Pakistan International Airways Flight 8303 Preliminary Report - Oof

"For Sweden" (rallybeetle) 06/24/2020 at 13:00 • Filed to: Pakistan International Airways Flight 8303, Pakistan International Airways, Pakistan, Aviation, Planelopnik

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Some key preliminary findings (direct quotes from !!!error: Indecipherable SUB-paragraph formatting!!! ):

The crew did not follow standard callouts and did not observe CRMaspects during most parts of flight.

“Karachi Approach” inquired “confirm track mile comfortable for descend” and later advised to take an orbit, so that the aircraft can be adjusted on the required descend profile. No orbit was executed and the effort to intercept the glide slope and localizer (of ILS) was continued. The FDR indicated action of lowering of the landing gears at 7221 ft at around 10.5 Nautical Miles from Runway 25L.

“Karachi Approach” advised repeatedly (twice to discontinue the approach and once cautioned) about excessive height. Landing approach was not discontinued. However, FDR shows action of raising of the landing gears at 1740 ft followed by retraction of the speed brakes (at a distance slightly less than 05 nautical miles from the runway 25L). At this time, the aircraft had intercepted the localizer as well as the glide slope. Flaps 1 were selected at 243 knots IAS, the landing gears and speed brakes were retracted. Over-speed and EGPWS warnings were then triggered.

According to the FDR and CVR recordings several warnings and alerts such as over-speed, landing gear not down and ground proximity alerts were disregarded. The landing was undertaken with landing gears retracted. The aircraft touched the runway surface on its engines. Flight crew applied reverse engine power and initiated a braking action.

The “Aerodrome Control” observed the scrubbing of engines with the runway but did not covey this abnormality to the aircraft. It was conveyed to the “Karachi Approach” on telephone. Subsequently “Karachi Approach” also did not relay this abnormality to the aircraft.

The landing was discontinued and a go-around was executed. FDR recording indicates a brief action of selection of landing gear lever to down position, which was immediately followed by its movement to up position.

Outside of the report, the Minister of Aviation stated the pilots were preoccupied by discussion of the coronavirus affecting them and their families.

Takeaways:

Stress and uncertainty over coronavirus dominated the cockpit and distracted from proper crew resource management.

Pilots dropped the gear to speed descent instead of descending in circles as instructed by ATC. !!!error: Indecipherable SUB-paragraph formatting!!! had a similar instance of outside stresses and disregard for ATC instructions.

Pilots do not notice overspeed, ground proximity, and gear down warnings. This is not unusual when pilots do not focus on flying the airplane.

Pilots forget to lower gear for landing. Lowering the gear to dump speed 10 nautical miles before may have satisfied this subconscious memory item.

ATC bungles landing clearance and does not directly inform pilots of situation. Hopefully further investigation determines of coronavirus discussions dominated that workplace as well.

Pilots applied brakes after landing, suggesting they thought the gear was down. They then moved the landing gear lever after initiating a go-around, as if to raise a gear they thought was down.

ItalianJobR53 - now with added 'MERICA and unreliability > For Sweden 06/24/2020 at 13:06

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Big oof

facw > For Sweden 06/24/2020 at 13:10

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Lot of failures there...

ttyymmnn > For Sweden 06/24/2020 at 13:16

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Over on one of the aviation discussion sites somebody said, “But nobody bothered to cite pilot error in the MAX crashes.” Because clearly, the pilots were the only factor to blame in those crashes. The Airbus v Boeing fanbois on those sites are insane. 

For Sweden > ttyymmnn 06/24/2020 at 13:23

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I’ve also seen plenty of people, usually more stick-and-rudder people, argue that a “real pilot” could have immediately diagnosed the fault and landed both MAX flights .

Turbineguy: Nom de Zoom > For Sweden 06/24/2020 at 13:56

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This accident chain is a mile long; I’m sure the airline will enforce sterile cockpit procedures after the CVR tape has been dissected . P retty impressive that he was able to go around after dragging both engines on the runway, although that did ultimately damage the engines resulting in a dual failure . 

Turbineguy: Nom de Zoom > For Sweden 06/24/2020 at 14:02

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Of all the opinions I’ve read about those crashes, I still can’t figure out how they weren’t treated as a simple runaway trim condition. Lots of blame to go around but Boeing really stepped in it for not including proper MCAS system coverage in the  Max type training they provided the airlines. 

ttyymmnn > Turbineguy: Nom de Zoom 06/24/2020 at 14:16

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Full of the sound of the Gran Fury, signifying nothing. > For Sweden 06/24/2020 at 14:17

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From what I was reading, but I can’t remember where, other PIA pilots said that the captain like to put a little too much faith in the automation. As I recall, they said that he liked to descend with the gear stowed but the handle down, letting the system drop the gear when he got to Vle (maximum speed at which the landing gear can be deployed) . In this case, however, they never got the speed down to Vle because they were too high on the approach and descending quickly, never getting below Vle because of this . He was expecting the gear to be down thanks to t his shortcut but he didn’t verify it, ignoring the warnings because it should have been down  instead of verifying that it was down. Trust, but verify, right?

That’s reminiscent of OZ214, where the pilot expected the 777 that he was flying to automatically increase the thrust if the aircraft got too far below the glideslope , but he was in the wrong autopilot mode (FLCH - Flight Level CHange), and it lacks that protection; he was expecting it to be like the Airbus that he flew prior, and in this mode it wasn’t. There’s nothing wrong with a bit of automation, and I’m not saying that one manufacturer does it better than another, but you have to know what it can and cannot do otherwise you’ll end up doing stupid (like a lot of Tesla Autopilot users).

On a side note, I remember hearing in ground school about an instructor that told a student pilot to test the squat switch on the gear. The student asked how to do that and the instructor told him to raise the gear, expecting the squat switch to actually do its job and not retract the gear. What he didn’t expect was a defective squat switch, so when they raised the gear, sitting there on the ramp, the gear retracted. Oof. Didn’t think that one through, did he?

Turbineguy: Nom de Zoom > ttyymmnn 06/24/2020 at 14:38

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LoL. One of my top five favorite movies. 

ttyymmnn > Full of the sound of the Gran Fury, signifying nothing. 06/24/2020 at 14:45

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It seems like we’re almost at a point of human/tech integration where we need to go in one of two directions: 1) Remove much of it and make sure pilots know how to fly, or 2) Go full auto and take the pilot out of the loop entirely. I’m much more in favor of number 1.

Full of the sound of the Gran Fury, signifying nothing. > ttyymmnn 06/24/2020 at 15:01

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I’m with you. One reason I like to fly Southwest is because I know that they work for a company that likes to keep the pilots flying the airplane, although they have changed their tune a little on automation, now using more of it because they can see the economic benefits.

You do have to take in cultural considerations as well. In many other countries, the idea of flying for recreation really isn’t a thing, so there aren’t a lot of pilots flying for fun as we often do in the US . Their families push them in certain career paths, and they’re not really at liberty to disobey so they go through with it even if it’s not something that they had their heart set on - it’s just a job to them. It’s this type of pilot, the one that knows nothing but airliners and automation and doesn’t know how to fly by the seat of their pants like they would if they flew a Cub , that scare me. Someone like this wouldn’t have been flying an airliner 35-45 years ago, but now the systems have made it relatively easy that they don’t necessarily require a lot of skill or hours to work as a line pilot. But when something goes wrong...

The other extreme is the hotshot ex military pilot who thinks that he knows everything about flying but doesn’t have a solid grasp of the how the FBW and avionics systems really work . They think that their skills hustling fighters around makes them invincible and they just end up fighting the automation with disastrous results.

I don’t know which of these two extremes scares me the most.

ttyymmnn > Full of the sound of the Gran Fury, signifying nothing. 06/24/2020 at 15:41

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I think you see the same cultural considerations in driving. By the time American kids reach age 16, they have been immersed in car culture their whole life. The very idea of driving is not at all foreign to them. Many people come to this country having ridden a bicycle their whole life. They don’t have that same depth of understanding from having spent their childhood in a car. It would be an interesting comparison to see how many US pilots train for commercial aviation who are entirely new to flying. I would wager the number is pretty low.

When my oldest boy was younger, I arranged a tour of the airport fire station for his birthday. It was awesome. As I stood outside the fire station talking to one of the firefighters, he pointed out how fast the SWA pilots taxi, well above the 30 mph speed limit. He said that’s a SWA thing, with the pilots wanting to get to the gate as quickly as possible to improve their on-time numbers. Last summer, we flew to CA on SWA, and the pilot was seriously hauling ass on the way to the gate. As we walked down the concourse, I passed him and said with a smile , “You left it all out there on the track, didn’t you?” I’m not sure he understood what I meant. 

SBA Thanks You For All The Fish > For Sweden 06/24/2020 at 15:44

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Yeah, I’m tired of the “Boeing drivers” still quoting the BA press releases.

Both the Lion Air and ET passengers would still be alive, had their companies bought Airbus equipment. The redundancy, error checking and back-ups would have saved everybody.

SBA Thanks You For All The Fish > Full of the sound of the Gran Fury, signifying nothing. 06/24/2020 at 15:45

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Whoa. Really? This guy was used to having the plane drop the gear for him?

Wholly Schitt, that’s alarming.

Full of the sound of the Gran Fury, signifying nothing. > SBA Thanks You For All The Fish 06/24/2020 at 16:06

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There’s an old maxim that says something along the lines of ‘if a machine can do a job better than a human, let the machine do it’. Obviously, in this case, the machine couldn’t, but then again it was never designed to be operated in this manner . That’s not to say that the machine is wrong; the pilots need to understand the machine and its limitations and work within reasonable parameters to accomplish a goal, and that apparently did not happen here, with horrendous results. Procedures and checklists may be dull and boring, but they exist for a good reason, and sadly come from the loss of many lives. As George Santayana so eloquently stated , “Those who cannot remember the past are condemned to repeat it.”  

SBA Thanks You For All The Fish > Full of the sound of the Gran Fury, signifying nothing. 06/24/2020 at 16:09

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Thanks for the posts... this accident didn’t make sense at all to me. Until now.

Yeah. This is the missing piece. This dumbass was so lazy that he thought he could just “pre lower” the landing gear lever and let “Auto Gear Down” lower it over the threshold.  His dumbassery was so great that he didn’t even hear (apparently) all the cockpit warnings.  I’m gobsmacked.

Full of the sound of the Gran Fury, signifying nothing. > SBA Thanks You For All The Fish 06/24/2020 at 16:28

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Here’s my take - I think he heard all of the warnings, but based on his flawed technique for gear deployment he assumed that the warnings were in error, not his flying, and therefore the warnings could be dismissed . This was a pilot with over 17 ,000 hours in his logbook , so he wasn’t some newbie, but I don’t know the breakdown between civilian and military flying; I’m assuming he has a military background based on that number of hours.

Here’s an interesting article about this flight: https://www.dailyo.in/variety/pakistan-flight-crash-pia-flight-8303-pia-flight-pakistan-crash/story/1/33008.html

Full of the sound of the Gran Fury, signifying nothing. > SBA Thanks You For All The Fish 06/24/2020 at 18:38

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I have to respectfully disagree with your conclusion. If the pilots don’t understand the systems and they don’t properly aviate when things go pear-shaped it doesn’t matter if it’s brand A or brand B. Yeah, Boeing screwed up big time by not disclosing MCAS, but if the situations were handled as runaway trim incidents those aircraft would have still flown. Modern airliners are remarkably stable and can be flown by hand if need be, but if you forget about this and spend all of your time concentrating on the automation, well, you’re doomed. Read about AF447. The pilots fought the computers (and each other, albeit unintentionally) instead of flying the airplane and delegating the workload to solve the problems that they encountered.

https://en.wikipedia.org/wiki/Air_France_Flight_447

gmporschenut also a fan of hondas > SBA Thanks You For All The Fish 06/24/2020 at 23:33

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https://en.wikipedia.org/wiki/Qantas_Flight_72  Along with the AF flight, airbus has had issues, only theirs at cruising altitude, which may give the pilot a bit more time to think. 

SBA Thanks You For All The Fish > Full of the sound of the Gran Fury, signifying nothing. 06/25/2020 at 01:44

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!!! UNKNOWN CONTENT TYPE !!!

We’ll just have to disagree on this one. The Boeing drivers pretty consistently crashed and burned in the simulators when faced with this scenario. “Handling it like runaway trim” probably sounded good in the Boeing press briefing, but try that at 500' AGL, the annuciators screaming about “STALL”, “SPEED” and “TERRAIN” and your only hope being debugging it in a few seconds— even as the impossibly high forces on the manual trim wheels make corrections impractical.

My point on the Airbus was that the level of system maintenance automation would have flagged the issues from the prior night’s flights, taken the aircraft out of service and alerted maintenance. And, with redundant AoA sens ors, even if the pilot HAD managed to get a pushback authorized? The three redundant sensors would have prevented the tragedies by outvoting the damaged sensor.

For these crash scenarios? Airbus simply has a better design philosophy. A single component failure should never catalyze an airframe loss... except in Boeing’s World.

SBA Thanks You For All The Fish > gmporschenut also a fan of hondas 06/25/2020 at 01:46

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yeah, my point here is that the simulators have knocked the Boeing drivers down a peg... at 500' AGL, full takeoff thrust and the annuciators going crazy?

Basically NOBODY solves this puzzle right without altitude sufficient to work the problem.

Full of the sound of the Gran Fury, signifying nothing. > SBA Thanks You For All The Fish 06/25/2020 at 04:50

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Yes, those are very good points. There is just too much legacy left in the 737 cockpit, the unfortunate end result of listening to a handful of customers with extensive 737 experience that wanted minimal changes to how the aircraft was operated for maximum backwards compatibility. And the single AoA sensor and charging extra for additional ones or warning systems? Borderline criminal. There have been other times where a surprising lack of redundancy, like the rudder PCU issues years ago, makes you question how this was even certified, but it makes it easier to understand why they wanted to keep the legacy design in order to avoid complete recertification. In that regard it’s really hard to compete with a cockpit philosophy that’s a few decades newer.

It’s one thing for a Southwest pilot, someone working for an airline with a massive amount of 737 experience, to identify and handle a problem like the MCAS issue, and another for a relatively low-hour pilot to do the same. If the additional AoA sensors were standard and maintenance automation better we wouldn’t be having this discussion. If anything, Boeing should have pushed for a 757/767 cockpit back in the ‘80s when they transitioned to the -300; all of the BITE and automation was there at their disposal. It might have annoyed some customers with the retraining and spares costs, but it would have given the 737 a brighter future. Once again, it came down to keeping costs low and appealing to a handful of core customers rather than getting input from multiple customers, a la the 777 program. It would also have opened up opportunities to sell more 757/767s as customers needs changed, rather than turning the 737 into the jack-of-all-trades, master of none that it has become. In this regard Southwest was both the best and the worst thing to happen to the 737.

However, that’s all speculation, and Boeing learned their lesson with other programs, but it was too late for the 737. When you’ve got a cash-cow like that it makes it even tougher. In that regard I guess you could say that the 737 Max problem was inevitable, particularly after the McDonnell Douglas merger. It’s almost like MD sabotaged Boeing from within, although it was not intentional - poisoning the well, as it were. If anything, that merger was more like a cancer, at least IMHO. And this coming from someone that grew up in the SoCal aviation world, was named after an aircraft manufacturer, whose earliest memories were of hanging out at LGB with his late father and their aircraft-band radio just watching ‘planes for hours on end.

But all is not completely rosy on the other side of the fence. AF447 illustrates a lack of understanding of the aircraft by seemingly well-trained crew, systems that essentially resulted in two pilots actions canceling each other out and a gross failure to aviate under trying circumstances. There was too much reliance on technology on their part and a lack of abilities when the computers weren’t there to protect them. CRM was a known commodity by then but didn’t seem to be employed by the crew, further sealing their fate.

Years ago Lufthansa had an incident whilst landing in the rain in Warsaw in an A320. Because of weather and potential and shear they were coming in a little hotter than normal, a good decision given the conditions. As they landed, or at least attempted to land, the aircraft got caught in ground effect, essentially hovering over the runway.

The pilot wanted to deploy the spoilers to get the thing on the ground, but some software engineer basically overrode that and wouldn’t allow the spoilers to be deployed because the computers said that there wasn’t weight on the wheels and therefore the aircraft is still flying and thus the spoilers shouldn’t be deployed in order to protect the idiot in the pointy end from himself. That software engineer wasn’t on board and he didn’t know what was necessary to safely land the aircraft in this particular situation, but there were a couple of guys in the front of that thing that did. This did not  matter to the computers and their cold, hard, infallible logic. The pilots weren’t being allowed to fly the aircraft based on their knowledge and experience and just became another couple of passengers about to join all of the ones on the other side of the cockpit door in a sightseeing tour of the swampy grasslands off of the end of the runway. Those folks up in the nose are there for a reason - let them do what they’re paid to do.

There has to be a balance, and these various incidents show opposite sides of the same coin, namely too much technology vs. too little. In the end neither philosophy won and hundreds of lives were lost in the process. Knowledge was gained, but at what cost? There are no winners.

Rusty Vandura - www.tinyurl.com/keepoppo > SBA Thanks You For All The Fish 06/25/2020 at 09:15

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It was  alarming and he ignored them.

Rusty Vandura - www.tinyurl.com/keepoppo > Full of the sound of the Gran Fury, signifying nothing. 06/25/2020 at 09:16

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“Okay, so this is the alarm that sounds right about now when I do it this way.”

Rusty Vandura - www.tinyurl.com/keepoppo > Full of the sound of the Gran Fury, signifying nothing. 06/25/2020 at 09:21

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Plane crashes are peculiar because of how they affect everyone . I’m not sure exactly why. Perhaps because so many people fly. Perhaps because people who do fly are of a social class that they are more connected to news about the crash. Perhaps because so many people die in each one, belted into their seats, well aware that they are about to die.

In any event, I could not bring myself to finish reading that transcript and I do consider myself to be, as Ttyymmnn puts it, an aviation fanboi .

facw > For Sweden 06/25/2020 at 11:25

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And now:

 Pakistan International Airlines grounds 150 pilots over "bogus" licenses after deadly crash

facw > ttyymmnn 06/25/2020 at 11:30

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Put me down for #2. Frankly I think #1 is a terrible idea. Sure there’s less risk that the pilot misunderstands the autopilot, but y ou’d just be introducing even more room for pilot error. At a time when commercial aviation is just about as safe as it has ever been, trying to go back to the “good old days” seems like a really big mistake.

For Sweden > facw 06/25/2020 at 11:38

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another oof

facw > For Sweden 06/25/2020 at 11:39

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And note that it sounds like these pilots were identified last year but allowed to continue flying...

ttyymmnn > facw 06/25/2020 at 11:45

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Fair enough. But we still need skilled pilots who can handle the plane with the shit hits the fan, and not somebody who is only proficient at monitoring systems.

facw > ttyymmnn 06/25/2020 at 11:53

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Indeed. M y thinking is as plane automation improves, you may be able to move to just one skilled pilot in the cockpit. Ultimately you might be able to get rid of both pilots and have a small pool of remote pilots to handle emergencies (though you’d have to make sure both your security and your connectivity is good). Of course maybe the cost of the pilot and the extra revenue from being able to add another row or two of seats are low enough that it’s not worth removing pilots from the plane, but I do think fully automated planes are within reach.

ttyymmnn > facw 06/25/2020 at 12:11

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I know I’m old fashioned, but I’d still rather have two pilots up front in case one becomes incapacitated.

As far as automation goes, though, I’m immediately struck by the recent crash of the RCAF helicopter as it tried to land on a ship. Due to some anomaly that hadn’t been tested for, the helo though it was going too slowly in whatever flight mode it was in and pitched the nose down on its own to gain speed . They were too close to the water and crashed before the pilot could figure out what the hell was going on, and six people died.

https://www.beasleyallen.com/news/cyclone-helicopter-conflicted-with-pilot-causing-canadian-air-force-crash-that-killed-six/

Maybe it’s not so much a matter of removing the automation but instead having a bit less of it, streamlining it. 

facw > ttyymmnn 06/25/2020 at 12:18

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I think one pilot is ok if the pilot is already the backup (and possibly you have further remote backup). My bigger concern would be the Germanwings scenario, where you can’t trust one person alone in the cockpit (though many places already dropped the two people in the cockpit at all times requirement).

And yes there will probably be (hopefully very rare) corner cases where automation fails, but it’s not like we don’t have crashes due to pilot error.

SBA Thanks You For All The Fish > Full of the sound of the Gran Fury, signifying nothing. 06/26/2020 at 08:22

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I know a SWA pilot very, very well. And, he is a pompous dick, but I think the failure of 10,000 hour ex-military guys to get this scenario de-bugged in the Sims finally brought him around.

My take remains that “the airlines” are partially culpable here. SWA negotiated a $1 Million per plane penalty into the supply contract for “any re-training” requirement to fly a MAX. I believe those contract terms should be illegal— tainting what should be a “safety Only” process.

To this day, with what will be a multi-year delay and hundreds of billions in economic losses, I’m perplexed why Boeing didn’t bite the bullet (they claim the flight computers have been completely re-designed) and add redundant AoA sensors and truly make the MAX the safest 7x7 ever built. Instead? They are half-assing it to the point I’ll never fully trust those assholes ever again.

Boeing,  like VW, should have an executive team looking at long prison sentences.