reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2012 B737 windshear & GPWS Islamabad Pakistan

Brief account : 

During an ILS approach with severe thunderstorms in the vicinity the aircraft encountered a down-burst. The crew did not react properly to either windshear or subsequent GPWS warnings and the aircraft was destroyed on impact 4 miles short of the runway. 

Crew-related factors : 

There were many contributory failings which led to the crew being in this situation. Both were reasonably experienced pilots but had not been adequately trained, particularly in relation to the automation fitted to this aircraft. The F/O was under-confident and of marginal competence, and had for a long time been unofficially "mentored" by the Captain, whom he had followed to the airline from their previous employer about 3 months before the accident. 70% of all their flying since then had been together.    

The weather was severe but the Captain seemed committed to landing. The F/O expressed his fears about what they were encountering numerous times. The autopilot locked on to the ILS localiser and glideslope although the aircraft was not configured correctly. When the aircraft encountered the first storm cell the Captain did not respond to the wind-shear alert, leaving the autopilot and autothrust engaged. It transpired that neither pilot had received the relevant training.  

The report notes that "In the same extreme anxiety and desperation FO shouted “go around, go around” at 18:39:29.3 hrs, but no action was taken by the Captain (PF), and FO (PNF) also did not take over the controls of aircraft to initiate a go around"   

Subsequently, the aircraft deviated below the glideslope and off the localiser. Stall warnings occurred and the autopilot disengaged as another downburst was encountered, and a GPWS alert was triggered. The F/O again called for a go-around again about 10 seconds before impact but the Captain did not respond. Finally the report states that "At 18:39:57.1 hrs, FO was observed shouting in desperation / anxiety and telling Captain “go around, go around sir, go around” [as the aircraft CVR terminated]". "Neither the Captain nor the FO followed Boeing recommended remedial procedures / actions due to their lack of knowledge, training and experience to handle this type of abnormal situation".

In this event the flight was effectively being operating by a single pilot (the Captain) assisted by the F/O, not by two pilots functioning as an integrated crew, and the traditional PF/PM procedure makes it very easy for this to happen.

No flight deck SOP can guarantee to deal with all the individual weaknesses, inadequate training, and other organisational lapses such as those that led to the catastrophic outcome. However if PicMA had been the SOP, as it positively requires both pilots to participate in the operation it can go a considerable way to mitigate them, by its long term effect in forcing crews to become accustomed to proper collaboration and working together, rather than just advocating it as a beneficial concept.

Type: 
B737-200
Where: 
Islamabad Paksitan
Expected weather: 
Instrument
Pilot in charge: 
Capt
Early transition: 
No
Go-around : 
No
Damage: 
Serious
PicMA potential: 
Major
Year: 
2012
Time: 
Day
Deterioration: 
Yes
Vert Guidance: 
G/S
Both Head Up: 
No
LoC: 
Yes
Operator: 
Bhoja
Fully prepared: 
Yes
Actual Weather: 
Thunderstorm
Autopilot : 
Y
CCAG: 
High