reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2010 A321 CFIT Islamabad Pakistan

Brief account : 

The crew of an A321 lost contact with the runway during a visual circling approach and continued in IMC outside the protected area and flying into terrain after repeatedly ignoring EGPWS Terrain Alerts and PULL UP Warnings. The Captain had pre-planned a non-standard circuit which had been continued into IMC, and had then failed to maintain situational awareness, control the aircraft through correct FMU inputs or respond to multiple EGPWS Warnings. The inexperienced First Officer appeared unwilling to take control in the absence of corrective action by the Captain. 

Crew-related factors : 

The authority gradient was extremely high, a Captain of 61 years and over 25000 hours and an FO of 34, 1800 hours total and less than 300 on type.  The Captain had adopted a domineering attitude to the FO from the start of the flight.  

The Captain appeared to have become fixted on using an unofficial set of waypoints to fly a much wider circuit than was appropriate or recommended by ATC. The impact point was close to one of the waypoints on this non-standard flight plan inserted into the FMS earlier by the crew. The track actually flown by the aircraft was found to have taken it beyond the designated protected area for a circling approach.

Over a period of 70 seconds prior to impact, there were 5 Terrain Ahead Cautions, 13 Terrain Ahead PULL UP Warnings, one reactive Terrain Caution and the final two reactive PULL UP Warnings. The First Officer had appeared to be fully aware of the importance of acting on the EGPWS Alerts, and the Investigation concluded that he had "simply remained a passive bystander in the cockpit and did not participate as an effective team member, failing to supplement / compliment or correct the errors of his Captain assertively in line with the teachings of CRM due to the Captain’s behaviour (earlier) in the flight".

Given the Captain's attitude it is hard to know whether he would have respected a different crew procedure anyway, particularly given that the accident occurred during an allegedly "visual" circuit. However, had the company SOP been PicMA it might have led to 

1) earlier action being in training and checking to cause him to respect other aspects of SOPs  

2) more in-depth discussion of the terrain and its relation to the desired circuit prior to this approach 

3) a greater degree of experince of setting up approaches for the FO, which might have led to an increased level of confidence.      

Type: 
A321-100
Where: 
Islamabad Pakistan
Expected weather: 
Visual
Pilot in charge: 
Capt
Early transition: 
Yes
Go-around : 
No
Damage: 
Serious
PicMA potential: 
Major
Year: 
2010
Time: 
Day
Deterioration: 
Yes
Vert Guidance: 
None
Both Head Up: 
No
LoC: 
Yes
Operator: 
Air Blue
Fully prepared: 
No
Actual Weather: 
Thunderstorm
Autopilot : 
Y
CCAG: 
High