Vliegtuigongeval op 28 SEP 1992 met Airbus A300B4-203 AP-BCP

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Status:	Accident investigation report completed and information captured
Datum:	maandag 28 september 1992
Tijd:	14:30
Type:	Airbus A300B4-203
Luchtvaartmaatschappij:	Pakistan International Airlines - PIA
Registratie:	AP-BCP
Constructienummer:	025
Bouwjaar:	1976-03-23 (16 years 6 months)
Aantal vlieguren:	39045
Aantal vluchten:	19172
Motoren:	2 General Electric CF6-50C2
Bemanning:	slachtoffers: 19 / inzittenden: 19
Passagiers:	slachtoffers: 148 / inzittenden: 148
Totaal:	slachtoffers: 167 / inzittenden: 167
Schade:	Vernield
Gevolgen:	Written off (damaged beyond repair)
Plaats:	18 km (11.3 mijl) S of Kathmandu-Tribhuvan Airport (KTM) ( Nepal)
Fase:	Nadering (APR)
Soort vlucht:	Internationale lijnvlucht
Vliegveld van vertrek:	Karachi International Airport (KHI/OPKC), Pakistan
Vliegveld van aankomst:	Kathmandu-Tribhuvan Airport (KTM/VNKT), Nepal
Vluchtnummer:	PK268

Beschrijving:
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."

Bronnen:

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

Veiligheidsmaatregelen

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.

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Foto's

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

Kaart

Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Karachi International Airport en Kathmandu-Tribhuvan Airport bedraagt 1827 km (1142 miles).
Accident location: Approximate; accuracy within a few kilometers.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.

languages:

Airbus A300

561 built
8^e ongeval
3^e dodelijk ongeval
2^e zwaarste ongeval (toen het plaatsvond)
6^e zwaarste ongeval (op dit moment)

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Nepal

The zwaarste ongeval

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