AIRBLUE FLIGHT 202 TOXIC COCKPIT ENVIRONMENT AND TRAGEDY

On July 28, 2010, at 09:41 local time, an Air Blue airline A321 jet-powered passenger aircraft with tail number AP-BJB, arriving from Karachi, crashed into a mountain while approaching Islamabad, the capital of Pakistan. All onboard — two pilots, four cabin crew members, and 146 passengers — lost their lives. There was no technical fault found on the aircraft in this accident.

The root cause of this accident, which claimed the lives of 152 people, included not only rule violations and disregard for the aircraft’s protective systems but also noncompliance with CRM rules and the negative behavior of subordinates being suppressed and rendered passive by their superior. The aircraft’s captain, Pervez Ikbal Chodhari, was an experienced pilot with 25,497 flight hours, including 1,060 hours on the A321 type. The first officer had a total of 1,837 flight hours, with 286 hours on the A321 type. Although CRM rules are intended to ensure cooperation and communication between the two pilots in the cockpit during events and decision-making, there was no evidence of CRM compliance in the cockpit of Air Blue flight ABQ-202 from Karachi to Islamabad. In this accident, which claimed 152 lives, there was no technical fault in the aircraft, the flight crew’s licenses were valid, and neither pilot had health issues.

Although the accident report received much criticism, it was not prepared by an independent board but by the Accident Investigation Board formed by the Pakistan Civil Aviation Authority (PCAA) for this accident. There are drawbacks to having accident investigations conducted by the Civil Aviation Authority after aircraft accidents. It should be noted that after an aircraft accident, potential parties responsible for errors or negligence may include the aircraft operator, the maintenance provider, the flight crew, the control tower, the airport administration, and the country’s Civil Aviation Authority. Having the Civil Aviation Authority conduct the investigation is equivalent to asking the authority to investigate itself. Nobody admits fault easily. Therefore, even if the Civil Aviation Authority’s supervision deficiencies or incorrect actions contributed to the accident, they are not investigated. In Turkey, this problematic situation was prevented in 2013 with the establishment of an Accident Investigation and Inquiry Board (KA‹K) under the Ministry of Transport and Infrastructure of the Republic of Turkey to investigate transportation accidents. In 2019, this institution was renamed the Transportation Safety Investigation Center (UE‹M), responsible for examining serious accidents and incidents in transportation, including road, rail, maritime, and aviation sectors, preparing reports, delivering them to relevant national or international institutions when necessary, and publishing annual statistics on accidents and incidents.



Following the crash of Air Blue airline’s A321 passenger aircraft that killed 152 passengers, the members of the Accident Investigation Board established by the Pakistan Civil Aviation Authority (PCAA) were: Board Chairman (PCAA), Flight Operations Representative (PCAA), Technical Representative (PCAA), Air Traffic Representative (PCAA), Medical - Flight Medicine Representative (PCAA), Airworthiness - Maintenance Representative (PCAA), Pakistan Air Force Representative, and Air Blue Airline Representative. Additionally, representatives from foreign organizations supported the Accident Investigation Board in its work. The crash of the A321 aircraft involved the interest of many foreign organizations. Examining the representatives sent to support the board shows this very strikingly. The representative of the accident investigation authority BEA of France, the country of Airbus, the Type Design Owner and Manufacturer of the aircraft, served as a technical advisor. The representative of IAE, the Type Design Owner of the aircraft’s V2500 jet engines, was from the NTSB, the accident investigation authority of the USA. The technical advisor for the NTSB was a representative appointed by Rolls Royce through IAE. The FAA, the United States Civil Aviation Authority, was also represented. (IAE is a partnership between the U.S.-based Pratt & Whitney and UK-based Rolls Royce, headquartered in the USA.) Many advisory representatives from different organizations were included in the board. The European Union Aviation Safety Agency (EASA) was not represented by a consultant.

Let us return to the flight in which the accident occurred. After takeoff, at 07:52 local time, the cabin crew served tea and croissants to the flight crew. During the initial climb, the captain tested the first officer’s knowledge by asking questions and, contrary to company procedures/norms, used insulting words and a mocking tone. The captain’s question-and-answer sessions, advice, and instructions continued intermittently for approximately one hour after takeoff. Following these intermittent demeaning sessions, the first officer generally remained silent, lost confidence, became submissive (suppressed), and later did not intervene when the captain made errors or violations.



The captain was aware of the weather conditions at the destination airport, Islamabad, which were cloudy, rainy, and overcast. He received this information from both the control tower and the METAR report from the ATIS (Automatic Terminal Information Service) system. Under these conditions, the tower instructed incoming aircraft to circle above the clouds and only descend for landing once visual contact with the runway was confirmed. The procedure also defined the approach path to the runway, and no other approaches were permitted outside this procedure. Understanding that due to bad weather the aircraft might not be able to land and could be diverted to another airport, the captain instructed the first officer to input four different waypoints into the Flight Management Computer (FMC) that were not in the flight plan and not compliant with procedure.

As they approached Islamabad airport, heavy clouds and rain were present. The tower instructed the aircraft to circle above the clouds until visual contact with the ground was established. The captain then activated his plan, engaging the four waypoints that were not allowed by procedure. In the last 70 seconds of the flight, the system called EGPWS (“Enhanced Ground Proximity Warning System”) issued 21 “Too Close to Terrain – Pull Up” audible warnings, but the captain did not respond. Throughout this process, the first officer made no intervention apart from stating “We are too close to the ground” and “We need to climb.” When the tower asked the first officer if they had visual contact with the ground because of doubts about the aircraft’s behavior, he consulted the captain, saying, “What should I answer?” Following the captain’s instructions, he responded, “Yes. We have visual contact.”

The twenty-first EGPWS warning ended abruptly when the aircraft struck the Margalla Hills. The resulting fire, fueled by the crash and wreckage, was extinguished after some time due to heavy rain. Rescue teams, who had to carve paths through the densely forested mountainous area to reach the crash site, found that there was nothing they could do for the 152 people aboard the aircraft.