B1900C PSM+ICR Accident in Pakistan 2010
The Pakistan Civil Aviation Authority (CAA) has recently published the report into the loss of a Beechcraft B1900C in 2010. The aircraft, AP-BJD, was being operated by JS Air (as subsidiary of the JS Group) when it crashed on 5 November 2010, killing 21 people. The accident featured what a 1998 AIA/AECMA study termed a Propulsion System Malfunction + Inappropriate Crew Response (PSM+ICR).
The 17 passengers worked for Italian oil and gas company ENI, who had chartered the aircraft. They were en route to work at the Bhit Shah gas field.
The Accident Flight
Shortly after take-off from Jinnah International Airport (JIAP), Karachi, the aircraft experienced a No 2 Engine anomaly. The crew decided to land back at Karachi. The aircraft could not sustain flight. It impacted the ground in a stalled state with a 45° right hand bank about 1 nm from the airport.
The Captain (53, ex-Pakistan Air Force, ATPL, 8,114 hours total, 1,820 hours on type) was the Pilot Flying (PF) and the First Officer (FO: 33, ATPL, 1,746 hours total, 1,338 hours on type) was Pilot Monitoring (PM).
Following analysis of the Cockpit Voice Recorder (CVR), the investigators comment that just before take-off:
It is important to note that autofeather switch should be in “Arm” position instead of “OFF” as per the OEM instructions and laid down procedures in [Flight Crew Operaing Manual] FCOM and QRH [to avoid the need for manual feathering]…
At 02:04:02.8 UTC Captain told FO “all set, we are cleared for takeoff”.
It is important to note that cockpit crew were supposed to carry out “run up checks” prior to entering the runway as per QRH however, those were not carried out.
At 02:04:05 UTC, the engine torque and propeller RPM parameters began to increase and there was an increase in longitudinal acceleration indicating start of takeoff roll.
At 02:04:14.2 UTC FO told Captain “power set autofeather light is ON”.
At 02:04:18.7 UTC Captain said “off”.
As the cockpit crew before takeoff intentionally selected the autofeather switch to “OFF” position, therefore the light was “ON” and the autofeather “OFF” position is confirmed by the Captain.
The aircraft continued to accelerate and at 02:04:31 UTC it rotated. However, two seconds later the engine noise reduced. At 02:04:36.5 UTC the FO told Captain that the “right engine prop has gone”. At 02:04:41.1 UTC the FO said “it is feathering…should I select it to feather position?”. The Captain said “yes, put it to feather position” at 02:04:43.1 UTC. The investigators comment that:
…probably [the] FO 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.
The crew then decided to return to Karachi. The crew never raised the landing gear as per the FCOM/QRH, restricting aircraft performance. The investigators highlight that the Captain called Air Traffic and erroneously identified a No 1 engine problem.
At 02:05:17.7 UTC Captain told FO “wait for a minute, wait for a minute”. As per the recorded data, at this particular moment the airspeed of aircraft was 98 knots with altitude recorded as 268 ft Above Mean Sea Level…
[At] this stage, [the] Captain had not been able to achieve the minimum safe recommended flying parameters and the airspeed of aircraft was continuously decreasing with increasing pitch attitude as well as right angle of bank and first time it is observed that Captain told FO to wait and hold his ongoing actions, whereas it is considered that at this stage FO feathered the propeller as the reduction in engine noise was observed at this stage in CVR recording…
At 02:05:21.0 UTC sound of high pitch tone, similar to stall warning was recorded on CVR which continued till end of recording.
The investigators comment that about 3 seconds later the crew realised the situation was unrecoverable. The last recorded data was at 02:05:29.0 UTC. The investigators highlight the high workload through the less than one minutes flight, and go on:
The Beechcraft 1900C-1 at its full all up weight is capable of sustaining safe flight after experiencing non availability of one engine provided the OEM recommended procedures as per QRH and FCOM are followed.
The first recommended action after experiencing engine failure after V1 or takeoff is having positive control of aircraft and raising the landing gears in order to reduce the drag immediately so that aircraft can quickly achieve minimum safe flying parameters ie altitude 400 ft above ground level while maintaining minimum single engine safety speed.
On examination of the Captain’s recurrent simulator training:
…it was observed that on 1 October 2009 he achieved performance level “satisfactory with briefing” during simulator check critical areas…and likewise on 7 October, 2010 again evaluated by the JS Air Designated Check Pilot and CAA Inspector “Satisfactory with briefing (SB)” for critical areas like; “Simulated Engine Fire after V1” and “One engine out go-around”.
…He could not safely handle these training exercises during critical phases of takeoff / just after takeoff without briefing to achieve the satisfactory performance level…
…the Captain was not confident and lacked the required proficiency level / skill to independently handle the aircraft operations with single engine during critical phases of flight…
Meanwhile the FO, who was a qualified B1900 captain:
…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 got mentally pre-occupied to a level where he could not perform the recommended remedial actions as per the QRH and FCOM. Thus, he did not effectively contribute towards handling of abnormal set of conditions.
While the crew had received Crew Resource Management (CRM) training:
… the cockpit crew did not follow the CRM tools / techniques effectively and efficiently to safely get out of abnormal set of conditions and imminent danger… The failure of CRM aggravated the abnormal set of conditions to unsafe and directly contributed towards causation of accident.
The investigators say:
During the subsequent interviews with the [Aircraft Maintenance Engineers] AMEs, it was learnt that upon return from a previous chartered flight on 4 November 2010, ground maintenance staff observed few drops of oil under the Engine No. 2.
The AMEs inspected all the suspected areas and components of Engine No.2, but did not find any anomaly.
They went on to do several ground runs and made a Fuel Control Unit adjustment.
All performance parameters of the engine were found normal and thus the aircraft was declared fit for further routine / chartered flight operations.
It was also observed from the aircraft and engine log books that the defects and their corresponding rectifications including the ground runs …were not documented in any of the aircraft or engine documents / technical log books. It indicated that there had been a general trend in the engineering set up of M/s JS Air of not documenting the maintenance performed on the aircraft or engines.
The poor recording practices are a concern however the investigators concluded the engine was serviceable and there were no pre-existing anomalies which could have prevented normal operation.
The investigators believe the propeller beta valve may have failed as it:
…is the only part in the propeller governing system that has the authority to bring the propeller into a coarse or feather pitch in such a quick manner as observed in this accident.
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.
In summary the investigators state:
The only probable cause of propeller feathering on its own could be the wear & tear of the beta valve leading to beta system malfunction.
Some of the actions by the cockpit crew before takeoff and subsequent to the observed anomaly in the Engine No.2 were not according to the QRH / FCOM which aggravated the situation and resulted into the catastrophic accident.
Ten recommendations are made.
The report does not follow an ICAO Annex 13 layout, despite the paragraph headings. In particular considerable (new) factual information is presented in the analysis section. Surprisingly little FDR data is presented (in comparison to the extensive CVR data). The human factors analysis is rather basic.
We have written:
See also our earlier article: Metro III: Propulsion System Malfunction + Inappropriate Crew Response for another PSM+ICR.
AINonline has recently discussed the NTSB factual data on a Mexican air ambulance accident to XA-USD where a thrust reverser partially deployed: Crew Irregularities Reported in Fatal Learjet Crash, another PSM+ICR.
We have also written of another case were non-compliances and a failure to follow checklists were relevant: Gulfstream G-IV Take Off Accident & Human Factors
UPDATE 8 July 2018: Distracted B1900C Wheels Up Landing in the Bahamas
UPDATE 5 January 2019: British Midland Boeing 737-400 G-OBME Fatal Accident, Kegworth 8 January 1989