Crash-aerien 28 SEP 1992 d'un Airbus A300B4-203 AP-BCP

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Statuts:	Accident investigation report completed and information captured
Date:	lundi 28 septembre 1992
Heure:	14:30
Type/Sous-type:	Airbus A300B4-203
Compagnie:	Pakistan International Airlines - PIA
Immatriculation:	AP-BCP
Numéro de série:	025
Année de Fabrication:	1976-03-23 (16 years 6 months)
Heures de vol:	39045
Cycles:	19172
Moteurs:	2 General Electric CF6-50C2
Equipage:	victimes: 19 / à bord: 19
Passagers:	victimes: 148 / à bord: 148
Total:	victimes: 167 / à bord: 167
Dégats de l'appareil:	Détruit
Conséquences:	Written off (damaged beyond repair)
Lieu de l'accident:	18 km (11.3 milles) S of Kathmandu-Tribhuvan Airport (KTM) ( Népal)
Élévation des lieux de l'accident:	2225 m (7300 feet) amsl
Phase de vol:	En approche (APR)
Nature:	Transport de Passagers Intern.
Aéroport de départ:	Karachi International Airport (KHI/OPKC), Pakistan
Aéroport de destination:	Kathmandu-Tribhuvan Airport (KTM/VNKT), Népal
Numéro de vol:	PK268

Détails:
PIA Flight 268 departed Karachi, Pakistan at 11:13 for a scheduled passenger flight to Kathmandu, Nepal. The en route portion of the flight was uneventful and the aircraft was cleared for a Sierra approach to Kathmandu's runway 02. The flight was instructed to maintain 11500 feet and report at 16 DME (16 miles from the VOR/DME beacon, which is located 0,6 nm short of the runway). The Kathmandu approach is very difficult, since the airport is located in an oval-shaped valley surrounded by mountains as high as 9665 feet. Runway elevation is 4313 feet amsl. The next approach fixes for PK268 were at 13 DME (at 10500 feet), 10 DME (at 9500 feet) and 8 DME (at 8200 feet). A few seconds after reporting 10 DME, the aircraft descended through 8200 feet, which was the altitude for 8 DME. The Airbus impacted a steep cloud-covered hillside at approx. 7300 feet amsl at 9,16 DME.

Probable Cause:

Cause:
"The balance of evidence suggests that the primary cause of the accident was that one or both pilots consistently failed to follow the approach procedure and inadvertently adopted a profile which, at each DME fix, was one altitude step ahead and below the correct procedure. Why and how that happened could not be determined with certainty because there was no record of the crew's conversation on the flight deck.
Contributory causal factors were thought to be the inevitable complexity of the approach and the associated approach chart."

Sources:

» ICAO Circular 296-AN/170 (p.267-326)
» ICAO Adrep Summary 2/94 (#1)

Opérations de secours

Nepal issued 21 Safety Recommendations

Issued: --	To: ICAO	AP-BCP (1)
ICAO should review the conventions of commercial approach chart with a view to encouraging standardisation and reducing chart clutter.
Issued: --	To: PIA	AP-BCP (10)
The airline should expand its briefing material for difficult instrument approaches and make this material available in or very near the crew reparting centre.
Issued: --	To: PIA	AP-BCP (11)
The airline should practice the SIERRA approach in the simulator as part of the process of pilot qualification to operate to Kathmandu and that such approaches should be pan of a line-orientated training session.
Issued: --	To: PIA	AP-BCP (12)
The operator should ensure that all its routecheck pilots are route-checked at least once per year.
Issued: --	To: PIA	AP-BCP (13)
The airline should provide Cockpit Resource Management training as soon as practicable for captains, -pilots and flight engineers.
Issued: --	To: PIA	AP-BCP (14)
The airline should train its flight engineers to interpret non-precision approach charts and provide them with charts for all non-precision approaches flown by the company.
Issued: --	To: PIA	AP-BCP (15)
The airline should carry out checks of recorded flight data to ensure that company standard operating procedures are being followed.
Issued: --	To: CAA Pakistan	AP-BCP (16)
The Civil Aviation Authority of Pakistan should appoint and provide flight operations inspectors and the airline should allow them on the flight deck as observers.
Issued: --	To:	AP-BCP (17)
Airlines which operate regular scheduled services to Kathmandu should, where necessary, modify their GPWS equipments to provide automatic callouts of radio height.
Issued: --	To: Nepal DCA	AP-BCP (18)
HMG/N Department of Civil Aviation should study the practicalities of providing an instrument landing system (ILS) and radar coverage at Kathmandu.
Issued: --	To: Nepal DCA	AP-BCP (19)
HMG/N Department of Civil Aviation should consider taking steps to improve air traffic controllers\' motivation, performance and selfesteem by: a, Issuing formal air traffic controller licences. b. Introducing specific controller position training and ratings. c. Introducing periodic competency checks. d. Immediately introducing improved salaries and allowances to operational ATCOs at Tribhuvan International Airport
Issued: --	To: Nepal DCA	AP-BCP (2)
His Majesty\'s Government of Nepal, Ministry of Tourism and Civil Aviation, Department of Civil Aviation should re-design the State SIERRA approach chart to comply with ICAO PANS OPS by including a table of recommended minimum altitudes for each nautical mile of the final approach.
Issued: --	To: ICAO	AP-BCP (20)
ICAO should sponsor research into improving GPWS technology so as to improve system performance in mountainous terrain.
Issued: --	To: Airbus	AP-BCP (21)
Airbus Industrie should amplify the instructions in their Flight Crew Operating Manual regarding pilot response to GPWS warnings.
Issued: --	To: Nepal DCA	AP-BCP (3)
HMG/N, Department of Civil Aviation should improve and simplify the SIERRA approach procedure by addressing thc following aspects: a. Unnecessary changes in the glidepath should be eliminated b. The holding pattern should be revised. c. A facility should be provided to validate DME range before the descent below minimum safe en-route altitude commences.
Issued: --	To:	AP-BCP (4)
The chart producers should ensure that their SIERRA approach charts comply with ICAO PANS OPS by including table of recommended minimum altitudes for each nautical mile of the final approach.
Issued: --	To: PIA	AP-BCP (5)
The operator should take steps to stop the dubious practice of some crews transcribing data from approach charts.
Issued: --	To: PIA	AP-BCP (6)
The airline\'s crews should be encouraged to alert their management and their pilots\' association to those charts which they consider to be unsatisfactory.
Issued: --	To: PIA	AP-BCP (7)
The airline should fit control column chart clipboards to all its A300s.
Issued: --	To: PIA	AP-BCP (8)
The airline should equip all its aircraft with sufficient lightweight-headsets for each member of the flight crew and those headsets should have boom microphones.
Issued: --	To: PIA	AP-BCP (9)
The airline should adopt the hot microphone system for CVR recordings.

Show all...

Photos

accident date: 28-09-1992
type: Airbus A300B4-203
registration: AP-BCP

Sierra approach profile

Approach profile

accident date: 28-09-1992
type: Airbus A300B4-203
registration: AP-BCP

Plan

Ce plan montre l'aéroport de départ ainsi que la supposée destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre Karachi International Airport et Kathmandu-Tribhuvan Airport est de 1827 km (1142 miles).
Accident location: Approximate; accuracy within a few kilometers.

Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.

languages:

Airbus A300

561 built
8^ème loss
3^ème accident fatal
le accident 2^ème le plus grave (à ce moment là)
le accident 6^ème le plus grave (en ce moment)

» safety profile

Népal

le accident The le plus grave (à ce moment là)
le accident The le plus grave (en ce moment)

» safety profile

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