Captain and First Officer (FO) of the ill-fated Bhoja Air Flight BHO-213 (Boeing 737-236A) failed to comply with the basics of Crew Resource Management (CRM) training which contributed in causation of the unfortunate mishap, investigation report said. The Civil Aviation Authority of Pakistan on Thursday released a final report on Bhoja air crash investigation that left 127 passengers on board, including six flight crew members, killed on April 20, 2012.
The Bhoja air crash investigation was conducted by a US accredited representative, who was appointed by the National Transportation Safety Board (NTSB) and assisted by technical advisers from Boeing, the Federal Aviation Administration and Pratt & Whitney.
According to the report, the flight took off for Islamabad at 1705 hrs from Karachi. The reported weather at Islamabad at that time was thunderstorm with gusty winds. The report, which was released after almost three years of the incident, said that primary causes of accident included ineffective management of the basic flight parameters such as airspeed, altitude, descent rate attitude, as well as thrust management.
The contributory factors were the crew's decision to continue the flight through significant changing winds associated with the prevailing weather conditions and the lack of experience of the crew to the airplane's automated flight deck. It said that reasons of ineffective management of the automated flight deck were the induction of inexperience cockpit crew for Boeing 737-236A; inadequate cockpit crew simulator training and absence of organisational cockpit crew professional competence and monitoring system.
The incorrect decision to continue for the destination and not diverting to the alternate aerodrome despite the presence of squall line and very small gaps observed by the Captain between the active weather cells is also considered a contributory factor in causation of the accident, the report said, adding that operator's Ops Manual approved by CAA Pakistan clearly stated to avoid active weather cells which was violated by the cockpit crew.
The report said that FO possessed average professional competence level and was due for his six monthly recurrent simulator training for Boeing 737-200 aircraft (equipped with a semi-automated flight deck). Bhoja Air requested an extension for his recurrent simulator training on March 7 2012. As per the existing laid down procedures of the CAA, two months extension was granted for recurrent simulator training on March 9, 2012.
The extension was granted for Boeing 737-200 aircraft, whereas the newly-inducted Boeing 737-236A aircraft was equipped with automated flight deck. The report also revealed that critical information regarding automation of the newly-inducted Boeing 737-236A was not available with Flight Standard Directorate of CAA as the information was not provided by the Bhoja Air Management.
Therefore, due to the ignorance of Bhoja Air Management and the CAA, the said extension in respect of FO for simulator training was initially requested by former and subsequently approved by the latter. This resulted in absence of variance type training conformance of FO because of which he did not contribute positively in recovering the aircraft out of unsafe set of conditions, primarily due to lack of automation knowledge, proper training and relying on captain to take remedial actions.
Similarly, the Captain's airline flying experience on semi-automated flight deck aircraft and his selection for automated aircraft without subsequent training and monitoring to enhance his professional competence and skills was also one of the factors in causation of the accident. It said that cockpit crew's incorrect decision to continue the flight for destination and non-adherence to Boeing recommended QRH and FCOM remedial actions due to non-availability of customised aircraft documents at Bhoja Air for Boeing 737-236A and the inability of the CAA to ensure automated flight deck variance type training and monitoring requirements primarily were also contributory factors in causation of the accident.