Assignment

Topic

Program: BSAM Semester: 8

Course: Aircraft Accident Investigation Section: B

Assignment No: 2 Assigning Date:

Name: AKASH SAP-ID: 70109246

Due Date: Submission Date: 08/03/2024

Remarks:

Marks: / 10
Instructor’s Signature
ACCIDENT OF PIA FLIGHT PK8303 AIRBUS A320-214 REG NO AP-BLD
CRASHED NEAR KARACHI AIRPORT ON 22-05-2020

TABLE OF CONTENTS

• Brief description
• Constitution / composition of the investigation team
• Scope / purpose of investigation
• Custody of records of aircrew, ATCOs and aircraft
• Crash site
• Mapping and identification of aircraft parts
• Wreckage removal and collection of vital evidence
• FDR / CVR readout activity at BEA, Paris France
• Preliminary findings
• Way forward
• Summary

Brief Description:
On May 22, 2020, at 13:05 hrs.' PST, the Pakistan International Airlines Airbus A320-
214, registration number AP-BLD, took off from Lahore (Allama Iqbal International
Airport) for a scheduled commercial passenger flight (PK8303) to Karachi (Jinnah
International Airport) with 8 crew members and 91 passengers on board. The flight
faced a series of challenges during its approach and landing at Karachi Airport,
including a touchdown without landing gear and a subsequent go-around. However,
during the downwind leg, both engines failed, leading to a rapid descent and eventual
crash in a populated area near the airport. Tragically, out of the 99 individuals on board,
97 were fatally injured, with only two passengers surviving. On the ground, four people
were injured, and one of them reportedly succumbed to their injuries later at a hospital.

Constitution/Composition of the Investigation Team:

The investigation was initiated by the Federal Government under Civil Aviation Rules
(CARs) 1994. The investigation team was comprised of four members initially, including
the Investigator In-Charge, Operations Investigator, and members responsible for
technical and ATS (Air Traffic Services) investigation. According to CARs 1994 and
ICAO Annex 13, co-opted members, as well as Accredited Representatives
(ACCREPs), were added, bringing the total number of team members to 12. These
members encompass AAIB Pakistan investigators, BEA France investigators, NTSB
USA investigator, co-opted members, and advisors.

Scope/Purpose of Investigation:
This safety investigation conducted by AAIB adheres to ICAO Annex 13 and CARs
1994. Its primary objective is to prevent accidents and incidents of similar nature, not to
assign blame or liability. It is essential to note that this report should not be used to
determine fault or liability. The publication of this preliminary report aims to inform the
aviation industry and the public about the general circumstances of the event, following
international guidelines.

Custody of Records of Aircrew, ATCOs, and Aircraft:

Aircrew records related to medical fitness, licensing, training, and personal documents
were collected from relevant authorities and PIA. ATCOs' records, including licensing,
training, medical fitness, and duty rosters, were also secured. Aircraft technical
documents, records, and logbooks were collected from PIA and are now in the custody
of AAIB.

Crash Site:
The crash site is situated in a residential area northeast of Jinnah International Airport.
The wreckage is approximately 1,340 meters from the runway threshold and is spread
over a 75-meter area, with some aircraft parts found on the roofs of nearby houses.
Mapping and Identification of Aircraft Parts:
Most of the aircraft parts were found on the southern side of the street. Nearby
buildings had heights ranging between 9 and 11 meters. A mapping of the wreckage
showed parts on rooftops (marked in green) and on the ground (marked in orange). The
layout indicated a low-speed impact with buildings on both sides of the street.
Configuration details at impact included:
• Tailplane (THSA) at 2.8 degrees nose up.
• Speed below 150 knots indicated airspeed.
• Landing gear configuration without the free-fall mechanism.
• Slat at position slat 1 (18 degrees), with flaps retracted to 0 degrees.
• Ram Air Turbine (RAT) deployed before impact.

Wreckage Removal and Collection of Vital Evidence:

 Various aircraft components were identified and removed from the crash site. Vital
components preserved included the Flight Data Recorder (FDR), Cockpit Voice
Recorder (CVR), Enhanced Ground Proximity Warning System (EGPWS) computer,
Quick Access Recorder (QAR) computer, Flight Controls Data Concentrator (FCDC)
computer, and Air Data Inertial Reference Unit (ADIRU) computer. FDR and CVR were
transported to BEA in France for analysis. The CVR underwent comprehensive
examination due to fire damage, while the FDR, in good condition, facilitated
straightforward data retrieval. Advanced analysis of FDR and CVR data was conducted
at BEA.

FDR / CVR Readout Activity at BEA, Paris, France:

• Transportation to BEA: The Flight Data Recorder (FDR) and Cockpit Voice
Recorder (CVR) were carefully transported to the Bureau d'Enquêtes et
d'Analyses pour la Sécurité de l'Aviation Civile (BEA) in Paris, France. This
significant step took place on a dedicated flight on June 1, 2020, under the
personal custody of the investigator in-charge.

• Examination and Technical Tasks: After their arrival at BEA, an in-depth

examination was carried out. On June 2, 2020, technical checks and related
tasks were undertaken with meticulous attention to detail. These activities were
conducted in the presence of the investigator in-charge, ensuring the integrity
and accuracy of the process.

Preliminary Findings:
The initial findings from the investigation into the crash of PIA Flight PK8303 on May 22,
2020, are based on a thorough analysis of available evidence, which includes data
obtained from the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR), as
well as CCTV/security camera footage from Jinnah International Airport (JIAP) and
radar data provided by "Karachi Approach."
The preliminary findings offer insight into several critical aspects of the flight:
• Weather Conditions: The weather conditions at the departure, en-route, and
destination airfields were reported as suitable for the flight.
• Flight Sequence: The flight took off from Lahore's Allama Iqbal International
Airport (AIIAP) at 13:05 hrs. The departure and cruising phases were largely
uneventful. However, it was observed that the flight crew did not consistently
adhere to standard procedures and crew resource management (CRM)
principles during various phases of the flight.
• Approach to Jinnah International Airport: During the approach to Jinnah
International Airport, the aircraft was cleared to follow the "Nawabshah 2A"
arrival procedure and was informed to anticipate an Instrument Landing System
(ILS) approach for runway 25L. Notably, the aircraft found itself at a higher
 altitude than the required descent profile. To shed the excess altitude, the crew
activated the "OPEN DES" mode, disengaged both autopilots, and extended the
speed brakes.
• Height Advisory: Despite multiple advisories from "Karachi Approach" regarding
the aircraft's excessive altitude, the landing approach was not aborted. The
aircraft proceeded to intercept the localizer and glide slope with its landing gear
extended. However, at a point approximately 5 nautical miles from the runway,
the landing gear was retracted, and the speed brakes were also retracted. This
sequence of actions triggered over-speed and Enhanced Ground Proximity
Warning System (EGPWS) warnings.
• Initial Landing Attempt: During the initial landing attempt, both engines of the
aircraft contacted the runway, causing friction and damage. Subsequently, the
landing was abandoned, and a go-around procedure was initiated. The flight
crew declared a "Mayday" emergency due to engine failures. The aircraft
eventually crashed approximately 1340 meters short of runway 25L. This impact
occurred at a low speed with a high angle of attack. Notably, the aircraft's
configuration indicated that the landing gear was extended while the flaps were
retracted.
These preliminary findings offer a crucial understanding of the sequence of events that
led to the tragic crash of PIA Flight PK8303. The investigation is ongoing, and further
analysis will be conducted to determine the underlying causes and contributing factors,
as well as to develop safety recommendations for future aviation safety enhancements.

Way Forward:
The continuation of the investigation will encompass several important steps. This
includes advanced analysis of FDR and CVR data, a detailed technical analysis of
aircraft and engine components, exploration of reasons for the anomalies discovered in
the preliminary findings, and an examination of potential shortcomings in various
aspects of the flight.
Planned activities also include scrutinizing aircrew and Air Traffic Control Officers
(ATCOs) records, analyzing aircraft documents, evaluating maintenance records, and
assessing the actions taken by ATCOs and the operator (PIA). The investigation will
also analyze pilot performance, CRM, and safety management systems.
Collaboration with Accredited Representatives (ACCREPs) from the Bureau d'Enquêtes
et d'Analyses pour la Sécurité de l'Aviation Civile (BEA) and the National Transportation
Safety Board (NTSB) is planned. This collaboration will involve the reconstruction of the
flight profile after FDR data is no longer available and in-depth discussions on actions
and decisions throughout the flight.
These ongoing steps are critical for gaining a comprehensive understanding of the
circumstances leading to the PIA Flight PK8303 crash and for formulating safety
recommendations to enhance future aviation safety.

• Challenges with CVR: The Cockpit Voice Recorder (CVR) posed unique
challenges due to damage incurred during the post-impact fire. This required a
comprehensive approach, involving the removal of the connector and flex cable.
 Following this, a series of examinations was conducted, encompassing visual
microscopic inspections, electric checks, and data readout on a specialized
"golden chassis."

• FDR Data Retrieval: In contrast to the CVR, the Flight Data Recorder (FDR) was
found to be in a good state. This facilitated a relatively straightforward process of
opening FDR and retrieving its data. This included a recording of the entire
activity, in adherence to recommended practices, ensuring a comprehensive
record of the process.

• Advanced Analysis: Advanced analysis of the FDR and CVR data commenced
at BEA, Paris, France, after their retrieval and validation. The team at BEA was
actively engaged in the analysis, with discussions and preliminary findings
evolving between June 2 and June 5, 2020. Detailed reports and insights would
be subsequently furnished as the investigation progresses.

Summary:
This Preliminary Report is being issued in strict adherence to the guidelines set forth in
ICAO Annex 13 para 7.1 and 7.5, as well as para 2 of the official Notification No Ref AT-
13(1)/2020, dated 22 May 2020, which was issued by the Federal Government. The
purpose of this report is to provide a comprehensive understanding of the progress
made in the investigation thus far, including the tasks that have been completed to date,
a summary of key findings, and an outline of the remaining steps in the investigative
process.
The objective of this Preliminary Report is to offer a preliminary view of the situation and
the initial insights that have been garnered. It's important to note that the information
presented in this report is based on the data and evidence available up to this point.
The findings are not final, and further in-depth analysis is required to uncover the root
causes and contributing factors of the accident.
The investigative process will continue to evolve, encompassing advanced analysis
aimed at uncovering the underlying causes of the incident. This will culminate in the
compilation of a draft final report, which will subsequently be shared with the Accredited
Representatives (ACCREPs) in accordance with the pertinent provisions outlined in
ICAO Annex 13.