What happened
On November 5, 2010, a JS Air Beechcraft 1900C-1, registration AP-BJD, crashed during a chartered flight departing Jinnah International Airport (JIAP), Karachi. The aircraft was transporting 21 people, including employees of the Eni company, to the Bhit Shah Oil Fields.
Shortly after takeoff, the crew observed abnormal operation in Engine No. 2, specifically noting that the propeller had feathered on its own. The flight crew decided to return to JIAP and requested a right-hand downwind for runway 25R. During the approach, the aircraft lost altitude and impacted the ground approximately one nautical mile from runway 07R while in a stalled state with a 45-degree bank. The impact and subsequent intense post-impact fire resulted in 21 fatalities.
The investigation
The investigation, conducted by the Pakistani authorities with assistance from the NTSB (USA) and TSB (Canada), analyzed flight data recorder (FDR) and cockpit voice recorder (CVLT) information. Investigators examined the aircraft's maintenance logs, which revealed that several entries had been recorded in pencil and lacked proper signatures. The investigation also reviewed the crew's training records, noting a lack of required semi-annual simulator/emergency procedure training.
Findings
- The primary cause was the inappropriate skill level of the Captain in managing the engine anomaly, combined with the crew's failure to raise the landing gear after the event.
- The First Officer performed remedial actions before the aircraft reached a minimum safe altitude of 400 feet AGL, which deviated from manufacturer-recommended procedures.
- A lack of situational awareness and failures in Crew Resource Management (CRM) prevented effective flight deck management.
- The propeller feathering was likely caused by wear and tear of the beta valve, leading to a malfunction in the beta system.
- Contributory factors included inadequate monitoring of simulator training and non-compliance with ICAO guidelines regarding recurrent emergency training.
Safety action
- Operators in Pakistan are advised to implement stricter supervision of pilot skill levels during simulator checks.
- Emphasis must be placed on strict compliance with OEM-recommended procedures during non-normal situations and the use of CRM tools.
- Ground handlers and operators must ensure all maintenance entries are recorded in official logbooks using permanent ink, avoiding lead pencils or erasable media.