On Feb 25th 2024 Pakistan's Government released the final report concluding the probable causes of the crash were:
Primary Causes
- Aircraft made Gears Up landing where both Engines’ nacelle made contact with R/W. Both Engines were damaged causing loss of Engine Oil and lubrication which resulted in failure of both Engines during Go-Around.
- Non-adherence to SOPs and disregard of ATC instructions during the event flight.
- Lack of communication between the ATC and the flight crew regarding Gears Up landing particularly once aircraft was on the R/W.
Contributing Causes
- Ineffective implementation of FDA programme.
- FDA regulatory oversight programme was ineffective in producing sufficient and timely improvement.
- Lack of clear and precise regulations to restrict flying while fasting.
- Inadequate level of CRM application during the event flight.
The final report analyses:
Operational Procedures
Cockpit Environment of PIA 8303 – CVR analysis revealed that the cockpit environment was conducive and cordial. Throughout the flight, flight crew continued discussion on various topics. The discussion also included the topic of COVID-19 Pandemic, however, there was no indication of any fear or compulsion to fly during the COVID-19 Pandemic.
Sterile Cockpit Rule – Flight deck shall be considered sterile during all flight operations at or below 10,000 ft AGL including ground operations of the aircraft, and during all other critical phases of flight as declared by PIC. Communication and activities on the flight deck should be limited to those essential to the safe operation of the flight. Flight crew did not follow the Sterile Cockpit Rule during the event flight and were discussing various topics not related to aircraft operations.
Approach Briefing Prior to Descent – Prior to descent, flight crew were required to conduct Approach briefing. However, they were discussing various topics not relevant to this phase of flight. Approach briefing was not conducted which includes briefing of arrival trajectory, missed Approach strategy and accordingly cross checking of FMS preparation (Descent Preparation by flight crew FCOM / PRO / NOR / SOP / 16 & FCTM / PR / NP / SOP / 160).
Beginning of Descent, FL340 / >100 NM
(a) Prior to descent, FO was found to be Pilot Flying (PF), whereas Captain was found Pilot Monitoring (PM). Aircraft was in cruise at FL340, CAS 268 kts and Mach 0.77. Thrust Levers were in Climb Notch, SLATS were retracted (CONF0). The display of selected altitude on FCU was set to FL150. AP-2 and both FDs (FD-1 and FD-2) were engaged, and A/THR was active.
(b) At 09:15:00, FO requested ATC for descent. At 09:15:07, ATC called “Pakistan 8303 Descent FL100, Pilot discretion proceed direct MAKLI”. The MAKLI waypoint is located 4 NM before SABEN and 15.3 NM from R/W 25L threshold.
(c) At 09:15:38, flight crew initiated descent from FL340, the selected altitude on FCU was changed to FL100 and DES MODE was engaged (flight crew pushed the ALT knob on the FCU). The CAS was 268 kts (managed target speed). V/S was constant, around 1,000 ft/min, which indicated that aircraft was below the FMS descent profile.
(d) After clearance of PIA 8303 to descent FL100 direct to MAKLI, there was neither FMA callout nor cross check of FMS setting by flight crew (“DIR TO MAKLI” and “DES Green – FL100 – Check”). As per the Airbus Golden Rules for pilots provided in the FCTM, understanding / monitoring the FMA is required at all time and it also includes cross-checking of all FMA changes. Indicative of lack of application of procedures / adherence to SOP by flight crew (Golden Rules for Pilot FCTM / AOP / 40).
During Descent, FL315 / 88 NM – After clearance from Karachi Approach at 09:18:13 for 5,000 ft, at 09:18:36, aircraft was passing through FL310 with A/THR Thrust MODE engaged (N1 reduced to IDLE on both Engines), which indicated that the aircraft was starting to capture the FMS descent profile. V/S increased to 2,400 ft/min. CAS increased to a maximum of 284 kts before reducing towards the managed target air speed of 269 kts. A/THR MODE changed to IDLE MODE to adjust the thrust while AP followed descent profile. The selected altitude became 5,000 ft. It was observed that no FMA callout or check (FL50 - check) were performed by either of flight crew, they were discussing various topics not relevant to this phase of flight. Indicative of lack of application of procedures / adherence to SOP (Golden Rules for Pilot FCTM / AOP / 40).
Mistuning of Radio Frequency – Till 09:18:16, PIA 8303 was in contact with Area Control Karachi. At 09:19:30, a sound similar to Audio Control Panel (ACP) VHF PB was heard in CVR recording. From 09:23:16 to 09:24:36, seven (07) calls were given to PIA 8303 by Area Control Karachi, Approach Control Karachi and PIA 8368 (another aircraft in air). PIA 8303 did not respond to any call during this time and these calls were also not recorded in CVR. After analysing CVR and ATC transcripts, it appeared that probably flight crew mistuned the radio frequency (126.5 MHz instead of 125.5 MHz). PIA 8303 did not communicate radio frequency change to any of the ATC unit. It was observed that (during this time) both flight crew were busy in discussion not relevant to this phase of flight. At 09:25:37, PIA 8303 responded to Approach Control Karachi on Guard Frequency after receiving two calls on the Guard Frequency, thereafter, two-way communication was established between PIA 8303 and Approach Control Karachi.
Descent to 3,000 ft – At 09:25:54, Karachi Approach called PIA 8303 to descent 3,000 ft baro altitude 1004 hPa and cleared for ILS R/W 25L. At 09:26:00, the selected altitude became 3,000 ft. However, Captain and FO altimeter were set at baro altitude 1004 hPa 15 s later. The aircraft was descending through 15,369 ft baro altitude. No FMA callout or check (FL30 - check) were performed by either of flight crew (Golden Rules for Pilot FCTM / AOP / 40).
Final Approach, LOC Captured 9,640 ft / 16 NM
(a) At 09:29:53, APPR guidance MODES were armed (G/S and LOC blue on FMA). AP-1 was engaged in addition to AP-2. At 09:30:22, at 16 NM from R/W 25L, LOC* (Localizer Capture) MODE was engaged.
(b) Between 09:29:53 and 09:30:39 CAS remained around 250 kts and A/THR MODE switched between SPEED and IDLE MODE.
(c) During this time, there was no FMA cross check and verbal confirmation, related to “AP-1+2, A/THR SPEED 250 kts, G/S LOC blue” and “THR IDLE, LOC*” by flight crew, indicative of lack of airmanship and adherence to SOP (Golden Rules for Pilot FCTM / AOP / 40 & Glide Slope Interception from above FCTM / PR / NP / SOP / 190 / GUI).
Holding Pattern in FMS Flight Plan
(a) As managed DES MODE was active, the selection of 3,000 ft on FCU did not lead to any change in FMS flight plan. NAV MODE was still engaged, therefore descent profile was still computed by FMS to reach SABEN at FL089 / 230 kts (as per the flight plan entered into FMS).
(b) With this selection the aircraft still considered Holding Pattern at SABEN in its Lateral Profile, thus causing distance to the R/W threshold to increase by 23 NM (from 15 NM to 38 NM).
(c) Two main cockpit cues were available to the flight crew to indicate the presence of the Holding Pattern at the SABEN waypoint. On the ND, before reaching MAKLI, the Holding Pattern was indicated via a white curved arrow (left photo). After passing MAKLI (i.e. MAKLI had been sequenced), SABEN became the "TO" waypoint and, the full Holding Pattern was depicted
(d) On the Flight Plan displayed on the MCDU, the Holding Pattern was marked by a white “HOLD L”
(e) As the DES MODE was still engaged, on the vertical axis, aircraft continued to follow the descent profile computed by the FMS in order to reach 1,000 ft AGL at VAPP on Karachi ILS R/W 25L-Z trajectory. As flight crew had not cleared FMS flight path, Holding Pattern distance of 23 NM was still considered in distance computation (increasing the track mile). The FMS did not compute descent path assuming 15 NM (i.e. radial distance between MAKLI and R/W 25L), but assuming 38 NM (with additional descent in a left-hand pattern). Thus, the vertical profile was still managed by FMS including Holding Pattern at SABEN in descent computations. Without this Holding Pattern, the simulator tests have shown that FMS would have computed a managed vertical profile leading to MAKLI at 3,000 ft, while the lateral guidance would have followed the Localizer Signal for R/W 25L (when captured).
(f) In CVR recording, there was a discussion between Flight crew of “Take out the HOLD” which also confirms the presence of HOLD at SABEN in FMS Flight Plan.
ATC 1st Call (Track Mile Comfortable for Descent at 15 NM)
(a) At 09:30:35, aircraft passed MAKLI with 9,363 ft baro altitude, 245 kts CAS, and FLAPS at 0°. 1 s later, Karachi Approach asked, “Pakistan 8303 confirm track mile comfortable for descent?” to which PIA 8303 replied, “Affirm”. Aircraft was still around 9,000 ft baro altitude at approximately 15 NM from R/W 25L threshold. In CVR recording, Captain exclaimed, “What has happened?, Stop, Stop Oh No! Take out the HOLD, take out the HOLD, take out the HOLD, take out the HOLD” (in Urdu). FO responded, “HOLD taken out, should we report this issue?” (in Urdu). Captain replied, “No, this could be due to HOLD”, tell Karachi Approach “Established on Localizer” (Both in Urdu).
(b) There was no verbal re-calculation, no crosscheck between flight crew of the vertical flight path of aircraft [Situation Awareness, Flight Path Monitoring (FPM): Detection of Deviations vs Normal Flight Path and Profile Computation (FCTM / PR / NP / SOP / 170) and Human Factor Attitude: Overconfidence & Complacence].
Open Descent (OPEN DES) MODE on Final Approach
(a) At 09:30:44, OPEN DES MODE was engaged with a target at 3,000 ft by pulling the ALT Knob on FCU. Aircraft was at 9,210 ft baro altitude, 245 kts CAS, Rate of Descent had reduced to 660 ft/min and distance from R/W 25L threshold was approximately 14.8 NM. Speed Brakes were extended at this time.
(b) For a 3° G/S at 14.8 NM from R/W 25L threshold, aircraft was required to be at 4,700 ft baro altitude. Aircraft was significantly above the published vertical Approach path and was actually at flight path angle of almost 6°. This was a scenario of Glide Slope Interception from above (FCOM / PRO / NOR / SOP / 18 Initial Approach / Flight path monitoring interception glide from above). V/S MODE should be used with an initial target at 1,500 ft/min. However, OPEN DES MODE was used which is not recommended on final Approach. This was the lack of airmanship due to non-adherence to SOP for G/S capturing from above. There were no FMA call out (THR IDLE, OP DES, G/S) and information sharing on descent strategy (FCOM / PRO / NOR / SOP / 18 / Approach using LOC G/S guidance and lack of situation awareness regarding vertical profile).
ATC 2nd Call (Level Passing at 10 NM)
(a) At 09:31:13, Karachi Tower contacted Karachi Approach on hotline and shared its observation about incoming PIA 8303, “Sir, it’s too high” (in Urdu). Karachi Approach responded, “Yes, it is too high and I am observing it and will give orbit” (in Urdu). This indicates awareness of ATC that aircraft was high on Approach.
(b) At 09:31:24, Karachi Approach called, “Pakistan 8303 report level passing”. Flight crew replied, “Out of 75 for 3,000”. Flight crew verbalized “75” (7,500 ft) to ATC while still at 7,700 ft, rounding down the actual altitude.
(c) At 09:31:26, 11.4 NM from R/W 25L threshold, 250 kts CAS, SABEN waypoint was overflown at 7,830 ft baro altitude. As per the ILS-Z R/W 25L Approach Chart, target altitude for set course from SABEN is 3,000 ft. Therefore, aircraft was excessively high (4,830 ft in excess) above the desired G/S.
(d) When aircraft was at 11 NM from R/W 25L threshold, it was still excessively high (4,500 ft), At 09:31:31, Karachi Approach prompted, “75 for 3,000, the present position is 10 miles from touchdown”. ATC reminded aircraft position versus flight level and suggested aircraft was too high with regard to the distance remaining to the R/W. However, Karachi Approach suggestion was not taken into account by the flight crew and at 09:31:37, PIA 8303 replied “No problem, Sir”.
Management of Flight Path
(a) The factors that led aircraft to pass SABEN at 7,800 ft and continue descent straight towards R/W 25L were: -
(i) Flight crew not clearing flight path in FMS, which led FMS to compute vertical profile including Holding Pattern distance in the track mile.
(ii) Non-selection by flight crew of OPEN DES MODE after ATC clearance at beginning of descent. Even if flight crew did not clear the flight plan, use of OPEN DES MODE would have allowed a direct vertical profile to 3,000 ft and ILS-Z R/W 25L G/S.
(iii) Activation of Approach MODE (APPR PB pressed) before SABEN waypoint, with FMS flight plan still including the holding pattern (NAV / DES engaged and LOC* / GS* armed). This led to engagement of LOC MODE and FMS to follow R/W 25L localizer while the altitude was significantly above the G/S. As flight crew had already activated Approach MODE, it would have been necessary to activate NAV MODE at SABEN to ensure that FMS follows Holding Pattern instead of continuing ILS LOC.
(iv) Continuation of descent after SABEN without realizing holding pattern, even though aircraft was at 7,800 ft baro altitude, still being significantly above the G/S and despite of ATC calls.
(b) Aircraft trajectory was not challenged by flight crew and there was no mental picture of the flight path even after being prompted by ATC (lack of situation awareness). Rather flight crew verbalized that situation was under control (Human performance: Overconfidence and Complacency).
Landing Gears Down – At 09:31:34, 7,440 ft baro altitude, 10.8 NM from R/W 25L threshold, Rate of Descent 2,900 ft/min, target speed was changed to 248 kts. At 09:31:39, Landing Gears selector was set to DOWN position. Landing Gears were DOWN and Locked 13 s later at 7,239 ft baro altitude. Neither PF nor PM verbalized the selection of the Landing Gears Lever to DOWN position and there was no cross check (lack of adherence to SOP, FCOM / PRO / NOR / SOP / 90 / Gear Callouts). At the time of extension of Landing Gears, the Rate of Descent was around 2,350 ft/min, which increased up to 7,500 ft/min probably due to increase in drag along with Speed Brakes extended and FLAPS1 selected.
ATC 3rd Call (Orbit Proposal)
(a) At 09:31:41, Karachi Approach asked PIA 8303, “Sir orbit is available if you want”. Captain verbalized, “Say it’s OK”. After 6 s, FO replied to ATC, “Negative Sir we are comfortable, we can make it, Insha-Allah”.
(b) At this time, aircraft trajectory was still excessively high (4,100 ft). ATC proposal for use of orbit pattern was aimed at losing altitude. However, flight crew did not consider this option, instead continued excessively high on Approach (lack of situation awareness).
Altitude Capture – At 09:32:18, 4,817 ft baro altitude, 7.7 NM from R/W 25L threshold, AP Vertical MODE changed to ALT*, Rate of Descent was 4,115 ft/min. 2 s later, selected Speed target was reduced from 248 kts to 230 kts. Flight crew didn’t call FMA check, no call out of “SPEED”, “ALT*” (Non adherence to SOP, Golden Rules for Pilot FCTM / AOP / 40).
ATC 4th Call (Turn Left Heading 180°)
(a) At 09:32:24, Captain said to FO, “He will be surprised what we have done” (in Urdu); probably Captain was referring to ATC Controller during his discussion with FO, indicating overconfidence and complacence.
(b) At 09:32:25, Karachi Approach gave call, “Pakistan 8303 disregard turn left heading 180”. Aircraft parameters at this time were as follows: -
PIA 8303 Approach: ALT 4,100 ft / Distance 6.9 NM ~ FPA 5.9°
Standard Approach: ALT 2,300 ft / Distance 6.9 NM ~ FPA 2.9°
(c) 8 s later, aircraft was descending through 3,900 ft baro altitude. PIA 8303 replied, “Sir, we are comfortable now and we are out of 3,500 for 3,000 established ILS 25L”. ATC instructions were disregarded by flight crew verbalizing 3,500 ft to ATC while still at 3,900 ft and once again rounding down the actual altitude.
G/S* MODE Engagement due to Perturbations – At 09:32:34, AP Vertical MODE changed to Glide Slope Capture (G/S*). Aircraft was passing through 3,830 ft baro altitude and 6.5 NM from R/W 25L threshold. Despite being significantly above desired G/S, the G/S* MODE was engaged due to perturbations caused by the proximity of 3° G/S lobe top and 9° G/S lobe bottom. The criteria for G/S* MODE was met while aircraft being close to 6° G/S. Flight crew were unable to challenge the flight path.
ATC 5th Call (Turn Left Heading 180°) – At 09:32:38, Karachi Approach again called PIA 8303, “Negative turn left heading 180”. PIA 8303 responded, “Sir, we are established on ILS 25L”. Once again ATC instructions were disregarded by flight crew despite being significantly above the standard flight path.
ATC 6th Call (Caution)
(a) At 09:32:46, 3,090 ft baro altitude, 5.7 NM from R/W 25L threshold, CAS 242 kts, selected target speed CAS 225 kts and SLATS / FLAPS CONF1 was selected (VFE CONF1=230 kts). Pitch angle was -12.6° and still decreasing.
(b) At 09:32:46, Karachi Approach called, “Sir, you are five Miles from touchdown still passing 3,500”. At 09:32:51, PIA 8303 responded, “Roger”. Karachi Approach again cautioned that aircraft was still too high on the Approach path, however flight crew continued to press on high Approach.
Auto-Pilots (APs) Disengagement
(a) At 09:32:47, 2,730 ft baro altitude, 5.5 NM from R/W 25L threshold, pitch attitude reached -13.7°. This led to both APs disengagement due to excessive pitch down, as it exceeded 13° nose down. Rate of Descent reached 6,800 ft/min. FDs and A/THR remained engaged. Auto-Pilot OFF Warning triggered accordingly.
(b) Flight crew did not verbalize acknowledgement of the Master Warning. Flight crew did not monitor FMA, did not call out of AP disconnection and even no call out for manual takeover of the aircraft (Non-adherence to SOP, Golden Rules for Pilot FCTM / AOP / 40).
OVERSPEED Warning FLAPS1 Extended (VFE)
(a) 4 s later, almost simultaneous with the AP disconnection, “OVERSPEED” [Maximum speed with FLAPS Extended (VFE)] Warning triggered Master Warning along with CRC Aural Alert. The triggering condition for VFE Warning is VFE +4 kts with SLATS and / or FLAPS extended.
(b) Flight crew did not verbalize acknowledgement of the Master Warnings. They selected FLAPS beyond the VFE speed (Lack of application of procedures: Intermediate and final approach FCOM / PRO / NOR / SOP / 180).
First Sequence of GPWS Alerts – After 09:32:52, GPWS Alerts (GPWS MODE-1) triggered for 4 s. When “SINK RATE” Caution was triggered, flight crew did not call out GPWS Caution (airmanship and situational awareness FCOM / PRO / ABN / SURV / MEM / EGPWS Caution / Sink Rate). Just after GPWS Caution, there were 02 GPWS Warning of “PULL UP” that required an immediate Terrain Avoidance / Escape Manoeuvre. The procedure is a MEM item which is applied immediately by Memory to ensure a safe flight path as the flight crew has no time to refer to the ECAM / QRH / FCOM. However, flight crew did not perform this manoeuvre (Lack of situational awareness and application of abnormal procedures FCOM / PRO / ABN / SURV / MEM / EGPWS Warnings / PULL UP).
Landing Gears and Speed Brakes Retracted – At 09:32:57, Landing Gears were selected UP, and 2 s later Speed Brakes were retracted. 14 s later, Landing Gears were recorded Uplocked which is consistent with a nominal retraction sequence. Retraction of Landing Gears and Speed Brakes were not verbalized by either of the flight crew.
OVERSPEED Warning FLAPS2 / 3 Extended (VFE) – At 09:33:25, 1,180 ft baro altitude, 2.9 NM from R/W 25L threshold, CONF2 was selected at CAS 232 kts and 2 s later CONF3 was selected. FLAPS selection without speed check triggered a Master Warning and Red Alert on the ECAM. Indicating lack of application of procedures, intermediate and final Approach FCOM / PRO / NOR / SOP / 180. Flight crew did not verbalize acknowledgement of the Master Warning.
FO Suggested for an Orbit – At 09:33:33, 1,100 ft baro altitude and CAS 227 kts, FO was heard saying “Should we do the Orbit?” (in Urdu) to which Captain replied “No-No”, followed by “Leave it” (both in Urdu). This communication indicates FO has intention for an Orbit. Most probably Landing Gears and Speed Brakes were retracted by FO at 09:32:57.
Captain Took Over Controls – At 09:33:37, Captain took over controls by pressing sidestick PB along with pitch down inputs and small dual inputs were recorded during 4 s. The change of controls was not verbalized by either of the flight crew.
1,000 ft Stabilization Gate
(a) At 09:33:42, 1.9 NM from R/W 25L threshold, aircraft crossed 1,000 ft RA. This is the Stabilization Gate for IMC as per stabilization criteria provided in Airbus FCOM.
(b) The aircraft parameters deviation was more than the call out threshold. However, there was no “Un-Stabilized” call out by either of the flight crew, flight parameters exceedance was not monitored and no Go-Around was initiated. It indicated lack of procedure implementation in the domain of FCOM / PRO / NOR / SOP / 18 Intermediate and Final Approach, FCTM / PR / NP / SOP / 190 Trajectory Stabilization and FCTM / PR / NP / SOP / 260 Considerations about Go-Around.
“L/G GEAR NOT DOWN” Warning – At 09:33:48, aircraft was passing below 750 ft RA, 1.5 NM from R/W 25L threshold, CAS 217 kts (VFE CONF3 + 32 kts), Rate of Descent 2,100 ft/min, and Pitch attitude -5º. ECAM Red Warning “L/G GEAR NOT DOWN” and illumination of Red Arrow beside the Landing Gears Lever were triggered. The CRC and Master Warning Red light flashing were already active due to continued triggering of “OVERSPEED” VFE Alert. Flight crew did not monitor ECAM Warning and there was no call out of “L/G GEAR NOT DOWN” Warning (Lack of situation awareness and application of procedures).
500 ft Stabilization Gate
(a) 500 ft RA is Stabilization Gate for VMC as per stabilization criteria provided in Airbus FCOM.
(b) The aircraft parameters deviation was more than the call out threshold. However, there was no “Un-Stabilized” call out by either of the flight crew, flight parameters exceedance was not monitored and no Go-Around was initiated. It indicated lack of procedure implementation in the domain of FCOM / PRO / NOR / SOP / 18 Intermediate and Final Approach, FCTM / PR / NP / SOP / 190 Trajectory Stabilization and FCTM / PR / NP / SOP / 260 Considerations about Go-Around.
Second Sequence of GPWS Alerts – At 09:33:55 (440 ft RA), second sequence of GPWS Alerts triggered continuously until 09:34:16 (24 ft RA). CVR recording indicates that during this sequence a total of 13 Alerts were triggered: 10 “TOO LOW TERRAIN” Amber Cautions, 01 “SINK RATE” Amber Caution, and 02 “PULL UP” Red Warnings. On “SINK RATE” and “TOO LOW TERRAIN” (Amber Cautions), flight crew did not call out GPWS Caution (airmanship and situational awareness FCOM / PRO / ABN / SURV / MEM / EGPWS Caution / Sink Rate). On GPWS Warnings of “PULL UP”, that required an immediate Terrain Avoidance / Escape manoeuvre, flight crew did not perform any such manoeuvre (Lack of situational awareness and application of abnormal procedures FCOM / PRO / ABN / SURV / MEM / EGPWS Warnings / PULL UP).
Full Reverse Thrust Selected on Both Engines – At 09:34:23, crossing 7 ft RA, 200 kts CAS, full Reverse Thrust was selected on both Engines. Thrust remained at IDLE, but Thrust Reversers remained locked and did not deploy as aircraft was still airborne. ENG REV SET ECAM Alert associated with selection of Reverse Thrust in air was triggered along with a Single Chime Aural Alert and Master Caution Amber light. Flight crew selected Reverse Thrust in air instead of after MLG touchdown (Lack of Application of procedures FCTM / PR / NP / SOP / 250 / Reverse Thrust Efficiency).
R/W Contact and Go-Around
(a) At 09:34:28, aircraft both Engine nacelles made first contact with R/W. Maximum brake pedal inputs and opposite sidestick inputs were recorded from both flight crew (Captain: full nose down input, FO: 2/3 of full back input). At 09:34:36, Engine No. 2 Fire Alert triggered for 10 s along with associated Master Warning. At 09:34:42, FO said, “Take-off Sir, Take-off” (in Urdu), and 2 s later at 160 kts CAS, both TLA were advanced to TOGA for Go-Around. Aircraft got airborne at 09:34:45.
(b) The analysis of actions of both flight crew during R/W contact phase indicated an intention to Go-Around by the FO and intention to land out of same Approach by the Captain.
(c) Flight crew must not initiate a Go-Around after the selection of the Thrust Reversers. Regarding the Engine Fire Warning, the good airmanship should lead the flight crew to decide to stay on ground and stop the aircraft. (Lack of airmanship, situation awareness and application of procedures FCTM / PR / NP / SOP / 260 / Go-Around Near the Ground).
Flight Crew Actions after Go-Around
(a) At 09:34:52, 59 ft RA, CONF2 was selected, and third sequence of GPWS Alert initiated in which one “TOO LOW GEAR” Amber Caution was triggered. 5 s later, the flight crew instantly selected the Landing Gears Lever DOWN and UP. The duration was too short and there was no change in physical status of Landing Gears (UP and Locked). After getting airborne, the flight crew did not discuss about Gears Up landing and intended to fly ILS Approach for R/W 25L (lack of airmanship and situational awareness).
(b) At 09:36:12, 3,100 ft RA, Engine No. 2 Thrust Lever was reduced to IDLE, whereas Engine No. 1 Thrust Lever was kept at MCL. At 09:36:15, 3,000 ft RA, Engine No. 1 went to un-commanded IFSD and Engine No. 2 was at IDLE. Engine No. 2 (the only running Engine) remained at IDLE for about 1 min, until flight crew eventually realized it and Thrust Lever was re-advanced (lack of airmanship and situational awareness). After 1 min and 18 s (at 09:38:46), Engine No. 2 was operating at 65% nominal speed, multiple Stall Warnings were triggered and thereafter, aircraft altitude was continuously dropping. Aircraft Landing Gears were selected DOWN at 09:39:39 while descending below 800 ft. Aircraft altitude was continuously dropping and a sound similar to impact was heard in CVR at 09:40:18. Aircraft crashed 1,340 m short of R/W 25L threshold.
Possibility of Stopping the Aircraft on R/W (If Landing Gears were DOWN)81 – Airbus Engineering simulation considered the event flight touchdown parameters (189 kts GS, 4,500 ft down the R/W 25L threshold) and assumed Landing Gears were extended. The computed Operational Landing Distance (OLD) indicate the possibility of stopping the aircraft on R/W 25L using maximum reverse and maximum manual braking. There could have been a risk of tyre burst due to touchdown speed just below maximum tyre speed (195 kts GS).
Possibility of Safe Landing After Go-Around – It is not possible to predict or simulate the thrust available after damage to Engines during R/W contact. It is also not possible to estimate the additional power available if Engine No. 2 was not retarded to IDLE for about 1 min. Therefore, it could not be ascertained if safe landing options were available after Go-Around.
Flight Data Monitoring
(a) FDA Implementation by PIA
(i) FDA records indicated that Captain flew 289 flights in last 12 months prior to accident, out of which only 06 flights were analysed. Overall FDA rate for PIA was less than 5% and dedicated Flight Data Analyst was not available in PIA Safety Department till event flight. Since July, 2020, almost all flights are being analysed by a dedicated Flight Data Analyst.
(ii) After the accident, flights of Captain for last 12 months were analysed which indicated, numerous triggers during Approach related to High Speed, Path High, High Rate of Descent, Long Flare Distance and GPWS Warnings. There was no Go-Around initiated and several Unstabilized Approaches were continued.
Primary Causes
- Aircraft made Gears Up landing where both Engines’ nacelle made contact with R/W. Both Engines were damaged causing loss of Engine Oil and lubrication which resulted in failure of both Engines during Go-Around.
- Non-adherence to SOPs and disregard of ATC instructions during the event flight.
- Lack of communication between the ATC and the flight crew regarding Gears Up landing particularly once aircraft was on the R/W.
Contributing Causes
- Ineffective implementation of FDA programme.
- FDA regulatory oversight programme was ineffective in producing sufficient and timely improvement.
- Lack of clear and precise regulations to restrict flying while fasting.
- Inadequate level of CRM application during the event flight.
The final report analyses:
Operational Procedures
Cockpit Environment of PIA 8303 – CVR analysis revealed that the cockpit environment was conducive and cordial. Throughout the flight, flight crew continued discussion on various topics. The discussion also included the topic of COVID-19 Pandemic, however, there was no indication of any fear or compulsion to fly during the COVID-19 Pandemic.
Sterile Cockpit Rule – Flight deck shall be considered sterile during all flight operations at or below 10,000 ft AGL including ground operations of the aircraft, and during all other critical phases of flight as declared by PIC. Communication and activities on the flight deck should be limited to those essential to the safe operation of the flight. Flight crew did not follow the Sterile Cockpit Rule during the event flight and were discussing various topics not related to aircraft operations.
Approach Briefing Prior to Descent – Prior to descent, flight crew were required to conduct Approach briefing. However, they were discussing various topics not relevant to this phase of flight. Approach briefing was not conducted which includes briefing of arrival trajectory, missed Approach strategy and accordingly cross checking of FMS preparation (Descent Preparation by flight crew FCOM / PRO / NOR / SOP / 16 & FCTM / PR / NP / SOP / 160).
Beginning of Descent, FL340 / >100 NM
(a) Prior to descent, FO was found to be Pilot Flying (PF), whereas Captain was found Pilot Monitoring (PM). Aircraft was in cruise at FL340, CAS 268 kts and Mach 0.77. Thrust Levers were in Climb Notch, SLATS were retracted (CONF0). The display of selected altitude on FCU was set to FL150. AP-2 and both FDs (FD-1 and FD-2) were engaged, and A/THR was active.
(b) At 09:15:00, FO requested ATC for descent. At 09:15:07, ATC called “Pakistan 8303 Descent FL100, Pilot discretion proceed direct MAKLI”. The MAKLI waypoint is located 4 NM before SABEN and 15.3 NM from R/W 25L threshold.
(c) At 09:15:38, flight crew initiated descent from FL340, the selected altitude on FCU was changed to FL100 and DES MODE was engaged (flight crew pushed the ALT knob on the FCU). The CAS was 268 kts (managed target speed). V/S was constant, around 1,000 ft/min, which indicated that aircraft was below the FMS descent profile.
(d) After clearance of PIA 8303 to descent FL100 direct to MAKLI, there was neither FMA callout nor cross check of FMS setting by flight crew (“DIR TO MAKLI” and “DES Green – FL100 – Check”). As per the Airbus Golden Rules for pilots provided in the FCTM, understanding / monitoring the FMA is required at all time and it also includes cross-checking of all FMA changes. Indicative of lack of application of procedures / adherence to SOP by flight crew (Golden Rules for Pilot FCTM / AOP / 40).
During Descent, FL315 / 88 NM – After clearance from Karachi Approach at 09:18:13 for 5,000 ft, at 09:18:36, aircraft was passing through FL310 with A/THR Thrust MODE engaged (N1 reduced to IDLE on both Engines), which indicated that the aircraft was starting to capture the FMS descent profile. V/S increased to 2,400 ft/min. CAS increased to a maximum of 284 kts before reducing towards the managed target air speed of 269 kts. A/THR MODE changed to IDLE MODE to adjust the thrust while AP followed descent profile. The selected altitude became 5,000 ft. It was observed that no FMA callout or check (FL50 - check) were performed by either of flight crew, they were discussing various topics not relevant to this phase of flight. Indicative of lack of application of procedures / adherence to SOP (Golden Rules for Pilot FCTM / AOP / 40).
Mistuning of Radio Frequency – Till 09:18:16, PIA 8303 was in contact with Area Control Karachi. At 09:19:30, a sound similar to Audio Control Panel (ACP) VHF PB was heard in CVR recording. From 09:23:16 to 09:24:36, seven (07) calls were given to PIA 8303 by Area Control Karachi, Approach Control Karachi and PIA 8368 (another aircraft in air). PIA 8303 did not respond to any call during this time and these calls were also not recorded in CVR. After analysing CVR and ATC transcripts, it appeared that probably flight crew mistuned the radio frequency (126.5 MHz instead of 125.5 MHz). PIA 8303 did not communicate radio frequency change to any of the ATC unit. It was observed that (during this time) both flight crew were busy in discussion not relevant to this phase of flight. At 09:25:37, PIA 8303 responded to Approach Control Karachi on Guard Frequency after receiving two calls on the Guard Frequency, thereafter, two-way communication was established between PIA 8303 and Approach Control Karachi.
Descent to 3,000 ft – At 09:25:54, Karachi Approach called PIA 8303 to descent 3,000 ft baro altitude 1004 hPa and cleared for ILS R/W 25L. At 09:26:00, the selected altitude became 3,000 ft. However, Captain and FO altimeter were set at baro altitude 1004 hPa 15 s later. The aircraft was descending through 15,369 ft baro altitude. No FMA callout or check (FL30 - check) were performed by either of flight crew (Golden Rules for Pilot FCTM / AOP / 40).
Final Approach, LOC Captured 9,640 ft / 16 NM
(a) At 09:29:53, APPR guidance MODES were armed (G/S and LOC blue on FMA). AP-1 was engaged in addition to AP-2. At 09:30:22, at 16 NM from R/W 25L, LOC* (Localizer Capture) MODE was engaged.
(b) Between 09:29:53 and 09:30:39 CAS remained around 250 kts and A/THR MODE switched between SPEED and IDLE MODE.
(c) During this time, there was no FMA cross check and verbal confirmation, related to “AP-1+2, A/THR SPEED 250 kts, G/S LOC blue” and “THR IDLE, LOC*” by flight crew, indicative of lack of airmanship and adherence to SOP (Golden Rules for Pilot FCTM / AOP / 40 & Glide Slope Interception from above FCTM / PR / NP / SOP / 190 / GUI).
Holding Pattern in FMS Flight Plan
(a) As managed DES MODE was active, the selection of 3,000 ft on FCU did not lead to any change in FMS flight plan. NAV MODE was still engaged, therefore descent profile was still computed by FMS to reach SABEN at FL089 / 230 kts (as per the flight plan entered into FMS).
(b) With this selection the aircraft still considered Holding Pattern at SABEN in its Lateral Profile, thus causing distance to the R/W threshold to increase by 23 NM (from 15 NM to 38 NM).
(c) Two main cockpit cues were available to the flight crew to indicate the presence of the Holding Pattern at the SABEN waypoint. On the ND, before reaching MAKLI, the Holding Pattern was indicated via a white curved arrow (left photo). After passing MAKLI (i.e. MAKLI had been sequenced), SABEN became the "TO" waypoint and, the full Holding Pattern was depicted
(d) On the Flight Plan displayed on the MCDU, the Holding Pattern was marked by a white “HOLD L”
(e) As the DES MODE was still engaged, on the vertical axis, aircraft continued to follow the descent profile computed by the FMS in order to reach 1,000 ft AGL at VAPP on Karachi ILS R/W 25L-Z trajectory. As flight crew had not cleared FMS flight path, Holding Pattern distance of 23 NM was still considered in distance computation (increasing the track mile). The FMS did not compute descent path assuming 15 NM (i.e. radial distance between MAKLI and R/W 25L), but assuming 38 NM (with additional descent in a left-hand pattern). Thus, the vertical profile was still managed by FMS including Holding Pattern at SABEN in descent computations. Without this Holding Pattern, the simulator tests have shown that FMS would have computed a managed vertical profile leading to MAKLI at 3,000 ft, while the lateral guidance would have followed the Localizer Signal for R/W 25L (when captured).
(f) In CVR recording, there was a discussion between Flight crew of “Take out the HOLD” which also confirms the presence of HOLD at SABEN in FMS Flight Plan.
ATC 1st Call (Track Mile Comfortable for Descent at 15 NM)
(a) At 09:30:35, aircraft passed MAKLI with 9,363 ft baro altitude, 245 kts CAS, and FLAPS at 0°. 1 s later, Karachi Approach asked, “Pakistan 8303 confirm track mile comfortable for descent?” to which PIA 8303 replied, “Affirm”. Aircraft was still around 9,000 ft baro altitude at approximately 15 NM from R/W 25L threshold. In CVR recording, Captain exclaimed, “What has happened?, Stop, Stop Oh No! Take out the HOLD, take out the HOLD, take out the HOLD, take out the HOLD” (in Urdu). FO responded, “HOLD taken out, should we report this issue?” (in Urdu). Captain replied, “No, this could be due to HOLD”, tell Karachi Approach “Established on Localizer” (Both in Urdu).
(b) There was no verbal re-calculation, no crosscheck between flight crew of the vertical flight path of aircraft [Situation Awareness, Flight Path Monitoring (FPM): Detection of Deviations vs Normal Flight Path and Profile Computation (FCTM / PR / NP / SOP / 170) and Human Factor Attitude: Overconfidence & Complacence].
Open Descent (OPEN DES) MODE on Final Approach
(a) At 09:30:44, OPEN DES MODE was engaged with a target at 3,000 ft by pulling the ALT Knob on FCU. Aircraft was at 9,210 ft baro altitude, 245 kts CAS, Rate of Descent had reduced to 660 ft/min and distance from R/W 25L threshold was approximately 14.8 NM. Speed Brakes were extended at this time.
(b) For a 3° G/S at 14.8 NM from R/W 25L threshold, aircraft was required to be at 4,700 ft baro altitude. Aircraft was significantly above the published vertical Approach path and was actually at flight path angle of almost 6°. This was a scenario of Glide Slope Interception from above (FCOM / PRO / NOR / SOP / 18 Initial Approach / Flight path monitoring interception glide from above). V/S MODE should be used with an initial target at 1,500 ft/min. However, OPEN DES MODE was used which is not recommended on final Approach. This was the lack of airmanship due to non-adherence to SOP for G/S capturing from above. There were no FMA call out (THR IDLE, OP DES, G/S) and information sharing on descent strategy (FCOM / PRO / NOR / SOP / 18 / Approach using LOC G/S guidance and lack of situation awareness regarding vertical profile).
ATC 2nd Call (Level Passing at 10 NM)
(a) At 09:31:13, Karachi Tower contacted Karachi Approach on hotline and shared its observation about incoming PIA 8303, “Sir, it’s too high” (in Urdu). Karachi Approach responded, “Yes, it is too high and I am observing it and will give orbit” (in Urdu). This indicates awareness of ATC that aircraft was high on Approach.
(b) At 09:31:24, Karachi Approach called, “Pakistan 8303 report level passing”. Flight crew replied, “Out of 75 for 3,000”. Flight crew verbalized “75” (7,500 ft) to ATC while still at 7,700 ft, rounding down the actual altitude.
(c) At 09:31:26, 11.4 NM from R/W 25L threshold, 250 kts CAS, SABEN waypoint was overflown at 7,830 ft baro altitude. As per the ILS-Z R/W 25L Approach Chart, target altitude for set course from SABEN is 3,000 ft. Therefore, aircraft was excessively high (4,830 ft in excess) above the desired G/S.
(d) When aircraft was at 11 NM from R/W 25L threshold, it was still excessively high (4,500 ft), At 09:31:31, Karachi Approach prompted, “75 for 3,000, the present position is 10 miles from touchdown”. ATC reminded aircraft position versus flight level and suggested aircraft was too high with regard to the distance remaining to the R/W. However, Karachi Approach suggestion was not taken into account by the flight crew and at 09:31:37, PIA 8303 replied “No problem, Sir”.
Management of Flight Path
(a) The factors that led aircraft to pass SABEN at 7,800 ft and continue descent straight towards R/W 25L were: -
(i) Flight crew not clearing flight path in FMS, which led FMS to compute vertical profile including Holding Pattern distance in the track mile.
(ii) Non-selection by flight crew of OPEN DES MODE after ATC clearance at beginning of descent. Even if flight crew did not clear the flight plan, use of OPEN DES MODE would have allowed a direct vertical profile to 3,000 ft and ILS-Z R/W 25L G/S.
(iii) Activation of Approach MODE (APPR PB pressed) before SABEN waypoint, with FMS flight plan still including the holding pattern (NAV / DES engaged and LOC* / GS* armed). This led to engagement of LOC MODE and FMS to follow R/W 25L localizer while the altitude was significantly above the G/S. As flight crew had already activated Approach MODE, it would have been necessary to activate NAV MODE at SABEN to ensure that FMS follows Holding Pattern instead of continuing ILS LOC.
(iv) Continuation of descent after SABEN without realizing holding pattern, even though aircraft was at 7,800 ft baro altitude, still being significantly above the G/S and despite of ATC calls.
(b) Aircraft trajectory was not challenged by flight crew and there was no mental picture of the flight path even after being prompted by ATC (lack of situation awareness). Rather flight crew verbalized that situation was under control (Human performance: Overconfidence and Complacency).
Landing Gears Down – At 09:31:34, 7,440 ft baro altitude, 10.8 NM from R/W 25L threshold, Rate of Descent 2,900 ft/min, target speed was changed to 248 kts. At 09:31:39, Landing Gears selector was set to DOWN position. Landing Gears were DOWN and Locked 13 s later at 7,239 ft baro altitude. Neither PF nor PM verbalized the selection of the Landing Gears Lever to DOWN position and there was no cross check (lack of adherence to SOP, FCOM / PRO / NOR / SOP / 90 / Gear Callouts). At the time of extension of Landing Gears, the Rate of Descent was around 2,350 ft/min, which increased up to 7,500 ft/min probably due to increase in drag along with Speed Brakes extended and FLAPS1 selected.
ATC 3rd Call (Orbit Proposal)
(a) At 09:31:41, Karachi Approach asked PIA 8303, “Sir orbit is available if you want”. Captain verbalized, “Say it’s OK”. After 6 s, FO replied to ATC, “Negative Sir we are comfortable, we can make it, Insha-Allah”.
(b) At this time, aircraft trajectory was still excessively high (4,100 ft). ATC proposal for use of orbit pattern was aimed at losing altitude. However, flight crew did not consider this option, instead continued excessively high on Approach (lack of situation awareness).
Altitude Capture – At 09:32:18, 4,817 ft baro altitude, 7.7 NM from R/W 25L threshold, AP Vertical MODE changed to ALT*, Rate of Descent was 4,115 ft/min. 2 s later, selected Speed target was reduced from 248 kts to 230 kts. Flight crew didn’t call FMA check, no call out of “SPEED”, “ALT*” (Non adherence to SOP, Golden Rules for Pilot FCTM / AOP / 40).
ATC 4th Call (Turn Left Heading 180°)
(a) At 09:32:24, Captain said to FO, “He will be surprised what we have done” (in Urdu); probably Captain was referring to ATC Controller during his discussion with FO, indicating overconfidence and complacence.
(b) At 09:32:25, Karachi Approach gave call, “Pakistan 8303 disregard turn left heading 180”. Aircraft parameters at this time were as follows: -
PIA 8303 Approach: ALT 4,100 ft / Distance 6.9 NM ~ FPA 5.9°
Standard Approach: ALT 2,300 ft / Distance 6.9 NM ~ FPA 2.9°
(c) 8 s later, aircraft was descending through 3,900 ft baro altitude. PIA 8303 replied, “Sir, we are comfortable now and we are out of 3,500 for 3,000 established ILS 25L”. ATC instructions were disregarded by flight crew verbalizing 3,500 ft to ATC while still at 3,900 ft and once again rounding down the actual altitude.
G/S* MODE Engagement due to Perturbations – At 09:32:34, AP Vertical MODE changed to Glide Slope Capture (G/S*). Aircraft was passing through 3,830 ft baro altitude and 6.5 NM from R/W 25L threshold. Despite being significantly above desired G/S, the G/S* MODE was engaged due to perturbations caused by the proximity of 3° G/S lobe top and 9° G/S lobe bottom. The criteria for G/S* MODE was met while aircraft being close to 6° G/S. Flight crew were unable to challenge the flight path.
ATC 5th Call (Turn Left Heading 180°) – At 09:32:38, Karachi Approach again called PIA 8303, “Negative turn left heading 180”. PIA 8303 responded, “Sir, we are established on ILS 25L”. Once again ATC instructions were disregarded by flight crew despite being significantly above the standard flight path.
ATC 6th Call (Caution)
(a) At 09:32:46, 3,090 ft baro altitude, 5.7 NM from R/W 25L threshold, CAS 242 kts, selected target speed CAS 225 kts and SLATS / FLAPS CONF1 was selected (VFE CONF1=230 kts). Pitch angle was -12.6° and still decreasing.
(b) At 09:32:46, Karachi Approach called, “Sir, you are five Miles from touchdown still passing 3,500”. At 09:32:51, PIA 8303 responded, “Roger”. Karachi Approach again cautioned that aircraft was still too high on the Approach path, however flight crew continued to press on high Approach.
Auto-Pilots (APs) Disengagement
(a) At 09:32:47, 2,730 ft baro altitude, 5.5 NM from R/W 25L threshold, pitch attitude reached -13.7°. This led to both APs disengagement due to excessive pitch down, as it exceeded 13° nose down. Rate of Descent reached 6,800 ft/min. FDs and A/THR remained engaged. Auto-Pilot OFF Warning triggered accordingly.
(b) Flight crew did not verbalize acknowledgement of the Master Warning. Flight crew did not monitor FMA, did not call out of AP disconnection and even no call out for manual takeover of the aircraft (Non-adherence to SOP, Golden Rules for Pilot FCTM / AOP / 40).
OVERSPEED Warning FLAPS1 Extended (VFE)
(a) 4 s later, almost simultaneous with the AP disconnection, “OVERSPEED” [Maximum speed with FLAPS Extended (VFE)] Warning triggered Master Warning along with CRC Aural Alert. The triggering condition for VFE Warning is VFE +4 kts with SLATS and / or FLAPS extended.
(b) Flight crew did not verbalize acknowledgement of the Master Warnings. They selected FLAPS beyond the VFE speed (Lack of application of procedures: Intermediate and final approach FCOM / PRO / NOR / SOP / 180).
First Sequence of GPWS Alerts – After 09:32:52, GPWS Alerts (GPWS MODE-1) triggered for 4 s. When “SINK RATE” Caution was triggered, flight crew did not call out GPWS Caution (airmanship and situational awareness FCOM / PRO / ABN / SURV / MEM / EGPWS Caution / Sink Rate). Just after GPWS Caution, there were 02 GPWS Warning of “PULL UP” that required an immediate Terrain Avoidance / Escape Manoeuvre. The procedure is a MEM item which is applied immediately by Memory to ensure a safe flight path as the flight crew has no time to refer to the ECAM / QRH / FCOM. However, flight crew did not perform this manoeuvre (Lack of situational awareness and application of abnormal procedures FCOM / PRO / ABN / SURV / MEM / EGPWS Warnings / PULL UP).
Landing Gears and Speed Brakes Retracted – At 09:32:57, Landing Gears were selected UP, and 2 s later Speed Brakes were retracted. 14 s later, Landing Gears were recorded Uplocked which is consistent with a nominal retraction sequence. Retraction of Landing Gears and Speed Brakes were not verbalized by either of the flight crew.
OVERSPEED Warning FLAPS2 / 3 Extended (VFE) – At 09:33:25, 1,180 ft baro altitude, 2.9 NM from R/W 25L threshold, CONF2 was selected at CAS 232 kts and 2 s later CONF3 was selected. FLAPS selection without speed check triggered a Master Warning and Red Alert on the ECAM. Indicating lack of application of procedures, intermediate and final Approach FCOM / PRO / NOR / SOP / 180. Flight crew did not verbalize acknowledgement of the Master Warning.
FO Suggested for an Orbit – At 09:33:33, 1,100 ft baro altitude and CAS 227 kts, FO was heard saying “Should we do the Orbit?” (in Urdu) to which Captain replied “No-No”, followed by “Leave it” (both in Urdu). This communication indicates FO has intention for an Orbit. Most probably Landing Gears and Speed Brakes were retracted by FO at 09:32:57.
Captain Took Over Controls – At 09:33:37, Captain took over controls by pressing sidestick PB along with pitch down inputs and small dual inputs were recorded during 4 s. The change of controls was not verbalized by either of the flight crew.
1,000 ft Stabilization Gate
(a) At 09:33:42, 1.9 NM from R/W 25L threshold, aircraft crossed 1,000 ft RA. This is the Stabilization Gate for IMC as per stabilization criteria provided in Airbus FCOM.
(b) The aircraft parameters deviation was more than the call out threshold. However, there was no “Un-Stabilized” call out by either of the flight crew, flight parameters exceedance was not monitored and no Go-Around was initiated. It indicated lack of procedure implementation in the domain of FCOM / PRO / NOR / SOP / 18 Intermediate and Final Approach, FCTM / PR / NP / SOP / 190 Trajectory Stabilization and FCTM / PR / NP / SOP / 260 Considerations about Go-Around.
“L/G GEAR NOT DOWN” Warning – At 09:33:48, aircraft was passing below 750 ft RA, 1.5 NM from R/W 25L threshold, CAS 217 kts (VFE CONF3 + 32 kts), Rate of Descent 2,100 ft/min, and Pitch attitude -5º. ECAM Red Warning “L/G GEAR NOT DOWN” and illumination of Red Arrow beside the Landing Gears Lever were triggered. The CRC and Master Warning Red light flashing were already active due to continued triggering of “OVERSPEED” VFE Alert. Flight crew did not monitor ECAM Warning and there was no call out of “L/G GEAR NOT DOWN” Warning (Lack of situation awareness and application of procedures).
500 ft Stabilization Gate
(a) 500 ft RA is Stabilization Gate for VMC as per stabilization criteria provided in Airbus FCOM.
(b) The aircraft parameters deviation was more than the call out threshold. However, there was no “Un-Stabilized” call out by either of the flight crew, flight parameters exceedance was not monitored and no Go-Around was initiated. It indicated lack of procedure implementation in the domain of FCOM / PRO / NOR / SOP / 18 Intermediate and Final Approach, FCTM / PR / NP / SOP / 190 Trajectory Stabilization and FCTM / PR / NP / SOP / 260 Considerations about Go-Around.
Second Sequence of GPWS Alerts – At 09:33:55 (440 ft RA), second sequence of GPWS Alerts triggered continuously until 09:34:16 (24 ft RA). CVR recording indicates that during this sequence a total of 13 Alerts were triggered: 10 “TOO LOW TERRAIN” Amber Cautions, 01 “SINK RATE” Amber Caution, and 02 “PULL UP” Red Warnings. On “SINK RATE” and “TOO LOW TERRAIN” (Amber Cautions), flight crew did not call out GPWS Caution (airmanship and situational awareness FCOM / PRO / ABN / SURV / MEM / EGPWS Caution / Sink Rate). On GPWS Warnings of “PULL UP”, that required an immediate Terrain Avoidance / Escape manoeuvre, flight crew did not perform any such manoeuvre (Lack of situational awareness and application of abnormal procedures FCOM / PRO / ABN / SURV / MEM / EGPWS Warnings / PULL UP).
Full Reverse Thrust Selected on Both Engines – At 09:34:23, crossing 7 ft RA, 200 kts CAS, full Reverse Thrust was selected on both Engines. Thrust remained at IDLE, but Thrust Reversers remained locked and did not deploy as aircraft was still airborne. ENG REV SET ECAM Alert associated with selection of Reverse Thrust in air was triggered along with a Single Chime Aural Alert and Master Caution Amber light. Flight crew selected Reverse Thrust in air instead of after MLG touchdown (Lack of Application of procedures FCTM / PR / NP / SOP / 250 / Reverse Thrust Efficiency).
R/W Contact and Go-Around
(a) At 09:34:28, aircraft both Engine nacelles made first contact with R/W. Maximum brake pedal inputs and opposite sidestick inputs were recorded from both flight crew (Captain: full nose down input, FO: 2/3 of full back input). At 09:34:36, Engine No. 2 Fire Alert triggered for 10 s along with associated Master Warning. At 09:34:42, FO said, “Take-off Sir, Take-off” (in Urdu), and 2 s later at 160 kts CAS, both TLA were advanced to TOGA for Go-Around. Aircraft got airborne at 09:34:45.
(b) The analysis of actions of both flight crew during R/W contact phase indicated an intention to Go-Around by the FO and intention to land out of same Approach by the Captain.
(c) Flight crew must not initiate a Go-Around after the selection of the Thrust Reversers. Regarding the Engine Fire Warning, the good airmanship should lead the flight crew to decide to stay on ground and stop the aircraft. (Lack of airmanship, situation awareness and application of procedures FCTM / PR / NP / SOP / 260 / Go-Around Near the Ground).
Flight Crew Actions after Go-Around
(a) At 09:34:52, 59 ft RA, CONF2 was selected, and third sequence of GPWS Alert initiated in which one “TOO LOW GEAR” Amber Caution was triggered. 5 s later, the flight crew instantly selected the Landing Gears Lever DOWN and UP. The duration was too short and there was no change in physical status of Landing Gears (UP and Locked). After getting airborne, the flight crew did not discuss about Gears Up landing and intended to fly ILS Approach for R/W 25L (lack of airmanship and situational awareness).
(b) At 09:36:12, 3,100 ft RA, Engine No. 2 Thrust Lever was reduced to IDLE, whereas Engine No. 1 Thrust Lever was kept at MCL. At 09:36:15, 3,000 ft RA, Engine No. 1 went to un-commanded IFSD and Engine No. 2 was at IDLE. Engine No. 2 (the only running Engine) remained at IDLE for about 1 min, until flight crew eventually realized it and Thrust Lever was re-advanced (lack of airmanship and situational awareness). After 1 min and 18 s (at 09:38:46), Engine No. 2 was operating at 65% nominal speed, multiple Stall Warnings were triggered and thereafter, aircraft altitude was continuously dropping. Aircraft Landing Gears were selected DOWN at 09:39:39 while descending below 800 ft. Aircraft altitude was continuously dropping and a sound similar to impact was heard in CVR at 09:40:18. Aircraft crashed 1,340 m short of R/W 25L threshold.
Possibility of Stopping the Aircraft on R/W (If Landing Gears were DOWN)81 – Airbus Engineering simulation considered the event flight touchdown parameters (189 kts GS, 4,500 ft down the R/W 25L threshold) and assumed Landing Gears were extended. The computed Operational Landing Distance (OLD) indicate the possibility of stopping the aircraft on R/W 25L using maximum reverse and maximum manual braking. There could have been a risk of tyre burst due to touchdown speed just below maximum tyre speed (195 kts GS).
Possibility of Safe Landing After Go-Around – It is not possible to predict or simulate the thrust available after damage to Engines during R/W contact. It is also not possible to estimate the additional power available if Engine No. 2 was not retarded to IDLE for about 1 min. Therefore, it could not be ascertained if safe landing options were available after Go-Around.
Flight Data Monitoring
(a) FDA Implementation by PIA
(i) FDA records indicated that Captain flew 289 flights in last 12 months prior to accident, out of which only 06 flights were analysed. Overall FDA rate for PIA was less than 5% and dedicated Flight Data Analyst was not available in PIA Safety Department till event flight. Since July, 2020, almost all flights are being analysed by a dedicated Flight Data Analyst.
(ii) After the accident, flights of Captain for last 12 months were analysed which indicated, numerous triggers during Approach related to High Speed, Path High, High Rate of Descent, Long Flare Distance and GPWS Warnings. There was no Go-Around initiated and several Unstabilized Approaches were continued.
