Karachi Beechcraft 1900 crash

Accident

The aircraft was scheduled to fly chartered flight from Jinnah International Airport, Karachi to Bhit Shah Oil Fields to convey 17 employees of Eni company including one foreign national from Italy. The flight was registered as Jahangir Siddiqui Air Flight 201 (JS201). At the time of the accident, the plane was operating its first flight. At 01:55 UTC the cockpit crew contacted Karachi Ground for take off. The Karachi Ground Controller said “copied JS-201 start up approved runway two five left” which was acknowledged by cockpit crew. Captain cleared the area towards left side and started the Engine No 1.

The cockpit crew then requested Karachi Ground for the taxi instruction. After the instruction from Karachi Ground, they conducted a pre-take off checklist. At this point, right engine propeller feathering was checked in manual position. As per procedure run up checks are supposed to be carried out and feathering function of both engines is to be checked simultaneously, however, cockpit crew in this case only checked No 2 engine feathering mechanism serviceability manually contrary to the documented procedures.

At 02:03 UTC, the plane was cleared for take off. Soon after take off, the right engine went out, and the speed started to decrease slightly. The First Officer then put the engine into feathering position. At this stage, it is considered that probably the First Officer may have observed partial feathering due to which he wanted to feather the propeller of engine No 2 which was approved by Captain contrary to the documented procedures of no remedial action below 400 ft above ground level. It is important to note that the actual problem being discussed amongst the cockpit crew was related to No 2 engine, whereas at this stage Captain advised the First Officer to inform ATC Tower that they had problem with engine No 1 which indicates the confused state of mind, pre occupation and lack of situational awareness on part of Captain.

The First Officer later on reported a problem on engine No 1 (as based on his Captain advice), which in reality based on the First Officer's observation, he realized that the engine with abnormality occurred in engine no 2, but somehow followed his Captain's advice to report to the tower that they had problem with engine no 1.

The ATC cleared the aircraft for an emergency landing in Karachi. The cockpit crews later acknowledged. This was the last transmission from the aircraft to the tower. The Captain later noticed that the First Officer was moving the engine No 2 feather control lever and asked him "What are you doing?". The First Officer then told the Captain that the engine was not feathering. At this point, the speed of the aircraft was at 102 knots with increasing pitch attitude as well as right angle of bank and first time it is observed that Captain told First Officer to wait and hold his ongoing actions.

Then, further reduction in engine sound was observed. At this stage, it was evident that right bank was continuously also increasing due to full power on serviceable engine No 1 and as the power on engine No 1 was reduced indicated by reduction in engine noise, the right angle of bank started to decrease subsequently. It is important to note that the aircraft at this stage was flying at very low airspeed which was close to the stalling speed with landing gears down and at maximum all up weight.

An increase in engine sound occurred and a stall warning sounded until the end of the recording. At this stage, Captain was sure that the aircraft would be either forced landing on unprepared surface or impact the ground due to stalled state of aircraft, as in the Cockpit Voice Recorder (CVR), it was heard that he was saying several holy verses from the qur'an and saying "Bismillah (In the name of God)". Ground proximity warning “whoop, whoop” sounded till end of recording. The aircraft later hit the ground.

The accident aircraft was a privately chartered plane carrying people to a nearby facility managed by Eni, an Italian oil and gas company.

Nationalities of passengers

17 ENI passengers, 2 pilots, 1 technician and 1 security guard

The Captain was a Pakistani national born on 14 August 1957 at Karachi. He was described as quite religious and had a beard. He joined Pakistan Air Force (PAF) Academy in Risalpur in 1977 as trainee pilot. During his service career he flew various training / fighter and light communication aircraft including MFI-17, T-37, FT-5, FT-6, Piper (Seneca-II), Beech Baron, Y-12, Super King (B-200), Cessna-172 and Cessna-402 aircraft. He retired at the rank of Squadron Leader from PAF in 2003 while accumulating 6,279 hours. He started to fly as First Officer in JS Air on 13 June 2006. The Captain had accumulated a total flying experience of 8,114 hours.

The First Officer was a Pakistani national born on 16 February 1977. He was given multi-engine aircraft rating on Cessna-402 aircraft on 23 December 2004 after completing all requirements / formalities by CAA Pakistan. He joined JS Air and underwent his Beechcraft-1900 ground and simulator training at Farnborough Learning Centre, United Kingdom from 30 October 2006 till 10 November 2006 and successfully accomplished his training. After completing his flying training at JS Air, he was cleared by CAA Pakistan to fly as Co-pilot under supervision on 13 February 2007. The First Officer had accumulated a total flying experience of 1,746 hours.

Investigation

An inquiry has been ordered into the crash. There were several things that investigator probed as the probable cause of the accident, which are bird strike, in-flight structural failure, sabotage, in-flight fire, pilot incapacitation, mechanical failure, or pilot error. However, there were no evidence indicating a bird strike, pilot incapacitation, sabotage and an in-flight structural failure. All of them were ruled out. Investigators later ruled out in-flight fire as the cause of the accident, as the fire occurred on the flight was due to post-impact rather than a pre-impact fire.

The investigation started with the examination on the plane's propellers, as evidence found by investigators (from the CVR) suggested that an engine failure occurred in mid-flight. Investigators retrieved the propeller from the wreckage and stated that the beta valve in the aircraft may have malfunctioned in mid flight. There are two possibilities of beta valve malfunction; mis-rigging after some maintenance work or fair wear & tear during routine service. Unfortunately, the beta system’s integrity and rigging status could not be verified because the propeller governor had been completely consumed in the post ground impact fire. However, it was confirmed from the documented history and the engineering staff that there was neither any reported defect related to the beta system nor was there any scheduled or unscheduled maintenance performed in the recent past. Therefore, the only probable cause of occurrence could be fair wear and tear of the beta valve.

However, investigators stated that even if a mid-air engine failure occurred, the pilots still could returned to the airport safely. It was revealed that if an aircraft had a mid air engine failure in one of its engine, the plane still could fly. All twin engine aircraft are designed to sustain a safe flight even if one of the engines has failed or is switched off due to any abnormality provided the emergency handling procedures are correctly followed. Similarly, Beechcraft 1900C also had the capability to sustain safe flight with single engine operation. This suggests that pilot error maybe the main cause of the accident.

Investigators reviewed the CVR data and stated that the pilot may have lacked situational awareness. After experiencing the abnormal engine No 2 operation, at one stage the cockpit crew indicated confusion about the engine No 1 or 2 and subsequently transmitted incorrect information to the ATC Tower that they were experiencing abnormal operation of engine No 1. The First Officer was exposed to serious level of stress and anxiety when he observed the propeller feathering of No 2 (right) engine. The situation was aggravated due to the fact that the auto feathering was selected to “Off” which entailed the cockpit crew to manually manage feathering of Propeller in case of any anomaly. He did communicate to the Captain correct information, however, Captain did not register engine No 2 and told him to inform ATC Tower that they were experiencing problem with engine No 1 and FO communicated the same without questioning Captain or correcting himself. He got mentally pre-occupied to a level where he could not perform the recommended remedial action. Thus, he did not effectively contribute towards handling of abnormal set of conditions.

As investigators checking the flight history of the Captain, it was revealed that the Captain, his performance, during his simulator training check flights, remained almost the same. He could not safely handle these training exercises during critical phases of takeoff / just after takeoff without briefing to achieve the satisfactory performance level in these mandatory exercises. The report also stated that the Captain was "lack of confident". Investigators also revealed that the Captain lacked the required proficiency level / skill to independently handle the aircraft operations with single engine during critical phases of flight.

Even though the Captain had the most mistakes, the First Officer was also noted by the CAA in his failure of raising the landing gear while an in-flight emergency occurred. Investigators concluded that cockpit crew neither discussed nor raised the landing gears after takeoff. The wreckage also confirmed the landing gears in extended position at the time of ground impact. The Beechcraft-1900C aircraft will have very low rate of climb with landing gears in down position due to increased drag while operating with single engine. Any angle of bank is going to aggravate the situation and the marginal rate of climb would at one stage change into a rate of descend which actually happened in this particular case. The First Officer was a qualified Captain on Beechcraft-1900C aircraft, however his actions and assistance available to the Captain of aircraft was not at optimum level. He failed to retract the landing gears after takeoff and undertook remedial actions well below the defined minimum safe altitude contrary to the recommended procedures, which shows his pre-occupation, anxiety and stress in handling abnormal situation. Due to these non conformances, the aircraft failed to achieve the safe flying parameters despite having a serviceable engine.

On December 18, 2015 Pakistan's Safety Investigation Board released their final report stating that the accident was caused by the inability of the captain to handle the abnormal operation of engine No 2 just after takeoff, failure of the cockpit crew to raise the landing gear after experiencing the engine anomaly, and execution of remedial actions by the First Officer before the attainment of minimum safe altitude. The crew did not follow standard procedures, did not take proper actions, lacked situational awareness, experienced Crew Resource Management failure, and handled the anomaly unprofessionally.

Aftermath

The crash prompted Eni Chief Executive Paolo Scaroni to head to Pakistan with the head of Eni's exploration and production division, Claudio Descalzi. Dawn reported that the crash was "a reminder of the need to constantly review and enforce air safety protocols in Pakistan", though noted that while the country "has generally had a good air safety record" that this crash happened "while memories of the catastrophic Air Blue crash – the worst aviation disaster in the country's history – are still fresh". The Express Tribune also said the crash evoked memories of the previous crash, noting that the coverage was "reminiscent of that of the Airblue crash" because "soon after the crash, images of the site splashed onto TV screens, with bulletin after bulletin giving detailed coverage, implicit with the promise that this tragedy will be investigated and justice will be done".