Bhoja Air Flight 213
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Bhoja Air Flight 213 was a domestic scheduled passenger flight operated by
Pakistan Pakistan ( ur, ), officially the Islamic Republic of Pakistan ( ur, , label=none), is a country in South Asia. It is the world's List of countries and dependencies by population, fifth-most populous country, with a population of almost 24 ...
i airline
Bhoja Air Bhoja Air ( ur, ) was a Pakistani airline based in Karachi, Sindh, Pakistan. The airline was founded in 1993 and operated a small domestic network of scheduled passenger flights. Due to financial difficulties, the airline completely suspended o ...
from
Karachi Karachi (; ur, ; ; ) is the most populous city in Pakistan and 12th most populous city in the world, with a population of over 20 million. It is situated at the southern tip of the country along the Arabian Sea coast. It is the former cap ...
to
Islamabad Islamabad (; ur, , ) is the capital city of Pakistan. It is the country's ninth-most populous city, with a population of over 1.2 million people, and is federally administered by the Pakistani government as part of the Islamabad Capital T ...
. On 20 April 2012, the Boeing 737-236A aircraft serving the route crashed in bad weather during its final approach to land. All 121 passengers and 6 crew members aboard were killed. With 127 deaths, it remains as the second deadliest air disaster in Pakistan. The crash was caused by the crew's inadequate flight management during adverse weather conditions. The flight crew were not trained adequately and properly on the automated system of the Boeing 737-236A, a more advanced version of the Boeing 737-200 series, and didn't retain sufficient knowledge on the correct procedures for handling an aircraft in bad weather conditions. Additionally, Bhoja Air's lack of oversight and multiple errors within Pakistan CAA's monitoring system of Pakistani airliners further contributed to the accident.


Accident

The aircraft was operating a domestic scheduled flight from
Jinnah International Airport Jinnah International Airport ( ur, جناح بین الاقوامی ہوائی اڈا) , formerly Drigh Road Airport or Karachi Civil Airport, is Pakistan's busiest international and domestic airport, and handled 7,267,582 passengers in 2017 ...
,
Karachi Karachi (; ur, ; ; ) is the most populous city in Pakistan and 12th most populous city in the world, with a population of over 20 million. It is situated at the southern tip of the country along the Arabian Sea coast. It is the former cap ...
, to
Benazir Bhutto International Airport Benazir Bhutto International Airport ( ur, , ) is a defunct airport which formerly served the Islamabad-Rawalpindi metropolitan area. It was the second-largest airport by air traffic in Pakistan, until 3 May 2018 when it was replaced by the ...
,
Islamabad Islamabad (; ur, , ) is the capital city of Pakistan. It is the country's ninth-most populous city, with a population of over 1.2 million people, and is federally administered by the Pakistani government as part of the Islamabad Capital T ...
, which was the airline's first evening flight in almost 12 years. It was the inaugural flight of Bhoja Air's second daily service on this route (
Bhoja Air Bhoja Air ( ur, ) was a Pakistani airline based in Karachi, Sindh, Pakistan. The airline was founded in 1993 and operated a small domestic network of scheduled passenger flights. Due to financial difficulties, the airline completely suspended o ...
was earlier closed down amidst financial difficulties in the year 2000, but restarted operations in March 2012). There were six crew and 121 passengers on board. The flight departed from Karachi at 17:05 PST (12:00 UTC) and was due to land at Islamabad at 18:50 (13:50 UTC). The flight was piloted by Captain Noorullah Khan Afridi (58) and First Officer Javaid Malik (53). The flight was uneventful until its approach to Islamabad.


Approach

While approaching Islamabad,
Lahore Lahore ( ; pnb, ; ur, ) is the second most populous city in Pakistan after Karachi and 26th most populous city in the world, with a population of over 13 million. It is the capital of the province of Punjab where it is the largest city. ...
automatic terminal information service Automatic terminal information service, or ATIS, is a continuous broadcast of recorded aeronautical information in busier terminal areas, i.e. airports and their immediate surroundings. ATIS broadcasts contain essential information, such as current ...
(ATIS) broadcast the weather information in and around Lahore, including the Islamabad area. The broadcast stated that clouds and thunder were present in Islamabad and a dust storm warning was issued around Lahore area. First Officer Malik asked the Captain on whether they should divert to
Peshawar Peshawar (; ps, پېښور ; hnd, ; ; ur, ) is the sixth most populous city in Pakistan, with a population of over 2.3 million. It is situated in the north-west of the country, close to the International border with Afghanistan. It is ...
, but Captain Afridi refused, stating that "God will help us". Approximately a minute later, he noticed that
squall line A squall line, or more accurately a quasi-linear convective system (QLCS), is a line of thunderstorms, often forming along or ahead of a cold front. In the early 20th century, the term was used as a synonym for cold front (which often are accompa ...
had formed in the area. He started to become pre-occupied with the weather. First Officer Malik gave multiple information regarding the weather condition, however due to the pre-occupied state of Captain Afridi, the Captain ignored them all. Controller in Lahore cleared Flight 213 to descent. The seatbelt sign was turned on due to a possible turbulence and the crew decided to discuss the weather again. Following the discussion, Captain Afridi finally concluded that the flight must land at Islamabad regardless of the weather condition. As Flight 213 became nearer to the squall line, Captain Afridi became increasingly worried. Subsequently, he increased the airspeed to . First Officer Malik then stated that the flight would enter the squall line. Meanwhile, the aircraft began to experience
turbulence In fluid dynamics, turbulence or turbulent flow is fluid motion characterized by chaotic changes in pressure and flow velocity. It is in contrast to a laminar flow, which occurs when a fluid flows in parallel layers, with no disruption between ...
. Captain Afridi contacted Islamabad and asked on whether there was a gap between the squall line as he intended to penetrate it from the west side. The controller in Islamabad initially answered that there was no gap between the line, but then a very small gap was observed in the south. Captain Afridi responded that they would try to penetrate through the line. The flight crew then asked the cabin crew to ask the passengers to occupy their seats as the turbulence began to intensify. First Officer Malik later suggested that they should go towards the right (east) to avoid the storm system, but Captain Afridi refused, insisting that they should land at Islamabad. Flight 213 descended through and levelled off at . Even though no formal approach briefing had taken place, First Officer Malik stated that the aircraft's approach preparation had been set. The
autopilot An autopilot is a system used to control the path of an aircraft, marine craft or spacecraft without requiring constant manual control by a human operator. Autopilots do not replace human operators. Instead, the autopilot assists the operator' ...
and auto-throttle were engaged and the aircraft was cleared to descent further. Islamabad ATC then gave another weather update to the crew, stating that there was light drizzle in Islamabad with gusts of up to , which was acknowledged by the crew. Captain Afridi stated that the squall line had arrived in Islamabad and that they would be flying at a very close distance with it. A few minutes later, he noticed that the sky suddenly had become dark, meaning that Flight 213 was entering the squall line. The aircraft continued its descent. After being cleared by the ATC for an ILS approach to runway 30, the crew configured the aircraft for landing. The flaps,
slats Super Low Altitude Test Satellite (SLATS) or Tsubame was a JAXA satellite intended to demonstrate operations in very low Earth orbit (VLEO, below 200 km), using ion engines to counteract aerodynamic drag from the Earth's atmosphere which i ...
and the landing gear were extended and the aircraft started to turn after its
lateral navigation In aviation, lateral navigation (LNAV, usually pronounced ''el-nav'') is azimuth navigation, without vertical navigation (VNAV). Area navigation (RNAV) approach plates include LNAV as a non-precision instrument approach (NPA). When combined with V ...
was engaged in the "selected mode", which was later deactivated by Captain Afridi during the middle of the turn. First Officer Malik then stated that the airspeed was at , which was met with surprise from the Captain. Few seconds later, raindrops began to pound the aircraft, further startling Captain Afridi. Captain Afridi became extremely pre-occupied with the changing flight parameters and the effect of the adverse weather condition to the aircraft. Meanwhile, his co-pilot First Officer Malik seemed to be pretty ignorant about the matter. Instead of recommending a
missed approach Missed approach is a procedure followed by a pilot when an instrument approach cannot be completed to a full-stop landing. The instructions for the missed approach may be assigned by air traffic control (ATC) prior to the clearance for the approac ...
, the first officer continued to carry out cockpit checks. Flight 213 then levelled off at and the autopilot captured the
glideslope Instrument landing system glide path, commonly referred to as a glide path (G/P) or glide slope (G/S), is "a system of vertical guidance embodied in the instrument landing system which indicates the vertical deviation of the aircraft from its o ...
. With a bank angle of approximately 5 degree to 20 degree to the right, the aircraft entered its
final approach In aeronautics, the final approach (also called the final leg and final approach leg) is the last leg in an aircraft's approach to landing, when the aircraft is lined up with the runway and descending for landing.Crane, Dale: ''Dictionary of ...
phase and the crew put the aircraft into a descent.


First downdraft

The rain rapidly intensified, pounding the aircraft at an extreme rate. The aircraft was struck by a downdraft and because of it the pitch started to increase. As the autopilot tried to maintain the glideslope, the airspeed decayed. The thrust was increased albeit not sufficient enough. The GPWS alarm blared, alerting the crew about the presence of windshear. Captain Afridi yelled "no! no!" and his co-pilot First Officer Malik asked the captain to go-around. The downdraft finally dissipated and the crew decided to manually control the aircraft. The autothrottle, however, remained in engaged position. By this time, the airspeed had decreased from and the aircraft had deviated from the glideslope. Due to the incident, the crew became confused and pre-occupied with the weather condition. The
TAWS In aviation, a terrain awareness and warning system (TAWS) is generally an on-board system aimed at preventing unintentional impacts with the ground, termed "controlled flight into terrain" accidents, or CFIT.Federal Aviation AdministrationInsta ...
"Whoop Whoop!" alarm sounded, but the crew didn't give any response to it. The flight continued its approach. First Officer Malik maintained his communication with the controller while Captain Afridi was at the controls. Both the pitch angle and the thrust were decreased.


Second downdraft

The aircraft encountered another downdraft. This time, it was more severe than the last, reaching as high as . The "Whoop whoop Pull Up!" alarm blared, causing Captain Afridi to pull the
yoke A yoke is a wooden beam sometimes used between a pair of oxen or other animals to enable them to pull together on a load when working in pairs, as oxen usually do; some yokes are fitted to individual animals. There are several types of yoke, us ...
. The altitude and the thrust, however, continued to decrease. Due to the landing configuration of the aircraft, the airspeed began to decay again. The downdraft suddenly dissipated in just four seconds. Captain Afridi, who had been struggling to make the aircraft to pitch up, caused the aircraft's nose to rise rapidly. This, in turn, caused the activation of the
stick shaker A stick shaker is a mechanical device designed to rapidly and noisily vibrate the control yoke (the "stick") of an aircraft, warning the flight crew that an imminent aerodynamic stall has been detected. It is typically present on the majority of ...
, warning the crew of an impending stall. Alarmed by the stick shaker, Captain Afridi immediately made a nose down input. The altitude rapidly decreased and the thrust remained at a low setting. Multiple warnings blared inside the cockpit, starting from the GPWS "Whoop whoop pull up!" to the windshear warning. Captain Afridi, now frantic, rapidly pulled up the nose again and causing another stick shaker activation. First Officer Malik shouted multiple times to the captain to get out of the stall condition. Controller in Islamabad later cleared Flight 213 to land, however due to the chaotic situation inside the cockpit the crew never acknowledged the call. Captain Afridi maintained his nose-down input and First Officer Malik could be heard panicking. The GPWS "Whoop whoop pull up" continued to blare inside the cockpit and the aircraft kept descending towards the ground.


Crash

At 18:40 PKT, with an airspeed of and a pitch angle of 0 degree, the aircraft slammed onto the ground with its main landing gears first. It crashed at a distance of from the runway, in the small village of Hussainabad in Rawalpindi, in heavy rain condition. The aircraft exploded and struck a terrace, causing further breakup. The wreckage was spread over radius. All 127 people on board were killed. A following
Airblue Airblue Limited (stylized as airblue) is a private Pakistani airline with its head office on the 12th floor of the Islamabad Stock Exchange (ISE) Towers in Islamabad, Pakistan. Airblue operates scheduled domestic and international flights, the ...
flight landed safely five minutes after the accident occurred. The airport was closed for three hours after the accident due to a lack of fire cover. The emergency crews based at the airport went to the crash site to assist in the firefighting operations there. A total of 100 army personnel were deployed to assist the other rescue personnel. The rescue operation was hampered due to the surge of onlookers at the site. Traffic jam reportedly blocked rescuers from reaching the site in a timely manner. Flights affected by the closure were diverted to
Allama Iqbal International Airport Allama Iqbal International Airport ( ur, , ) is the third largest civilian airport by traffic in Pakistan, after Jinnah International Airport, Karachi and Islamabad International Airport. It serves Lahore, capital of Punjab and second-larges ...
,
Lahore Lahore ( ; pnb, ; ur, ) is the second most populous city in Pakistan after Karachi and 26th most populous city in the world, with a population of over 13 million. It is the capital of the province of Punjab where it is the largest city. ...
. At least four houses were badly damaged due to the crash. However, despite the fact that it occurred in a residential area, there were no casualties on the ground.


Aircraft

The aircraft was a Boeing 737-236, registered AP-BKC, Built as
msn MSN (meaning Microsoft Network) is a web portal and related collection of Internet services and apps for Windows and mobile devices, provided by Microsoft and launched on August 24, 1995, alongside the release of Windows 95. The Microsoft Net ...
23167, it first flew on 13 December 1984 and was delivered to
British Airways British Airways (BA) is the flag carrier airline of the United Kingdom. It is headquartered in London London is the capital and List of urban areas in the United Kingdom, largest city of England and the United Kingdom, with a populati ...
on 7 January 1985 (registration G-BKYI), it was subsequently acquired by codeshare operation Comair (registered as ZS-OLB) in June 1999. The aircraft operated South African domestic routes until late 2010 when Comair retired its 737-200 fleet and it was sold to Bhoja Air in January 2012. The last inspection was carried out on the same day of the accident, exactly prior to its departure. No known defects were recorded.


Passengers and crew

Flight 213 was carrying 121 passengers and 6 crew members. The passengers were consisted of 110 adults, six children and five infants. The nationalities of the passengers were not disclosed. Most were thought to be citizens of Pakistan. According to the manifest, at least 2 military officials, a Station Commander Officer of
Hyderabad Hyderabad ( ; , ) is the capital and largest city of the Indian state of Telangana and the ''de jure'' capital of Andhra Pradesh. It occupies on the Deccan Plateau along the banks of the Musi River (India), Musi River, in the northern part ...
and a squadron leader, were on board Flight 213. A Bhoja Air senior official was also reported to be on board. The
pilot in command The pilot in command (PIC) of an aircraft is the person aboard the aircraft who is ultimately responsible for its operation and safety during flight. This would be the captain in a typical two- or three-pilot aircrew, or "pilot" if there is only ...
of Flight 213 was identified as 58-year-old Noorullah Khan Afridi. According to fellow pilots, he had also worked as flying instructor for
Pakistan Air Force Academy The Pakistan Air Force Academy Asghar Khan ( ur, ) is an accredited three-year military academy which provides undergraduate education to officer candidates for the Pakistan Air Force. The eligible and selected candidates from all over Pakista ...
in
Risalpur Risalpur (Pashto/ ur, رسالپور) is a city in Nowshera District, Khyber-Pakhtunkhwa, Pakistan, on the Nowshera-Mardan Road. It is nearly 45 km from Peshawar and 18 km from Mardan and is located at 34°4'52N 71°58'21E. In a basin so ...
. Before joining Bhoja Air, he had served as a captain of a Boeing 737-400 in
Shaheen Air International Shaheen Air International ( ur, ) was a private Pakistani airline with its head office at Jinnah International Airport in Karachi and was founded by the Shehbai family. It remained Pakistan's second-largest airline until its liquidation in 201 ...
. He had been temporarily trained for the
Boeing 737-400 The Boeing 737 Classic is a series of narrow-body airliners produced by Boeing Commercial Airplanes, the second generation of the Boeing 737 series of aircraft. Development began in 1979 and the first variant, the 737-300, first flew in Februa ...
but the training was eventually discontinued as his supervisors in Shaheen Air International thought that he couldn't operate the automated flight deck in an "effective, efficient and safely" manner. The crew logbook showed that he had accrued a total flying experience of more than 10,000 hours, with 2,027 hours on the Boeing 737-200. However, only 82 hours were on the Boeing 737-236A. The
second in command ''Second in Command'' is a 2006 American action film starring Jean-Claude Van Damme and directed by Simon Fellows. The film was released direct-to-DVD in the United States on May 2, 2006. Plot Commander Sam Keenan (Jean-Claude Van Damme), a decor ...
was identified as 53-year-old Javaid Malik. Before working as a commercial pilot, he had served in the
Pakistan Air Force , "Be it deserts or seas; all lie under our wings" (traditional) , colours = , colours_label = , march = , mascot = , anniversaries = ...
. According to the investigation, he had been paired with Captain Malik since his employment with Shaheen Air International. He later joined Captain Afridi to leave Shaheen Air for Bhoja Air. He had accrued a total flying experience of 2,832 hours, of which 750 hours were on the Boeing 737-200. However, only 82 hours were on the Boeing 737-236A type.


Aftermath

A statement on Bhoja Air's website offered condolences to the affected families and said that it would fulfil its legal obligations under the Pakistani law applicable at the time of the accident. Pakistan Interior Minister Rehman Malik later told news media that the owner of Bhoja Air had been banned from leaving Pakistan in response to the crash. In the immediate aftermath, all hospitals in Islamabad and the neighboring city of Rawalpindi were put into high alert. Crisis centres were set up in Karachi and Islamabad to provide information to the relatives. President
Asif Ali Zardari Asif Ali Zardari ( ur, ; sd, ; born 26 July 1955) is a Pakistani politician who is the president of Pakistan Peoples Party Parliamentarians and was the co-chairperson of Pakistan People's Party. He served as the 11th president of Pakistan ...
cut short his trip to cities in
Punjab Punjab (; Punjabi: پنجاب ; ਪੰਜਾਬ ; ; also romanised as ''Panjāb'' or ''Panj-Āb'') is a geopolitical, cultural, and historical region in South Asia, specifically in the northern part of the Indian subcontinent, comprising ...
and returned to the capital, and he and Prime Minister
Yousuf Raza Gillani Yusuf Raza Gilani (Urdu: ; born 9 June 1952), is a Pakistani politician who served as 18th Prime Minister of Pakistan from 25 March 2008, until his retroactive disqualification and ouster by the Supreme Court of Pakistan on 26 April 2012. He ...
sent condolences to the families of those who died in the accident. The Civil Aviation Authority issued an office order at 9 a.m. the next day, requiring all airlines to transport the bodies of the victims free of cost. Those families who had already paid for the transportation before the order was released were refunded the amount. Bhoja Air announced that family of the victims will be flown to Islamabad. According to government officials, all of the victims will be transported to Pakistan Institute of Medical Sciences for the identification process and next-of-kin will be informed to refer to the institute for the identification and the retrieval of the body. Due to the large number of victims, an additional cold storage was provided to the institute. Two days after the crash of Flight 213, a Shaheen Air International flight suffered a burst tyre during landing in Karachi. Following another aviation incident in Pakistan, authorities conducted a special inspection to every private airliners in the country. Pakistan International Airlines was not included in the inspection as it had undergone such inspection a few months ago. On 30 April, Bhoja Air announced compensation of Rs. 500,000 to the legal heirs of the victims of the Flight 213. However, the compensation is long overdue. The families of the deceased protested outside the office of Bhoja Air in Karachi. On 28 May 2012, Bhoja Air's license was revoked by the
CAA CAA may refer to: Law * Citizenship (Amendment) Act, 2019 of India ** Citizenship Amendment Act protests, Protests regarding the Citizenship (Amendment) Act * Copyright transfer agreement, Copyright assignment agreement, to transfer copyright to ...
, due to failing a requirement under the Pakistani Civil Aviation laws that a carrier must maintain a minimum fleet of three aircraft. Of Bhoja Air's original fleet of 3, one crashed, another was grounded after it developed a fault, leaving only one operational aircraft.


Investigation

Investigations into the crash were opened by the
Civil Aviation Authority A civil aviation authority (CAA) is a national or supranational statutory authority that oversees the regulation of civil aviation, including the maintenance of an aircraft register. Role Due to the inherent dangers in the use of flight vehicles, ...
(CAA) and by the Safety Investigation Board of Pakistan.
Boeing The Boeing Company () is an American multinational corporation that designs, manufactures, and sells airplanes, rotorcraft, rockets, satellites, telecommunications equipment, and missiles worldwide. The company also provides leasing and product ...
is assisting the CAA with the investigation. The
flight data recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to as a "black box", an outdated name which has b ...
was recovered on the same day of the crash, while the aircraft's
cockpit voice recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to as a "black box", an outdated name which has b ...
was recovered from the wreckage on the next day. Both flight recorders were passed to the CAA. and later were sent to the United States for analysis by
Boeing The Boeing Company () is an American multinational corporation that designs, manufactures, and sells airplanes, rotorcraft, rockets, satellites, telecommunications equipment, and missiles worldwide. The company also provides leasing and product ...
. Pakistani officials promised a full investigation and Farooq Bhoja, the owner of Bhoja Air, was put on the
Exit Control List The Exit Control Lists (ECL; ur, ) is a system of border control maintained by the Government of Pakistan under Exit from Pakistan (Control) Ordinance, 1981. The people on the list are prohibited from leaving Pakistan. Priorities 1. Exit from P ...
, meaning he may not leave the country while the criminal investigation was underway against him and the airline.
CAA CAA may refer to: Law * Citizenship (Amendment) Act, 2019 of India ** Citizenship Amendment Act protests, Protests regarding the Citizenship (Amendment) Act * Copyright transfer agreement, Copyright assignment agreement, to transfer copyright to ...
, the regulatory authority for maintaining aviation safety standards in Pakistan, faced harsh criticism in Pakistani media for allegedly compromising on safety standards. The corruption within CAA, due to politically motivated appointments, was alleged to be the prime reason for increase in frequency of technical faults, crash landings and catastrophic air accidents. The CAA, however, maintained that it did not issue any airline license or airworthiness certificate under political pressure, however it did announce that the Bhoja Air engineers were not qualified to issue the air worthiness certificate. Following the accident, the CAA announced it would re-certify the fleet of all private airlines in the country. The CAA suspended the airworthiness certificates of two Bhoja Air aircraft on 24 April 2012. The CAA announced that the suspension was lifted on 28 April 2012.


Weather

Multiple reports indicated that hail and stormy condition were prevailing near the crash site when the accident happened. Bhoja Air official reported that the aircraft was brought down by heavy winds while local eyewitness claimed that the pilot had lost control of the aircraft. Pakistan's Civil Aviation Authority suggested that the flight might have been brought down by bad weather. There were also reports that the aircraft had been struck by lightning. Local media reported that there had been damaging rain in parts of the country. Intense convective systems were recorded in several regions, including the Islamabad-Rawalpindi metropolitan area. Data from numerous weather predictions (NWP) products on the day of the accident showed that a westerly wave was injecting cool air from the northwest, while winds from the
Arabian Sea The Arabian Sea ( ar, اَلْبَحرْ ٱلْعَرَبِيُّ, Al-Bahr al-ˁArabī) is a region of the northern Indian Ocean bounded on the north by Pakistan, Iran and the Gulf of Oman, on the west by the Gulf of Aden, Guardafui Channel ...
in the south of the country fed warm moisture into the upper part of Pakistan. Interaction between both
air mass In meteorology, an air mass is a volume of air defined by its temperature and humidity. Air masses cover many hundreds or thousands of square miles, and adapt to the characteristics of the surface below them. They are classified according to la ...
es eventually produced severe thunderstorms in the area, which resulted in the creation of strong updrafts and downdrafts. Satellite data also supported these findings. Imageries taken at 14:00 local time depicted a development of a severe weather system over the central part of
Khyber Pakhtunkhwa Khyber Pakhtunkhwa (; ps, خېبر پښتونخوا; Urdu, Hindko: خیبر پختونخوا) commonly abbreviated as KP or KPK, is one of the Administrative units of Pakistan, four provinces of Pakistan. Located in the Geography of Pakistan, ...
, which slowly migrated towards the east and then northeast. Approximately 4 hours later the system deteriorated, creating "severe high impact weather activity" in and around Islamabad. Radar echoes revealed a frontal weather activity which generated severe turbulence and wind shear, which were attributed to the development of microbursts. Analysis from the obtained data concluded that a strong wind shear and a converging system approached Islamabad's
Benazir Bhutto International Airport Benazir Bhutto International Airport ( ur, , ) is a defunct airport which formerly served the Islamabad-Rawalpindi metropolitan area. It was the second-largest airport by air traffic in Pakistan, until 3 May 2018 when it was replaced by the ...
from the southwest, which intensified at around 18:00 to 19:00 local time. The system later deepened and produced strong wind shear, updrafts and downdrafts. At the time of the crash, Islamabad area was being pounded with microburst. Surface winds were reported to be at . The flight recorders did confirm that the flight had encountered severe weather condition, as multiple wind shear warnings could be heard from the recording. Information regarding the weather condition in Islamabad were continuously updated by authorities from the airport's meteorological department, which was relayed to the controller so that it could be informed to the crew of Flight 213. Meteorological office in Karachi had also provided weather information to the crew, including
METAR METAR is a format for reporting weather information. A METAR weather report is predominantly used by aircraft pilots, and by meteorologists, who use aggregated METAR information to assist in weather forecasting. Raw METAR is the most common form ...
and other weather charts and wind charts. These information had been acknowledged by the crew during the flight. The voice cockpit recording even captured Captain Afridi's response to the information, in which he stated "“it was very nice whatever you told me". As per report, while weather information for Islamabad area was available, personnel in radar and control tower had no information on the presence of wind shear for Runway 30's final approach and thus they couldn't warn the crew on the weather phenomenon. However, the provided weather data was sufficient enough for the crew to abandon the approach. The approved manual from Bhoja Air clearly stated that an aircraft was not allowed to fly near a weather cell and should remain clear of it by at least . The flight plan had listed the nearby Allama Iqbal International Airport in Lahore as an alternate airport, meaning that the crew could have diverted to said airport had the weather condition been in unsuitable condition for an approach or landing. The crew of Flight 213, however, decided to continue their flight towards the active weather cell, thus threatening the safety of their flight.


Decision to fly

In accordance with Bhoja Air's written manual, the crew should have abandoned the approach to Islamabad due to the deteriorating weather condition. The flight to Islamabad, however, was continued by the crew. The flight crew was responsible for the decision on whether to continue, to divert, to deviate from track, or to cancel the flight altogether. As per the ICAO convention, the final responsibility of the safety of the flight lies with the captain of the flight. International regulations stated that controllers were not involved in the decision-making process on whether to continue or to divert a flight. Radar controller could only relay and advise the crew regarding the information that had been provided to them, including weather update. From said information, the crew could then use them for the final say. When they had decided, the controller should be informed about it so that they could assist the crew, particularly in times of need. Flight 213 was the only aircraft in the area at the time and full attention had been given by the controller. During the approach phase, the crew requested for a clearance to deviate from their track in order to penetrate a group of
cumulonimbus cloud Cumulonimbus (from Latin ''cumulus'', "heaped" and ''nimbus'', "rainstorm") is a dense, towering vertical cloud, typically forming from water vapor condensing in the lower troposphere that builds upward carried by powerful buoyant air currents. ...
s through a small gap. As the controller's radar was less accurate than the one being used by the pilots in the aircraft, the controller wasn't able to detect any active weather cells on the radar and thus the crew was asked on whether the area around them up until the southeast of Islamabad within a distance of were clear of severe weather activity. The crew later stated that the weather was clear until approximately and radar controller eventually provided radar vectoring for the airport's ILS Runway 30. From the available evidence, investigators concluded that the controllers had properly conducted their duties. The controller had advised the crew to take a new heading, but the suggestion was refused by the crew. The decision to continue the flight to Islamabad therefore lies with the crew of Flight 213. According to the CVR, the sole reason for the flight to continue flying towards Islamabad, despite the deteriorating weather condition around the area, was due to the fact that this particular flight, an evening flight from Karachi to Islamabad, was Bhoja Air's first ever flight for this sector in 12 years. Bhoja Air previously had been suspended due to financial difficulties in the early 2000s and had been recently relaunched in March 2012, merely a month earlier. As the flight was the inaugural flight for the Karachi-Islamabad sector, Captain Afridi concluded that the aircraft must land at Islamabad, regardless of the weather condition. First Officer Malik had advised Captain Afridi to divert the flight, however Captain Afridi insisted about continuing the flight. This was regarded as a critical moment as his sole reason to continue the flight would eventually lead to the accident.


Crew error

Multiple violations and crew error were captured on the recorders. There were multiple instances at which the crew had deliberately decided not to follow the approved procedures. The crew's decision to continue the flight to Islamabad was regarded as the first violation of such procedures. They later made further deviations and errors which ultimately caused the aircraft to crash. During the approach phase, investigators noted that the crew didn't conduct a formal approach briefing. Despite the visible severe weather activity on their radar, they also didn't obtain the airport terminal information service (ATIS) for Islamabad Airport. Subsequently, the aircraft was struck by strong updrafts and downdrafts, eventually causing various flight parameters to fluctuate. When the aircraft was struck by the first downdraft, the crew didn't carry out the correct procedure. The autopilot and the autothrottle were not turned off and the wings were not levelled. Flight operation manual from Boeing stated that flight crew should have disengaged both the autopilot and autothrottle immediately. Then, the crew should have increased the thrust to the maximum, levelled both wings and put the aircraft's nose to an initial pitch of 20 degree. At the time of the incident, the aircraft was following the glideslope, which had been captured earlier by the autopilot. The force of the downdraft then caused the aircraft's nose to pitch up and pushed the aircraft down to lower altitude. The computer, which had been fed with flight input from the pilots, then tried to compensate the condition. The autopilot tried to hold the aircraft within the respective glideslope. The autothrottle did increase the thrust, but it stopped before the maximum thrust as it tried to accelerate back to the selected speed that had been put by the pilots. These errors ultimately caused the airspeed to decay. During the commotion, Captain Afridi could be heard yelling in extreme anxiety, while First Officer Malik, instead of assisting the Captain, decided to shout to the captain for a go-around. He should have taken over the controls from the captain. According to the investigation, both pilots were probably unsure about the behaviour of the aircraft during automation mode. The downdraft later rapidly dissipated. The crew were quite shaken by the experience that no control activities were recorded on the aircraft for 6 to 8 seconds. The aircraft eventually deviated below the glideslope and its altitude had decreased. The crew decided to turn the autopilot off to control the aircraft manually, however the autothrottle was still engaged. In the following seconds, the confused flight crew inadvertently endangered the safety of the flight. Due to the decrease in height, the TAWS alarm warned the crew on the incoming terrain. The flight crew, who had been pre-occupied with the severe weather situation, ignored the alarm and didn't execute recovery actions. First Officer Malik was noted as being "ignorant" with the alarms as he was busy with the communication between Flight 213 and the controller, instead of assisting the captain, who had been severely pre-occupied with the dangerous weather condition for quite some time. As the flight crew managed to stabilize the aircraft, the autothrottle started to decrease the thrust to maintain the airspeed. The nose was pitched to 0 degree. However, the second, more powerful downdraft later hit the aircraft. The force of the downdraft caused the aircraft to descent rapidly. The crew still didn't carry out the correct recovery procedure. The autothrottle was still engaged and the aircraft was still in its landing configuration. The engaged autothrottle would have limited the thrust setting, while the landing configuration would have compromised the aerodynamics of the aircraft. The "Whoop whoop pull up" alarm then blared and the captain tried to pull the nose of the aircraft up. As the autothrottle had not been turned off, the thrust continued to decrease. The downdraft suddenly dissipated in a rapid manner, causing the aircraft to violently pitch up. The limited thrust setting, landing configuration of the aircraft, and the rapid pitch up, subsequently caused the stall warning to activate. Alarmed by the warning, Captain Afridi immediately made a nose down input, reaching as high as 12 degree. The autothrotlle was still not deactivated by the crew and hence the thrust remained at low setting, but the speed started to increase due to the steep dive. The aircraft was already at an unusually low altitude and the captain's decision to put the nose in a steep position caused the GPWS to sound. Another alarm then sounded inside the cockpit. This time, the wind shear warning started to sound, simultaneously with the "Whoop whoop pull up" alarm. Overwhelmed, Captain Afridi then frantically tried to silence the warning by pressing the autopilot disconnect switch on his yoke. He then pulled the nose up again, but the stall warning began to sound once more as Captain Afridi's input caused the nose to exceed the
critical angle of attack In fluid dynamics, angle of attack (AOA, α, or \alpha) is the angle between a Airfoil#Airfoil terminology, reference line on a body (often the chord (aircraft), chord line of an airfoil) and the vector (geometry), vector representing the relat ...
. The stick shaker warned the crew on the impending stall. First Officer Malik then could be heard yelling to the Captain to get out of the stall situation, but he didn't take over the controls from the captain and didn't make corrective actions either. During the entire chaotic situation, none of the crew made corrective inputs to recover the aircraft. A critical error from the crew was noted by investigators, as per the report: The breakdown of the
cockpit resource management Crew resource management or cockpit resource management (CRM)Diehl, Alan (2013) "Air Safety Investigators: Using Science to Save Lives-One Crash at a Time." Xlibris Corporation. . http://www.prweb.com/releases/DrAlanDiehl/AirSafetyInvestigators/ ...
and the crew who were unfamiliar with their aircraft eventually caused the aircraft to crash.


CRM breakdown

The cockpit situation was noted as being chaotic. Following the second downdraft, the cockpit resource management immediately collapsed. First Officer Malik was particularly noted for being "ignorant" and unhelpful to the unfolding situation. In several instances, he could be heard giving advices at his captain instead of taking over the control from him. According to investigators, his actions were mainly caused by his relationship between him and Captain Afridi. Both pilots met for the first time in Pakistan Air Force Academy, with Captain Afridi as the flight instructor and First Officer Malik as a cadet. First Officer Malik had been paired with the captain since their employment with Shaheen Air International. During First Officer Malik's employment with the airline, Captain Afridi looked after him. When Captain Afridi decided to quit and join Bhoja Air, First Officer Malik followed him as well since he felt insecure and under confident from Captain Afridi's departure. The flight logbook revealed that, out of the 23 flights that had been carried out by him, a total of 16 were flown with the captain. The investigation stated that Captain Afridi was seen as a fatherly figure to First Officer Malik. The two eventually became too comfortable with each other, preventing First Officer Malik to call out the captain's mistakes. Deviations from standard procedures were often not corrected and the first officer was also less likely to take over the control from the captain since he chose to rely and to trust with the captain's actions.


Oversight failure

The Boeing 737-200 and the Boeing 737-200 Advanced were completely different variants. The former was equipped with semi-automated flight deck, while the latter was fully automated. Civil Aviation Authority requested Bhoja Air to submit the ground schooling curriculum for cockpit crew of the Boeing 737-200 series. Bhoja Air Management claimed that all of their pilots had attended the required training. Bhoja Air didn't know about the difference between the variants until the crew were sent abroad for their recurrent training. The ground schooling curriculum didn't cover the training for flight deck automation for the Boeing 737-236A. Captain Afridi had undergone his recurrent simulator training in a British Airways Comair facility in
South Africa South Africa, officially the Republic of South Africa (RSA), is the southernmost country in Africa. It is bounded to the south by of coastline that stretch along the South Atlantic and Indian Oceans; to the north by the neighbouring countri ...
in January 2012. The flight instructor noted that the captain should be further trained on the aircraft's automation system as the system was considered to be relatively new by the captain. Several aspects were rated as "poor performance" and further training was needed. The South African instructor also recommended Bhoja Air to include new Boeing recommended procedures for an automated aircraft. Prior to joining Bhoja Air, he neither had the experience nor exposure to an automated flight deck. During his training for the Boeing 737-200A aircraft, which was equipped with fully automated flight deck, wind shear and TAWS procedures were not included in the training by Bhoja Air and thus he was not trained for the correct recovery procedures in both wind shear condition or TAWS activation. First Officer Malik didn't undergo the six-monthly simulator training, which was planned to be carried out in February 2012 for an automated flight deck. The training program was eventually "extended" by Bhoja Air for another 2 months and their request was granted by CAA. As such, he also was not familiar with the correct recovery procedure for an automated flight deck. As both the captain and the first officer were not trained on the automated flight deck of the Boeing 737-236A and the recovery procedures from wind shear condition and TAWS activation on said aircraft, the crew eventually made "fatal procedural mistakes". Due to the absence of such trainings, the captain sought refuge on the aircraft's automation to provide him a solution when he should have followed the recommended procedures from Boeing. Multiple errors were discovered from Bhoja Air management and also from CAA officials. Several faults within the monitoring system and the training program of Bhoja Air potentially had enabled the crash. Bhoja Air had not provided the manual for the Boeing 737-200A, had not implemented any recommendations that had been given by the South African flight instructor, and had not established a monitoring system to track the cockpit crew's performance at organizational level. The CAA inspector, who was responsible for Bhoja Air, was qualified but didn't have any experience on the Boeing 737-200 and therefore they could not conduct an observation on the automated flight deck training. The simulator training in South Africa was not monitored by said CAA official. Further errors were discovered within the regulations. As per the licensing circular that had been issued by CAA on year 2000, the CAA didn't mandate a training for the automated flight deck of the Boeing 737-236A.


Conclusion

Civil Aviation Authority released the final investigation report comprising 78 pages on 21 January 2015. The report found that the primary causes of the accident include the ineffective management by the cockpit crew of the basic flight parameters such as airspeed, altitude, descent rate, attitude, as well as thrust management. The report also found that the ineffective automated flight deck management in extreme adverse weather conditions by the cockpit crew caused the accident. The investigation found that ineffective flight deck management by the pilots in adverse weather conditions caused the accident. The pilots had inadequate flying experience, training and competence level in the aircraft. The inability of the CAA to ensure automated flight deck variance type training and monitoring requirements primarily due to incorrect information that had been provided by Bhoja Air was listed as one of the contributing factors to the crash.


See also

*
Delta Air Lines Flight 191 Delta Air Lines Flight 191 was a regularly scheduled Delta Air Lines domestic service from Fort Lauderdale, Florida, to Los Angeles with an intermediate stop at Dallas/Fort Worth International Airport (DFW). On August 2, 1985, the Lockhee ...
*
Martinair Flight 495 Martinair Flight 495 was a McDonnell Douglas DC-10 operated by Dutch airline Martinair, that crash-landed in severe weather conditions at Faro Airport, Portugal on 21 December 1992. The aircraft carried 13 crew members and 327 passengers, mainly ...
*
Eastern Air Lines Flight 66 Eastern Air Lines Flight 66 was a regularly scheduled flight from New Orleans to New York City that crashed on June 24, 1975 while on approach to New York's John F. Kennedy International Airport, killing 113 of the 124 people on board. The cras ...


Notes

# The
METAR METAR is a format for reporting weather information. A METAR weather report is predominantly used by aircraft pilots, and by meteorologists, who use aggregated METAR information to assist in weather forecasting. Raw METAR is the most common form ...
in force at the time of the accident was "OPRN 201300Z 23020KT 4000 TS FEW025CB SCT030 BKN100 25/15 Q1009.3/29.80". This translates as "METAR for Benazir Bhutto International Airport, issued on the 20th of the month at 13:00
Zulu Time Coordinated Universal Time or UTC is the primary time standard by which the world regulates clocks and time. It is within about one second of mean solar time (such as UT1) at 0° longitude (at the IERS Reference Meridian as the currently used ...
. Wind from 230° at . Visibility , thunderstorm occurring on station. Few clouds at , cumulonimbus clouds present. Scattered clouds at . Broken clouds at . Temperature , dewpoint . Altimeter setting 1009.3
hPa HPA may refer to: Organizations * Harry Potter Alliance, a charity * Halifax Port Authority, Canada * Hamburg Port Authority, Germany * Hawaii Preparatory Academy, a school in Hawaii, US * Health Protection Agency, UK * Heerespersonalamt, the Ger ...
/ 29.80
inHg Inch of mercury (inHg and ″Hg) is a non- SI unit of measurement for pressure. It is used for barometric pressure in weather reports, refrigeration and aviation in the United States. It is the pressure exerted by a column of mercury in heigh ...
".


References


External links

*
Bhoja AirArchive





Crash site of Flight 213
from ''
Associated Press The Associated Press (AP) is an American non-profit news agency headquartered in New York City. Founded in 1846, it operates as a cooperative, unincorporated association. It produces news reports that are distributed to its members, U.S. newspa ...
Archive'' {{Portal bar, Aviation, Pakistan 2012 in Pakistan 2012 meteorology Airliner accidents and incidents caused by microbursts Aviation accidents and incidents in 2012 Aviation accidents and incidents in Pakistan Accidents and incidents involving the Boeing 737 Original April 2012 events in Pakistan