The Civil Aviation Authority (CAA) admitted on Thursday for
the first time that the pilot and the air traffic control staff were
responsible for the 2010 Air Blue crash.
In the re-investigation report of the crash submitted to the
Peshawar High Court (PHC), CAA maintained that responsibility
for the incident also lay with the air traffic control staff for failing to
guide the aircraft out of the crisis. It revealed that the air traffic
controller guiding Airblue flight ED202 was inexperienced and as
such was unable to discharge his duty.
“Weather forecasts (at the time of the flight) indicated rain, poor
visibility and low clouds around the airport. The information
regarding the prevalent weather and the type of approach on
arrival was in the knowledge of aircrew,” the report submitted
before the court reads. It adds that the flight captain violated the
prescribed flight discipline for the weather conditions and placed
the aircraft in an unsafe situation.
“
• The air traffic services (both the radar and the control tower),
which could have helped the flight out of this situation, also failed
to avert a ‘controlled flight into terrain’ (CFIT) due to lack of
knowledge and training, and ambiguous procedures in the sort of
scenario the aircraft was flying in during the last phase of the
flight,” the report further notes.
CAA legal counsel Obaidur Rehman Abbasi, meanwhile, told the
bench they will present their recommendations on safety
measures at the next hearing, after which the hearing was
adjourned.
The summary of the re-investigation report was submitted in
response to PHC’s directives issued on February 19. In the previous
hearing, the CAA had produced the transcript of the Cockpit Voice
Recorder recovered from the crash site. The bench subsequently
asked Safety Investigation Board president Air Commodore
Muhammad Abdul Basit to summarise the transcript in simple
terms due to technical jargon.
Airblue flight ED202, bound for Islamabad, crashed into the
Margalla Hills on July 28, 2010, killing all passengers and flight
crew on-board.
• On November 9, 2012, investigation experts of the
International Civil Aviation Organisation (ICAO)
completed their reinvestigation into the Airblue crash
and concluded, among other things, that aviation
body’s initial investigation report into the incident
lacked vital information. The information missing from
CAA’s report, according to ICAO experts, included the
details on the weather conditions during the flight and
the maintenance of navigational aids. The ICAO report
also noted that while communication between the
flight and the air traffic controllers was mentioned, no
section in the final report was dedicated to it.
The foreign experts also maintained that the draft of
the first report had more details, but claimed they were
omitted after it was reviewed by the CAA director
general in March, 2011. They, as such, expressed
concern over the possibility of a conflict of interest.
Two UAE passenger aircraft avert
collision
• Two passenger aircraft, believed to be UAE-owned, avoided a midair collision on Friday morning over Pakistani airspace, local daily
Gulf News reported on Sunday.
Both flights were Lahore-bound, with one coming from Abu Dhabi
and the other from Dubai. Both pilots were alerted by their
onboard aircraft collision avoidance systems, the daily reported,
citing Pakistani newspaper The Nation.
Abu Dhabi-owned Etihad Airways confirmed that one of its
passenger planes was forced to take action on its flight path.
“Etihad Airways is aware of an incident within Pakistani airspace
involving flight EY241 to Lahore on Friday, 14 December. The
prescribed minimum separation between this flight and an aircraft
of another airline was infringed. Automated aircraft systems
advised our pilots who took appropriate action in accordance with
their standard operating procedures,” an Etihad spokesperson was
quoted as saying.
• “Safety was not compromised and the aircraft
continued to Lahore without incident. An investigation
of the circumstances is under way,” he added.
However, the identity of the other aircraft could not be
confirmed.
Both aircraft were reportedly flying at 34,000 feet at
around 1 am on Friday when the incident occurred,
Gulf News said.
The passenger planes had to fly without a radar system
support as it had malfunctioned, Gulf News reported
citing unnamed sources in The Nation's report.
• Aerodrome Facilities
• Where it is relevant to the particular occurrence, the Air Traffic
Services investigation may have to examine and verify the status of
many aerodrome facilities used by or available to the aircraft
involved in the occurrence. Amongst the items that may need to
be checked and verified are the following:
• a) characteristics of the runway(s) in use
• b) characteristics of the movement areas
• c) surrounding terrain, obstructions and meteorology
characteristics
• d) aerodrome diagrams
• e) lighting and guidance signage
• f) electronic surface movement detection systems
• g) standard, contingency and emergency operating procedures
• h) visual and electronic navigation aids
• i) communications networks
• j) environmental conditions
• k) facility status register
• Aircraft Performance
• The Air Traffic Services investigation should
establish, record and verify the accuracy of all
information relevant to actual performance of the
occurrence aircraft, in particular the flight planned
performance should be compared to actual
performance achieved. Valuable information may
be derived from recorded data, observations,
photographs, eyewitnesses, or from other air traffic
services personnel or aircrew in the vicinity.
• The selection of data to be collected and reviewed will
be dependent upon the circumstances of the
occurrence being investigated. However, it is most
desirable that the investigation examine the original
rather than copies of the recorded
• data wherever possible. It may be necessary, in certain
cases, to have the Operations Group examine the data
from which Flight Manual performance is determined
in order to establish its relevance to the particular
circumstances.
• The Air Traffic Services investigation should establish,
record and verify the accuracy of all information
relevant to its activity in relation to the conformance of
the flight. This may include determination of expected
outcomes originating from any air traffic services
control instruction, information or advice compared
with the actual outcomes.
• Reconstruction of horizontal and vertical profiles of
the flight by use of factual data may be a useful tool
in determining the Air Traffic Service officer’s
knowledge and expectation of the aircraft
performance in the air traffic service system. For
example, was the clearance instruction within the
capability of the aircraft performance envelope, or
was the aircraft directed towards hazardous
weather or terrain etc. Dependent upon the nature
of the occurrence, some or all of the following
items may be relevant:
• a) knowledge of aircraft performance and
limitations
• b) reconstruction of relevant flight profiles
• c) flight plan validity and conformance
• d) horizontal and vertical navigation
• e) aircraft physical operating environment
emergency operations
• Standard Operating Procedures and Practices
• Whilst it is not the function of an Air Traffic Services
investigator to become involved in the disciplinary
aspects of the enforcement of regulations and
instructions it is a necessary part of the
investigation to establish whether the applicable
directives, operating standards, procedures and
practices were complied with. All relevant material
should also be examined to establish whether, in
the light of the occurrence, they were proper and
adequate for ensuring safety of operations, and
whether they were presented in a format easily
understood.
• It may be necessary to also consider the safety
lessons and preventative aspects of
recommending a review of the existing
directives, operating standards, procedures
and practices or development of new
material. In examining these matters it is
important to distinguish between what
material has mandatory effect and what is
advisory
• Items that should be checked, and verified may
comprise a combination of the following:
• a) National legislation
• b) ICAO Annexes
• c) ICAO Procedures for Air Navigation Services
• d) air traffic services manuals and instruction
circulars
• e) workstation/sector handbooks and/or
instructions
• f) copies of any pertinent letters of agreement
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g) map/chart of area of responsibility
h) co-ordination requirements with other units
i) aeronautical information publications
j) applicable aircraft proximity standard/s
k) NOTAMs
l) flight progress preparation, processing and
displays
• m) level change and non-standard flight levels
procedures
• n) communications, navigation and surveillance
procedures
Witness Interviews
The Air Traffic Services investigator should bear in mind obligations to comply
with the laws of the State in which the air safety event occurred and that in
some States it may be the responsibility of the police to carry out witness
interviews. It may be desirable because of the circumstances of the occurrence
to form a Witness Group for locating witnesses and collecting their statements.
If such a group is formed it normally concerns itself with interviews with “eye
witnesses” located in the vicinity of the occurrence: the witnesses’
interviewing appropriate to other groups, e.g. Structures, Operations, is
generally performed by an investigator within that group. Collecting evidence
from witnesses is one of the investigator’s main tasks; information thus
obtained can, in fact, furnish a lead to obtaining further evidence, or
complement and/or clarify evidence already presented. The Air Traffic Services
investigation must not, however, overlook human fallibility, and must exercise
great caution when analyzing statements from witnesses that obviously
conflict with established material evidence or attempts to divert the focus of
the investigation from accident prevention and safety enhancement.
• Flight Reconstruction
• ATS surveillance systems and/or synthetic digital
data constitute vital information for reconstructing
the progress of relevant aircraft and presenting
horizontal and vertical navigation profiles for
analysis. This may also require analysis of other
aircraft not directly involved in the occurrence.
• Various recording and replay systems
have been developed by States. Such
systems vary from one which consists of
time-lapse filming (one frame per sweep)
of the spots representing moving aircraft
on display screens, to digital electronic
technology recording defined parameters
in binary formats. The data is normally
retained for at least a month and
replayed only in the event of an
occurrence.
• The reconstruction of the relevant stage of the flight,
i.e. the occurrence phase, necessitates close
coordination between many areas of the investigation
but it may be of equal concern to the Operations
Group. The intention should be to build
• up a complete picture of the final events as they
occurred in proper sequence and evaluate their
interrelationship. The period of time to be covered will
depend upon the circumstances; in general terms it
should commence at a stage where the flight departs
from normal operational parameters and it can
terminate at either the time of the occurrence or a
subsequent time which is significant to the
investigation.
• Where it is desired to synchronize display and
audio programs, the starting point must be
clearly defined. This information may also form
an essential link with information obtained by
other investigation groups and will provide the
basis of the reconstruction when combined with
available recordings of all related activities on
the ground and on-board the aircraft.
• Dependent upon the nature of the occurrence,
some or all of the following items may be relevant:
• a) separation standard
• b) relative tracks
• c) horizontal and vertical proximity
• d) surveillance service/s available/provided
• e) evasive actions
• f) flight conditions
• g) collision avoidance systems available
• h) aircraft proximity assessment
• Sequence of Flight
• The reconstruction of ATS surveillance system data
may bring to light items of importance in the
Operations investigation in relation to the other
areas of the occurrence investigation. It may also
happen that the particular characteristics of the
occurrence necessitate not only the reconstruction
of the occurrence flight but other previous flights
• Although the investigation will have to devote
particular attention to the phase in which the event
occurred, it will usually be desirable to evaluate the
development of the entire sequence of the flight.
Display reconstructions can also assist the
investigation of occurrences such as near mid-air
collisions and provide data for establishing aircraft
proximity. The Air Traffic Services investigation
should be aware of possible software and display
anomalies such as:
• a) target swapping
• b) data block swapping
• c) swapping of target tracks with other aircraft
and/or false targets
• d) incorrect data blocks
• e) display clutter
• f) data blocks becoming detached from assigned
targets
• g) displaced target symbols
• Dependent upon the nature of the occurrence,
some or all of the following items may be relevant:
• a) displays facilities
• b) symbols
• c) data blocks, leader lines and orientation
• d) control settings
• e) display operator notes
• f) aircraft identification procedures
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g) sensor/s inputs
h) display mapping
i) coverage diagrams
j) terrain clearance charts
k) SSR code
l) system display track number
m) system alerts and alarms
n) point of closest approach
• Flight Profile Reconstruction
• In occurrences such as aircraft proximity violations,
mid-air collisions and flight into terrain the Air
Traffic Services investigation should establish,
record and verify the actual horizontal and vertical
flight profiles of the aircraft concerned.
• Reconstruction will be limited only by information
derived from all available recorded data sources
obtained by air traffic services or on-board recorded
systems where available. The reconstruction should
be cross checked with any witness statement/s. s.
The selection and availability of data will be
dependent upon the particular circumstances of the
occurrence being investigated. However, it is most
desirable that the investigation examine the original
rather than copies of the recorded data wherever
possible. It may also be necessary, in certain cases,
to have the Operations Group examine and obtain
aircraft performance data in order to establish and
compare the flight path profile reconstruction with
manufacturer’s data and its relevance to the
particular circumstance
• Dependent upon the nature of the occurrence,
some or all of the following items may be relevant
to the reconstruction of
• the flight profiles and variations between actual and
planned flight profiles:
• a) horizontal trajectory and deviations
• b) vertical trajectory, deviations and altitude busts
• c) rate of climb/descent
• d) ground speed(s)
• e) estimated/actual time intervals
• f) waypoints and geographic graticule
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