattern was cancelled, leaving the aircraft almost twice as high as it should have been. This should have caused the crew to determine that a straight-in approach could not be safely completed and that they would need to circle until they had descended to the proper altitude. But instead, in a serious error of judgement, Captain Sajjad Gul decided that they could continue the approach.
As the approach progressed, the crew were forced to use pitch attitudes, speeds, and descent rates that were highly abnormal for their phase of flight in order to reach the desired flight path. Despite this, there was no discussion of these deviations and neither crewmember articulated any sort of plan for how the maneuver would be accomplished. The maximum speed with flaps extended was repeatedly exceeded and the overspeed warnings were ignored. The flight crew did not communicate with each other about what they were doing, nor did they verbalize any of the required callout items, such as configuration changes, flight mode changes, and so on. It’s not even clear who was behind the extraordinarily rapid descent. Although First Officer Azam was nominally the pilot flying, the roles of the flying and monitoring pilots were imprecisely defined and both pilots could be heard on the radio at various points. No effort was made to clearly delineate who was responsible for what.
This ad-hoc cockpit atmosphere likely laid the groundwork for the pivotal mistake — the retraction of the landing gear. Normally, configuration changes should be carried out by the non-flying pilot, in this case Captain Gul, at the command of the flying pilot. However, evidence indicates that First Officer Azam retracted the gear himself, even though he was pilot flying. Furthermore, as previously discussed, he did not call out the retraction or explain his intentions. His actions immediately followed a ground proximity warning, but the warning was not explicitly acknowledged by either pilot, nor did anyone suggest a course of action in response to it. Therefore, while Azam may have retracted the landing gear because he wanted to call off the approach, there was no obvious way for Gul to know this. In fact, Gul wanted to continue the approach, even in direct violation of a perfectly clear ATC instruction to orbit.
The situation further devolved as the aircraft approached the runway. Captain Gul took control without conducting a proper handover or clarifying what Azam’s new duties as non-flying pilot would be. The uncommanded disconnection of the autopilot went unacknowledged and for some time nobody appeared to be flying the airplane. Nobody ever called for the landing checklist, the most basic step to prepare for landing, nor did Gul ever inquire as to whether the plane was properly configured. Even more inexplicably, Azam never warned Gul that he had retracted the landing gear, even though he presumably knew it was in the “UP” position, having just put it there himself! Perhaps he thought that Gul would realize the approach was unsafe and go around, but if so, he never mentioned it. And besides, Gul could not have been unaware that he was doing something dangerous — rather, all indications are that safety was simply immaterial to his thought process.
As for why Gul himself didn’t realize the gear was stowed, there are a number of possible reasons. Most likely, he was focused on maneuvering the aircraft to land, tunnel vision creeping in as he closed in on his target. Bringing the aircraft down from such an unusual position would have required intense concentration and it’s unlikely he was taking the time to conduct an instrument scan. This could also be why he failed to notice the appearance of the landing gear warnings on the ECAM display. The fact that the aural “TOO LOW GEAR” warning was suppressed by concurrent “TOO LOW TERRAIN” annunciations was unfortunate and a possible contributor, but the hierarchy of GPWS warnings would never have become an issue if the approach was conducted in a sane manner.
In any case, by the time the plane crossed the runway threshold, no one had verified that they were ready to land and they were not on track to land within the touchdown zone. Due to the steep descent, they were far above the normal landing speed, and with touchdown occurring fully 4,500 feet down the runway, the possibility of a runway overrun was real even if the gear had been down. In fact, an Airbus study found that the plane could have been stopped on the runway if the gear was down and maximum manual braking and reverse thrust were applied. However, this implies that if anything short of maximum braking were used, the plane may well have run off the end, with uncertain results. The risk of a runway overrun in this situation should have been apparent to any sufficiently experienced pilot, but Gul insisted on putting the aircraft down anyway. His attempted actuation of the thrust reversers while the airplane was still in the air underscores the urgency with which he believed he needed to stop, and indicates that he may indeed have been aware of the danger.
What’s less clear is whether Gul understood, as they slid across the runway, that the gear was not down. At no point in the flight, from the landing onwards, did he make any comment that would suggest he was aware of what happened. In fact, as the plane was sliding, he attempted to apply the wheel brakes as he would during a normal landing, and he only released them when the plane lifted back off the runway. First Officer Azam, on the other hand, was aware that something was wrong almost immediately, since the flight data recorder captured him pulling his side stick back in order to climb almost from the moment of touchdown. However, he never explained his concerns to Gul, merely shouting “take off!” instead.
The decision to take off after sliding across the runway for 18 seconds was ill-advised and may have sealed their fate. Standard operating procedures prohibit going around after reverse thrust is selected, which had already occurred, even though the reversers didn’t deploy. Furthermore, it’s plainly unwise to take off with an active engine fire warning. On the other hand, however, some basic napkin math suggests that they may have been doomed as soon as they touched down, regardless of whether they committed to the belly landing or not. The final report states that when Azam called for the go-around after 14 seconds on the ground, they had only decelerated from 195 knots to 160 knots, which was still well above the normal touchdown speed. By that time they had been sliding for around 3,200 feet, with some part of the airplane in contact with the ground over two thirds of that distance. All things considered, this deceleration was rather paltry, because as it turns out, sliding is not as efficient as braking. Furthermore, the spoilers did not automatically deploy, and could not deploy, because there was no weight on the wheels. Normally, the A320’s spoilers deploy automatically on touchdown in order to “spoil” the lift from the wings and force the weight of the airplane down onto the landing gear, increasing the effectiveness of the brakes. But with the gear stowed, the spoilers couldn’t deploy, and with such a high airspeed, the wings would have continued to generate lift, causing the airplane to skim across the runway surface rather than fully settling onto the engines.
By the time flight 8303 lifted back off the ground, only 2,500 feet remained until the end of the 11,150-foot runway, plus a 1,000-foot paved overrun area. Having decelerated only 35 knots in the first 3,200 feet, it seems unlikely that they could have lost the other 160 knots in the remaining 3,500 feet with no means of braking available. The airplane most likely would have continued beyond the end of the paved surface. If it remained in motion for more than 600 feet after that, it would have struck a four-lane road, followed 100 feet beyond that by a large irrigation canal. Possible outcomes after that point are purely speculative, but probably bad.
Due to the complex nature of the damage incurred during the belly landing, investigators were unable to determine whether the plane could have landed safely after the go-around. Although the pilots undoubtedly made the situation worse by reducing power to the wrong engine after the loss of thrust in №1, the importance of this error to the outcome was uncertain. In theory, if the right engine had not been left at idle power for a full minute after the failure of the left engine, then they might have had enough thrust to clear the Model Colony neighborhood and reach the runway. But on the other hand, there was no guarantee that increasing power on the right engine earlier wouldn’t have caused it to fail earlier as well, resulting in the same outcome.
One interesting question not discussed in the final report was whether the crew could have anticipated that they would not reach the runway, forcing them to select a landing site that would have mitigated the consequences of the crash. One can’t help but notice that the actual crash site in Model Colony was barely a stone’s throw from relatively open terrain to the right of the flight path, including a wide boulevard and a field. Had the pilots straightened out a few seconds earlier instead of attempting to complete the base turn to the runway, the plane might have impacted in this field instead of striking buildings. But we will never know for sure whether such an opportunity existed. And even if it did, the situation faced by the crew was so overwhelming that the impact point was probably quite far down their list of immediate considerations.
Another question that has been raised since the accident was whether the controllers could have done more to prevent the disaster. Most notably, the approach controller chose not to double down after the crew ignored his instructions to orbit, and in fact he issued a landing clearance shortly afterward. The accident report contained no commentary about the appropriateness of the decision, but an air traffic controller who I asked for comment came to the conclusion that it was ultimately a judgment call — if the crew seemed insistent that they could land, and there was no conflicting traffic, most controllers would hesitate to overrule them.
Oddly, the official accident report focused more on the Approach controller’s failure to inform the crew that they had landed with the gear retracted. The AAIB went so far as to list this omission as a contributing factor to the accident. However, while it was true that the Approach controller promised to pass on the Tower’s observation, and that he never actually did so, this promise wasn’t made until after the plane was already back in the air. There’s no evidence that the crew would have done, or even could have done, anything differently with this information at that point in the flight. In fact, given that the AAIB chose not to speculate on alternative outcomes after the go-around, I would go so far as to say that the elevation of this point to a contributing factor was inappropriate.
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All things considered, while the actions of air traffic control may or may not have left something to be desired, the performance of the flight crew could only be described as shambolic. They made almost none of their required callouts, performed no checklists, ignored standard procedures, intentionally disregarded ATC instructions, triggered and ignored almost every possible top-level warning, and generally operated the airplane in a reckless and unsafe manner, without regard for human life. It would not be an exaggeration to describe their behavior as among the worst displays of airmanship ever recorded in a large commercial airliner. So who were these men? Why would they act this way?
Starting with Captain Gul, his records revealed a number of concerning details. Investigators learned that before he upgraded to the A320, he was considered for a supervisory position on the turboprop ATR-42/72, but was rejected due to a “lack of technical knowledge and general awareness.” But the real bombshell was in his psychological evaluations, which were reviewed by an independent psychiatrist after the accident. Using unusually harsh language, the psychiatrist wrote, “He was of bossy nature, firm, dominant and overbearing. He had below average intelligence. He tend[ed] to have little regard for the authority. He had low mechanical comprehension with low comprehension of space relations. His level of stress tolerance was also quite inadequate.” Most of these qualities were readily apparent on flight 8303, from his questionable decision-making, to his disregard for the input of others, to his insistence on landing the airplane from a nearly impossible position.
First Officer Usman Azam was not described with such flowery terminology, but his training records revealed that his airmanship skills were, at best, marginal. During his initial simulator check on the ATR in 2014, he barely scraped through the segments on engine failures, emergency procedures, and procedural execution with the lowest possible passing grade, “satisfactory with briefing.” In practice this means that his performance was somewhat less than satisfactory but the instructor was confident enough to sign off after discussing the mistakes with the trainee. A large number of items graded “satisfactory with briefing” can be a sign that a pilot is struggling and needs additional training. But Azam clearly didn’t get any, because on his initial line check months later, the number of items graded “satisfactory with briefing” had increased to five. This resulted in his placement under observation by a Pakistan Civil Aviation Authority inspector, whose findings delayed his promotion to First Officer on the A320.
Considering the above, the pairing of an overconfident captain with a struggling first officer probably didn’t improve the cockpit dynamic. But it was far from an explanation for how the flight went so badly awry.
One tempting answer was that the crew’s behavior could have been the result of alcohol intoxication. In Pakistan, breathalyzer tests are mandatory for pilots before every flight, but neither Gul nor Azam was tested before flight 8303, in breach of regulations. But when investigators received the crew’s toxicology test results, they showed conclusively that neither pilot had ingested alcohol or drugs before the crash, and the possibility was ruled out.
Instead, investigators raised an intriguing and novel question: could the crew’s abstention from food and drink in observance of Ramadan have induced similar impairment?
In order to find out, investigators conducted two studies: one to measure the performance of dehydrated pilots against a control group; and a second study measuring the performance of pilots with low blood sugar due to fasting, against pilots impaired by alcohol, pilots affected by excessive noise, and a control group.
The results of the studies showed, first of all, that dehydration resulted in a significant increase in the number of flight performance deviations; and second, that the impact of low blood sugar on flight performance was greater than that of excessive noise and comparable with alcohol intoxication. These findings were perhaps not surprising to anyone who has ever tried to operate heavy machinery while hungry, but this was to my knowledge the first time an air accident investigation body had studied the effects of fasting on pilot performance in connection with an aircraft accident. The results largely affirm the validity of existing rules surrounding pilot nutrition. In the European Union, for example, airlines are required to “define the time frames in which a regular meal should be consumed in order not to alter the human needs for nutrition without affecting the crew member’s body rhythms.” Pakistani regulations lacked this level of specificity, but PIA did have a rule on the books stating that “flight crew[s] shall have regular meals on duty.” Notably, while this rule technically prohibited any form of fasting, it did not specifically mention what pilots should do during the month of Ramadan. As a result, many pilots appeared to believe that observance of Ramadan was permitted.
In the end, the AAIB determined that no scientific basis yet existed that would allow them to say with reasonable confidence that dehydration and low blood sugar caused the pilots to act in the way that they did. For that reason, while they did recommend reforms in this area, they stopped short of concluding that the flight crew crashed the plane because they were “hangry.”
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All of this having been said, merely acknowledging the pilots’ personal failings and physiological pressures is neither an answer nor the end of the story. No pilot stoops to such levels simply because they were hungry, or because they woke up on the wrong side of the bed. On the contrary, such disregard for the rules of the air is allowed to arise only under conditions of severe institutional and cultural rot.
The AAIB attempted to address this issue with an in-depth look at PIA’s quality assurance, or rather lack thereof. The way airlines normally catch reckless behavior by flight crews is through a system known in many countries as Flight Operations Quality Assurance, or FOQA. A FOQA program is designed to retrieve data from as many flights as possible in order to review it for exceedances in specified parameters that could indicate undesirable patterns of behavior among company flight crews, such as steep approaches or long landings. Problem areas can then be identified and training refocused.
Although PIA had a FOQA-type program on paper, investigators found that less than 5% of all flights were actually being analyzed, resulting in a sample size too small to be useful. Of the 289 flights flown by Captain Gul in the year before the crash, they found that only 6 had been subject to analysis, even though the data from every flight was available. When the AAIB reviewed this data, they discovered numerous indicators of high speed, high glide path angle, high rate of descent, long flare distance, and GPWS warnings — all the same indicators that were present on flight 8303. In fact, Gul frequently flew unstable approaches, and not once did he ever initiate a go-around. It should probably come as no surprise that flight 8303 was not the first time Gul had attempted such a reckless approach, but the fact that PIA failed to detect his pattern of behavior is disappointing.
The absence of enforcement and feedback is one factor that can contribute to a company culture that tolerates reckless behavior. But it’s far from the only one, and to understand the whole picture, we need to go beyond the AAIB accident report, starting with one of the most well-known aspects of the flight 8303 disaster: the pilot licensing scandal. If you started reading this article to learn more about the scandal, then congratulations for sticking it out through page after page of me not mentioning it. Your gratification will arrive shortly.
To summarize, in 2018, investigators studying a non-fatal accident in Pakistan noticed that the recorded date of the pilot’s licensing exam was on a public holiday when no exams were held. In attempting to figure out where this pilot got his clearly fraudulent license, the inquiry allegedly fell down a rabbit hole leading to the discovery that as many as one third of Pakistani pilots held potentially suspicious licenses. Media reports about this inquiry emerged shortly after the PIA crash, garnering worldwide attention. However, the details of this inquiry have never publicly emerged, and various officials have given wildly differing accounts of its findings. Most reports agree that the inquiry discovered a widespread practice of pilot candidates paying others to take the exams in their place (a problem sadly not restricted to flight academies). As for the raw numbers, one early report claimed that out of 860 active airline pilots in Pakistan, 260 were under suspicion for various reasons, including 150 at PIA, mostly due to cheating on exams. Later reports reduced this number significantly, and more recent sources suggest that only 48 pilots actually had their licenses suspended and that only 7 PIA pilots ultimately lost their jobs. Another source says that 28 pilots were suspected of having entirely faked their purported university degrees, but yet another source put this number at only four. The minister of aviation was also on record claiming that 34 pilots did not sit for any of their eight exams, but this number appears nowhere else. In the end, all we can really say is that some number of Pakistani pilots probably cheated on their licensing exams, but no officials have managed to clarify the matter beyond that. In the absence of such verifiable information, many casual observers gained the mistaken impression that some Pakistani pilots’ licenses were not only fraudulently obtained, but outright fake, in that they had not been trained to fly passenger aircraft. Needless to say, this was not actually the case.
Although the outbreak of the licensing scandal shortly after the crash of flight 8303 led some to draw connections between the two, there was actually no direct relationship. The AAIB found that both of the accident pilots obtained their licenses legitimately and completed all training courses and exams. Still, one might posit that the crash and the scandal are related indirectly, in that both arise from a common cause. Consider the fact that Sajjad Gul, who ignored procedures and frequently flew the A320 in a dangerous manner, had no apparent blemishes on a training record stretching back to the late 1980s. Are we to believe that he never once made a mistake serious enough to show up on that record? Does it perhaps bear mentioning that when Gul first signed up for flight training at PIA, he was declared unfit by PIA’s panel of psychiatrists, only for the panel to be overruled by a federal ombudsman on a technicality? All signs indicate that Gul was a pilot who should have either washed out of training, or been forced to fall into line. And yet…
At its deepest level, the problem is that PIA as an organization is 40% airline, and 60% political patronage system. The airline is considered one of the most overstaffed in the world, which is easily verifiable using numbers that can be found with a five minute google search. In fact, despite having a fleet of only 31 aircraft — less than any notable North American carrier — PIA employs more than 14,500 people. As a randomly selected point of comparison, Icelandic flag carrier Icelandair has 47 airplanes but only 3,000 employees. To reiterate, that’s 50% more planes than PIA with one fifth the staff. Despite this, PIA is increasingly struggling to provide any services at all, with frequent flight cancellations and termination of most international routes. In September 2023, it was reported that only 17 of PIA’s aircraft were actually operational. Also in the fall of that year, gross mismanagement of funds led to the freezing of PIA’s bank accounts, leaving the airline unable to pay for fuel.
This crisis exists in part because PIA is run by a clique of powerful former military officers who hand out positions at the state-run airline to friends and patrons, while smoothing their passage through any checks and balances that may technically exist. It’s not clear what all these extra employees actually do — certainly they aren’t analyzing flight recorder data. But what is clear is that PIA is being used as a ladder for opportunistic individuals to pay their way into Pakistan’s political power structure, and flight safety is secondary. This cynical and transactional culture provides the perfect breeding ground for unscrupulous individuals who cheat on exams and ignore safety regulations with near-impunity.
As a result of PIA’s quality assurance problems and the pilot licensing scandal, the European Aviation Safety Agency suspended PIA’s right to fly to Europe for six months, beginning in June 2020. The United States followed suit weeks later. These suspensions were later extended indefinitely due to insufficient progress, and as of this writing they’re still in place. The US Federal Aviation Administration also downgraded Pakistan’s overall air safety rating in light of the inability of the Pakistan CAA to enforce its own rules and regulations.
In the wake of the disaster, some minor changes have taken place. For instance, PIA has greatly expanded its FOQA system, although its effectiveness remains largely untested. The Pakistan CAA also introduced a new rule recommending that medical examiners observe pilots drinking water or juice during pre-flight medical exams in the month of Ramadan in order to verify that they’re not fasting. PIA adopted this rule and is now enforcing it (allegedly). But what has remained unchanged is the organizational culture within PIA that allowed safety to fall by the wayside in the first place. As of this writing, PIA is still run by powerful military officers, the patronage system is still in place, and corruption is as rampant as ever, all while Pakistan’s institutions continue to unravel in the face of competing societal forces, compromising the CAA’s ability to act as a check on the airlines’ worst impulses. In February 2024, a plan was reportedly finalized to sell the airline as part of an effort to secure a bailout from the IMF, but it’s unclear whether this will result in improvements.
The fact remains that since 2010, there have been four major, fatal airline accidents in Pakistan, and so far there’s little reason to believe that this pattern will stop with flight 8303. If there’s one bright spot, then it might be crash survivor Zafar Masud, who announced his intention to set up a largely self-funded non-profit to advocate for transportation safety in Pakistan. But while Masud may have found his new calling in life, his will be an uphill battle against forces both human and entropic. And as for the people of Pakistan, who have for so long been failed by their own institutions, a difficult and winding road no doubt awaits before the airline that bears their flag can earn back the public’s wounded trust.
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