PIA Flight 268: Early Descent Error Causes Fatal Crash On September 28, 1992, Pakistan International Airlines Flight 268, an Airbus A300B4-103 registered as AP-BCP, crashed into the Mahabharat Range during approach to Kathmandu’s Tribhuvan International Airport, resulting in the deaths of all 167 individuals on board. The controlled flight into terrain (CFIT) incident remains Nepal’s deadliest aviation disaster and the most severe accident in PIA’s history. The flight, originating from Karachi, was conducting the complex "Sierra approach," requiring precise altitude adjustments at several distance-measuring equipment (DME) checkpoints. Investigators found that the aircraft initiated each descent step prematurely, placing it significantly below the required altitudes at various points. At 16 DME, it was 1,000 feet below the prescribed level, and at 10 DME, the discrepancy had increased to 1,300 feet. The aircraft collided with a mountain ridge at approximately 7,300 feet, south of the designated safe crossing altitude of 9,500 feet. Key factors contributing to the accident included pilot error, insufficiently clear navigational charts, and limited intervention by Nepalese air traffic controllers. While the flight crew accurately reported their altitudes, controllers failed to challenge their descent profile until moments before the impact. Visibility challenges due to overcast weather and the steep terrain further complicated situational awareness. Additionally, the Ground Proximity Warning System (GPWS) activated too late to prevent the crash. The accident investigation highlighted deficiencies in the approach plates issued to PIA pilots, which were deemed ambiguous. Recommendations included revisions to standardize navigational charts under ICAO guidelines and modifications to simplify the Sierra approach. Nepalese air traffic controllers' hesitancy to assertively manage deviations in terrain separation was also identified as a systemic issue. Despite these findings, no mechanical faults or terrorism were implicated. The absence of critical cockpit voice recordings hampered insights into the crew's decision-making process, although the flight data recorder provided sufficient evidence to outline the sequence of errors leading to the crash. This incident underscored the complexities of terrain-challenged approaches and the necessity for precise procedural compliance, clear communication, and robust charting to mitigate CFIT risks in similar operational contexts. Subscribe to our Aviation Safety Newsletter NOW and get the hot stuff free and without delay: https://lnkd.in/eGZqhPHR! Visit https://AEROTHRIVE.com for professional training courses, audits and solutions in aviation safety, compliance, quality and operations!
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When Plan A fails, it opens the door to adaptability, learning, and resilience. Here’s a breakdown of what happens next: Assessment and Reflection: When the initial plan fails, evaluating why it didn't work is crucial. This reflection helps uncover gaps in assumptions, resources, timing, or external factors. Activate Plan B (or C, D…): Successful planning involves having alternatives. Having a backup plan—or multiple contingency plans—helps ensure you’re not reliant on just one outcome. Learning from Mistakes: Failure is a powerful teacher. By examining the missteps, you gain insights into areas for improvement, making future plans stronger and more likely to succeed. Resilience and Adaptability: This is where resilience shines. Adjusting, pivoting, or even completely changing course can turn a failed attempt into a stepping stone toward eventual success. New Opportunities: Often, a failed plan reveals unforeseen opportunities or innovative paths that may have been overlooked. It’s a chance to be open to unexpected solutions. While Plan A might be ideal, it's often the plans that come after that prove the most rewarding. The flexibility and insights gained along the way can build a stronger foundation for long-term success. 4o
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???????? ?????????????? ???????? ???????? ?? ??????????? Have you ever wondered what happens when bad weather or unexpected events force a flight to divert? That's where Alternate Airports come into play! ???????? ???? ???? ?????????????????? ??????????????? An Alternate Airport is a pre-identified airport that can accommodate an aircraft in case of unforeseen circumstances, ensuring passenger safety. ?????? ?????????????????? ???????????????? ?????? ????????????????? 1. Weather conditions (fog, thunderstorms, etc.). 2. Air traffic control restrictions. 3. Aircraft technical issues. 4. Medical emergencies. 5. Security concerns. ???????????????????? ???? ???? ?????????????????? ??????????????! 1. Suitable runway length and surface. 2. Adequate lighting and navigation aids. 3. Communication equipment. 4. Emergency services (fire, medical, etc.). 5. Fueling and maintenance facilities. 6. Passenger handling capabilities. 7. Accommodation for crew and passengers (if needed). ?????????????????????? ????????! Did you know that pilots must plan for an alternate airport before every flight, considering factors like fuel reserves and weather forecasts? ????????????????????! Alternate airports play a vital role in ensuring aviation safety. They serve as a safeguard against unforeseen events, providing a secure and efficient contingency plan. Have you ever had to divert to an alternate airport? #AlternateAirport #AviationSafety #FlightPlanning #PilotLife #AirTrafficControl #AirportOperations #AviationIndustry #SafetyFirst
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Why did I share this? Because I think it highlights so clearly the need for better awareness and communication between operational roles in aviation! It raises so many questions, and a report will be forthcoming, but will it really address the very obvious question: Why are roles not training together more in aviation? As an example, I’ve lost count of the cyber security courses I’ve done, but I’ve never had any instruction on ground crew procedures for my home base airport. When do they run their runway inspections? Where do they enter and exit from? How long does it take? How can I be more aware? #aviationsafety #flightops #runwaysafety
An unusual incident occurred on June 25th at KPWM/Portland Jetport airport when an aircraft took off from a closed runway. First up, in the US, CTAF is common at smaller airports whose towers close overnight. So the takeoff “without clearance” is not the problem here. The issue was the runway was closed for works, and still occupied by ground crew. Initial reports suggest they maintained good SA and cleared the runway prior to any conflict occurring. The closure was NOTAM-ed. ATC attempted to contact the aircraft but were presumably on a different frequency, with ATC saying “I tried to warn them”. I wonder how that off the cuff mark might have felt had an accident actually occurred? Why were ATC not able to get hold of the crew on frequency? How did the crew miss the runway closure timing? Should ground crew be on the CTAF frequency? What safety protocols are in place, aside from the NOTAM (we all know how easy to miss they can be!) to provide another barrier to an event like this? This incident raises a lot of (quite easily answered) questions and highlights the HUGE need for better communication and awareness between different team roles in aviation at ALL TIMES! AvHerald report the incident, no official report has been issued yet. Let’s hope it focuses on how to stop these completely preventable incursion incidents from occurring. #aviationsafety #flightsafety #runwayincursion #aviationsafetyreport #runwayssafety https://lnkd.in/eKQKuHZQ
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"The report highlights five global high-risk categories of occurrence (G-HRCs) identified by ICAO. These G-HRCs are: controlled flight into terrain (CFIT), loss of control in-flight (LOC-I), mid-air collision (MAC), runway excursion (RE), and runway incursion (RI). In 2023, these G-HRCs collectively accounted for 100% of fatalities, 100% of fatal accidents, and 9% of the total number of accidents." https://lnkd.in/dUH8UHBK
In our 2024 Safety Report: Aviation safety amid the challenges of pandemic recovery - Uniting Aviation
https://unitingaviation.com
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An unusual incident occurred on June 25th at KPWM/Portland Jetport airport when an aircraft took off from a closed runway. First up, in the US, CTAF is common at smaller airports whose towers close overnight. So the takeoff “without clearance” is not the problem here. The issue was the runway was closed for works, and still occupied by ground crew. Initial reports suggest they maintained good SA and cleared the runway prior to any conflict occurring. The closure was NOTAM-ed. ATC attempted to contact the aircraft but were presumably on a different frequency, with ATC saying “I tried to warn them”. I wonder how that off the cuff mark might have felt had an accident actually occurred? Why were ATC not able to get hold of the crew on frequency? How did the crew miss the runway closure timing? Should ground crew be on the CTAF frequency? What safety protocols are in place, aside from the NOTAM (we all know how easy to miss they can be!) to provide another barrier to an event like this? This incident raises a lot of (quite easily answered) questions and highlights the HUGE need for better communication and awareness between different team roles in aviation at ALL TIMES! AvHerald report the incident, no official report has been issued yet. Let’s hope it focuses on how to stop these completely preventable incursion incidents from occurring. #aviationsafety #flightsafety #runwayincursion #aviationsafetyreport #runwayssafety https://lnkd.in/eKQKuHZQ
Reader Comments: (the comments posted below do not reflect the view of The Aviation Herald but represent the view of the various posters)
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The 400% increase in GPS spoofing incidents presents significant safety risks for aviation. This interference can cause false alerts in Enhanced Ground Proximity Warning Systems (EGPWS), leading to unnecessary go-arounds and heightened pilot workload, which may compromise flight safety. The establishment of a GPS Spoofing Workgroup underscores the urgency of addressing this issue, aiming to develop mitigation strategies and enhance industry awareness. However, the aviation industry must act swiftly to implement effective solutions to prevent potential accidents and ensure passenger safety.
400% increase in GPS Spoofing; Workgroup established
https://ops.group/blog
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Air crash investigation – Elmina air crash cause revealed. There are some air crash investigations that have remained unsolved, The most notable one is Malaysia Airlines MH370. On March 8, 2014, MH370 vanished from radar less than an hour after take-off. Despite extensive search efforts, only a few debris pieces linked to the plane have been found. The main wreckage, including the flight data recorder and cockpit voice recorder, remains missing. What happened to the aircraft and its 239 passengers is still unknown. In contrast, the Malaysian Air Accident Investigation Bureau (AAIB) recently solved one significant mystery. On August 16, 2024, they concluded their investigation into the crash of a Hawker Beechcraft 390 Premier 1 at Elmina, Shah Alam, Malaysia. Human error by the flight crew was determined to be the primary cause. The AAIB revealed that an unrated pilot inadvertently extended the spoilers, causing the plane to stall and crash two minutes before landing. The 148-page report provided a detailed account of the accident, emphasizing the importance of adherence to procedures. The role of the AAIB is not to assign blame but to enhance aviation safety by identifying the causes and contributing factors of accidents. Their goal is to prevent similar incidents from happening in the future. In this case, they found that deviations from standard operating procedures, inadequate crew training, regulatory grey areas, and poor communication all contributed to the crash. Two earlier accidents near Subang International Airport highlight the importance of proper crew training and communication – two key areas the AAIB addressed in their recent findings. On September 27, 1977, Japan Airlines Flight 715 also crashed near the Elmina Estate. The DC-8 captain, flying a non-precision approach in bad weather, descended below the decision height of 750 feet and crashed into a hillside. The first officer failed to challenge the captain, likely due to a lack of assertive support training. Today, such training might have prevented this tragedy. I remember this case vividly as I was holding in the air for the weather to improve at the same time on that day. On February 19, 1989, Flying Tiger Line Flight 66, a Boeing 747, crashed near Subang Airport. The cause was a miscommunication between the crew and air traffic control. The plane had been cleared to descend to 2,400 feet, but the crew mistakenly interpreted this as clearance to 400 feet. As a result, the aircraft descended 2,000 feet lower than instructed and crashed into a hillside. These examples demonstrate the value of air crash investigations. The airline industry has implemented numerous safety improvements, thanks to recommendations from past incidents. Mandatory Crew Resource Management (CRM) training and standardized phraseology in communications are just two examples of how the industry has evolved to prevent further accidents. Air Crash Investigators at Work
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Points to ponder
Author of ‘Life in the Skies’ and ‘Sky Tales.’ A retired airline pilot, flight simulator instructor & non-practising lawyer. Called to the Malaysian Bar at the age of 75.
Air crash investigation – Elmina air crash cause revealed. There are some air crash investigations that have remained unsolved, The most notable one is Malaysia Airlines MH370. On March 8, 2014, MH370 vanished from radar less than an hour after take-off. Despite extensive search efforts, only a few debris pieces linked to the plane have been found. The main wreckage, including the flight data recorder and cockpit voice recorder, remains missing. What happened to the aircraft and its 239 passengers is still unknown. In contrast, the Malaysian Air Accident Investigation Bureau (AAIB) recently solved one significant mystery. On August 16, 2024, they concluded their investigation into the crash of a Hawker Beechcraft 390 Premier 1 at Elmina, Shah Alam, Malaysia. Human error by the flight crew was determined to be the primary cause. The AAIB revealed that an unrated pilot inadvertently extended the spoilers, causing the plane to stall and crash two minutes before landing. The 148-page report provided a detailed account of the accident, emphasizing the importance of adherence to procedures. The role of the AAIB is not to assign blame but to enhance aviation safety by identifying the causes and contributing factors of accidents. Their goal is to prevent similar incidents from happening in the future. In this case, they found that deviations from standard operating procedures, inadequate crew training, regulatory grey areas, and poor communication all contributed to the crash. Two earlier accidents near Subang International Airport highlight the importance of proper crew training and communication – two key areas the AAIB addressed in their recent findings. On September 27, 1977, Japan Airlines Flight 715 also crashed near the Elmina Estate. The DC-8 captain, flying a non-precision approach in bad weather, descended below the decision height of 750 feet and crashed into a hillside. The first officer failed to challenge the captain, likely due to a lack of assertive support training. Today, such training might have prevented this tragedy. I remember this case vividly as I was holding in the air for the weather to improve at the same time on that day. On February 19, 1989, Flying Tiger Line Flight 66, a Boeing 747, crashed near Subang Airport. The cause was a miscommunication between the crew and air traffic control. The plane had been cleared to descend to 2,400 feet, but the crew mistakenly interpreted this as clearance to 400 feet. As a result, the aircraft descended 2,000 feet lower than instructed and crashed into a hillside. These examples demonstrate the value of air crash investigations. The airline industry has implemented numerous safety improvements, thanks to recommendations from past incidents. Mandatory Crew Resource Management (CRM) training and standardized phraseology in communications are just two examples of how the industry has evolved to prevent further accidents. Air Crash Investigators at Work
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727 Bay Crash: Inadequate Situational Awareness and CRM On May 8, 1978, National Airlines Flight 193, a Boeing 727-235 registered as N4744, was en route from Miami, Florida to Pensacola with multiple stopovers. The final leg of the journey encountered complications leading to the aircraft crashing into Escambia Bay near Pensacola Regional Airport, resulting in three fatalities and numerous injuries among the 58 occupants. The flight experienced low visibility due to fog during its descent into Pensacola. The instrumental landing system (ILS) for the usual runway had been out of commission since January, necessitating the use of a non-precision approach to an alternate runway. Despite available visual aids like the operational Visual Approach Slope Indicator (VASI) for runway 25, the flight crew was not aware of them. Analysis indicates several lapses in communication and procedure adherence which directly contributed to the accident. The first officer did not perform standard altitude and approach fix callouts during the approach. Additionally, when the ground proximity alarm activated, the first officer misread his altimeter, mistakenly shutting off the alarm at a critically low altitude. The situation was further exacerbated by a radar control error, directing the aircraft to intercept the final approach path at less than the recommended distance, placing the aircraft too close to the runway without adequate time for proper configuration. This misjudgment by the radar controller was noted in the National Transportation Safety Board (NTSB) report as a significant factor in the crash. The cockpit crew's handling of the aircraft during this high-stress scenario was less than optimal. There was a notable delay in deploying the landing gear as the captain was attempting to manage the hydraulic demands of the aircraft. The first officer’s mental pacing did not align with the actual descent rate, causing a lapse in necessary altitude callouts. Post-accident evaluations revealed that the evacuation was hindered by a lack of adequate life-saving equipment. The aircraft, not required by regulations to carry liferafts or approved flotation seat cushions for the route flown, left passengers reliant on insufficient flotation aids. Many passengers were also unaware of how to access or use life vests, a fact compounded by the rapid ingress of water into the cabin. The NTSB identified critical errors in CRM, situational awareness, and adherence to standard operating procedures. The accident led to discussions and eventual regulatory changes regarding equipment requirements and crew training to enhance safety in similar flight conditions. Subscribe to our Aviation Safety Newsletter NOW and get the hot stuff free and without delay:?https://lnkd.in/eGZqhPHR! My accident reviews are short summaries of publicly available accident reviews and reports and do not constitute any interpretation nor express my opinion or the opinion of any organization.
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One of the major risks to modern aviation. The French BEA released the final report to a serious incident of a near collision with the terrain. CFIT. Very interesting report Unfortunately it ignores the vulnerabilities of GNSS RFI on the foreword progress of the industry in finding a solution. It also does not suggest solution to other than wrong pilot setting as a source of altimeter error such as barometric measuring equipment errors. Still a very important report A must to industry professionals. https://lnkd.in/dT3TySSj
9H-EMU_EN.pdf
bea.aero
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Did you know that foreign object debris (FOD) damage causes the aviation industry an estimated $4 million a year, not to mention disastrous outcomes should the debris injure you or your passengers. If you work at an airport, put your hand up to participate in a FOD walk, to identify hazards that could jeopardise the safety of aircraft on the runway. Read about how airports and operators can manage the risk of FOD to prevent an accident from occurring: https://lnkd.in/gFHaeQ5w #aviationsafety #airportsafetyweek #foreignobjectdebris #fod #runway #aaa #casa
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