the civil aviation authority (caa) admitted on thursday for the first time that the pilot and the...

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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.

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Page 1: 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

  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.“

Page 2: 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

• 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.

Page 3: 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

• 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.

Page 4: 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

Two UAE passenger aircraft avert collision

Page 5: 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

• Two passenger aircraft, believed to be UAE-owned, avoided a mid-air 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.

Page 6: 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

• “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.

Page 7: 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

• 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

Page 8: 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

• 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.

Page 9: 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

• 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.

Page 10: 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

• 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:

Page 11: 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

• 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

Page 12: 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

• 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.

Page 13: 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

• 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

Page 14: 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

• 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

Page 15: 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

• 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

Page 16: 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

Witness InterviewsThe 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, orcomplement 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 obviouslyconflict with established material evidence or attempts to divert the focus of the investigation from accident prevention and safety enhancement.

Page 17: 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

• 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.

Page 18: 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

• 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.

Page 19: 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

• 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.

Page 20: 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

• 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.

Page 21: 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

• 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

Page 22: 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

• 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

Page 23: 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

• 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:

Page 24: 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

• 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

Page 25: 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

• 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

Page 26: 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

• 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

Page 27: 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

• 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.

Page 28: 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

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

Page 29: 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

• 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

Page 30: 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

QUIZ

Page 31: 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