A320 accident at KARACHI, PK, 22 May 2020 (AP-BLD)

Accident narrative

Aircraft Accident Investigation Board of Pakistan

FINAL INVESTIGATION REPORT

ACCIDENT OF PAKISTAN INTERNATIONAL AIRLINES FLIGHT PIA 8303 AIRBUS A320-214 AIRCRAFT REGISTRATION NUMBER AP-BLD CRASHED NEAR JINNAH INTERNATIONAL AIRPORT KARACHI ON 22ND MAY, 2020

Dated:

Final Report – Accident of PIA 8303 A320 AP-BLD on 22/05/2020

20th April, 2023

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Aircraft Accident Investigation Board of Pakistan

SCOPE Aircraft Accident Investigation Board (AAIB), Pakistan conducts investigations in accordance with Annex-13 to Convention on International Civil Aviation and Civil Aviation Rules 1994 (CARs 94). The sole objective of the investigation and the final report of an accident or incident under above stated regulations is the prevention of future accidents and incidents of similar nature. It is not the purpose of such an investigation to apportion blame or liability. Accordingly, it is inappropriate to use AAIB Pakistan investigation reports to assign fault or blame or determine liability, since neither the investigation nor the reporting process has been undertaken for that purpose. This report contains facts which have been determined up to the time of publication. Such information is published to inform the aviation industry and the public about the general circumstances of civil aviation accidents and incidents. Extracts may be published without specific permission provided that the source is duly acknowledged, and the material is reproduced accurately, and is not used in a derogatory manner or in a misleading context.

Final Report – Accident of PIA 8303 A320 AP-BLD on 22/05/2020

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Aircraft Accident Investigation Board of Pakistan

TABLE OF CONTENTS 1. 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 2. 2.1 2.2 2.3 2.4 2.5 3. 3.1 3.2 4. 4.1 4.2

FACTUAL INFORMATION………………………………………. 16 History of the Flight………………………………………………… 17 Injuries to Person(s)………………………………………………. 34 Damage to Aircraft………………………………………………… 34 Other Damage……………………………………………………... 34 Personnel Information…………………………………………….. 34 Aircraft Information………………………………………………... 38 Meteorological Information……………………………………….. 40 Aids to Navigation…………………………………………………. 42 Communications………………………………………………….. 43 Aerodrome Information……………………………………………. 45 Flight Recorders……………………………………………………. 53 Wreckage and Impact Information……………………………….. 53 Medical and Pathological Information…………………………… 77 Fire…………………………………………………………………. 77 Survival Aspects…………………………………………………… 77 Test and Research……………………………………………….. 78 Organizational and Management Information………………….. 110 Additional Information……………………………………………... 113 Useful or Effective Investigation Techniques…………………… 115 ANALYSIS…………………………………………………………. 116 General……………………………………………………………... 117 Flight Operations…………………………………………………… 117 Aircraft…………………………………………………………….... 141 Human Factors…………………………………………………….. 147 Survivability………………………………………………………... 150 CONCLUSION…………………………………………………….. 151 Findings……………………………………………………………. 152 Causes / Contributing Factors ..………………………………… 158 SAFETY RECOMMENDATIONS………………………………. 159 PIA………………………………………………………………….. 160 PCAA………………………………………………………………. 160

Final Report – Accident of PIA 8303 A320 AP-BLD on 22/05/2020

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Aircraft Accident Investigation Board of Pakistan

LIST OF FIGURES FIGURE 1 – FMA DISPLAY .................................................................................... 18 FIGURE 2 – STANDARD ARRIVAL CHARTS ........................................................ 18 FIGURE 3 – ILS-Z R/W 25L APPROACH CHART .................................................. 19 FIGURE 4 – FMA DISPLAY (OPEN DES MODE)................................................... 21 FIGURE 5 – G/S / LOCALIZER SCALE AND INDEX .............................................. 22 FIGURE 6 – FMA DISPLAY G/S ENGAGED .......................................................... 22 FIGURE 7 – G/S CAPTURE AND AUTO-PILOT DISENGAGEMENT AT JIAP, KARACHI ....................................................................................................... 23 FIGURE 8 – “L/G GEARS NOT DOWN” TRIGGERING CONDITIONS .................. 25 FIGURE 9 – OVERVIEW OF EVENTS TILL FIRST TOUCHDOWN ON THE R/W 25L .................................................................................................................. 27 FIGURE 10 – SCREENSHOTS OF SECURITY / CCTV CAMERAS FOOTAGES CONFIRMING CONTACT OF BOTH ENGINES’ NACELLES ............ 28 FIGURE 11 – ENGINE SPEED FROM LIFT-OFF TILL END OF FLIGHT .............. 30 FIGURE 12 – AERODROME / HELICOPTER CHART AIIAP, LAHORE ................ 47 FIGURE 13 – STANDARD INSTRUMENT DEPARTURE (SID) AIIAP, LAHORE... 48 FIGURE 14 – AERODROME / HELICOPTER CHART JIAP, KARACHI ................. 50 FIGURE 15 – STAR NAWABSHAH 2A ................................................................... 51 FIGURE 16 – STAR NAWABSHAH 1C................................................................... 52 FIGURE 17 – DIGITAL FLIGHT DATA RECORDER .............................................. 53 FIGURE 18 – COCKPIT VOICE RECORDER ........................................................ 53 FIGURE 19 – CCTV FOOTAGE BEFORE IMPACT ............................................... 54 FIGURE 20 – CCTV FOOTAGE AFTER IMPACT .................................................. 54 FIGURE 21 – AIRCRAFT WRECKAGE DISTANCE FROM THE R/W 25L THRESHOLD .......................................................................................................... 55 FIGURE 22 – ARIAL VIEW OF THE ACCIDENT SITE (DIRECTION OF FLIGHT FROM LEFT TO RIGHT) ......................................................................................... 55 FIGURE 23 – IMPACT POINT AT HEIGHT 10.50 M AND 46 M DISTANCE FROM EAST END OF STREET .............................................................................. 56 FIGURE 24 – HORIZONTAL TAIL PLANE.............................................................. 56 FIGURE 25 – L/H WING TOP SKIN WITH FLAP FAIRING .................................... 57 FIGURE 26 – HORIZONTAL TAIL PLANE L/H ....................................................... 57 FIGURE 27 – ELEVATOR SERVO-CONTROL....................................................... 57 FIGURE 28 – L/H SLAT TRACK ............................................................................. 57 FIGURE 29 – R/H WING (RIB 15 TO 24) LOWER SURFACE FACING UP AND FLAP TRACK 4 VISIBLE ......................................................................................... 58 FIGURE 30 – L/H MLG WITH MISSING WHEEL AND TYRES .............................. 58 FIGURE 31 – L/H MLG TYRE ................................................................................. 58 FIGURE 32 – MLG LOWER LEG, WHEELS AND TYRES ..................................... 58 FIGURE 33 – MLG L/H SIDE STAY FITTING ......................................................... 59 FIGURE 34 – RAT WITHOUT BLADES AND CONE .............................................. 59 FIGURE 35 – LEFT WING AT ROOFTOP .............................................................. 59 FIGURE 36 – ENGINE NO. 1 WITH PYLON AND REVERSE COWLS .................. 60 FIGURE 37 – ENGINE NO. 2 WITH PYLON ATTACHED ...................................... 60 FIGURE 38 – WRECKAGE LAYOUT AT JIAP, KARACHI ...................................... 60 FIGURE 39 – PARTS FOUND ON THE R/W .......................................................... 61 FIGURE 40 – FAN COWL LATCHES AND TR COWL LATCHES .......................... 61 Final Report – Accident of PIA 8303 A320 AP-BLD on 22/05/2020

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Aircraft Accident Investigation Board of Pakistan FIGURE 41 – TR LATCH BOX ................................................................................ 61 FIGURE 42 – SEAL AND RETAINER OF FAN COWL DOOR................................ 62 FIGURE 43 – 03 HOOKS OF NACELLE LATCHES ............................................... 62 FIGURE 44 – DAMAGED BRACKET FOUND ON THE R/W .................................. 62 FIGURE 45 – THSA ................................................................................................ 63 FIGURE 46 – RUDDER TLU ................................................................................... 63 FIGURE 47 – RUDDER TLU LEVER POSITION (MINIMUM AND MAXIMUM) ...... 64 FIGURE 48 – SLATS DESCRIPTION ..................................................................... 64 FIGURE 49 – SLAT TRACKS IN POSITION 1 ........................................................ 64 FIGURE 50 – FLAPS DESCRIPTION ..................................................................... 65 FIGURE 51 – L/H FLAP TRACK 4 FULLY RETRACTED ....................................... 65 FIGURE 52 – L/H FLAP TRACK 2 AND 3 FULLY RETRACTED ............................ 65 FIGURE 53 – LANDING GEARS CONTROL LEVER IN DOWN POSITION .......... 66 FIGURE 54 – MLG DESCRIPTION......................................................................... 66 FIGURE 55 – L/H MLG AND UPLOCK ROLLER .................................................... 67 FIGURE 56 – R/H MLG WITH THE RETRACTION ACTUATOR AND UPLOCK ROLLER .................................................................................................................. 67 FIGURE 57 – NLG DESCRIPTION ......................................................................... 68 FIGURE 58 – NLG DRAG STRUT ASSEMBLY WITH MISSING UPLOCK ROLLER .................................................................................................................. 68 FIGURE 59 – NLG UPLOCK WITH ITS HOOK IN OPEN POSITION AND ITS FREE-FALL INPUT LEVER IN POSITION “NOT USED” ........................................ 68 FIGURE 60 – MLG OR NLG VENT VALVE WITH THE FREE-FALL INPUT LEVER IN POSITION “NOT USED” ....................................................................... 69 FIGURE 61 – AUTO BRK MED SWITCH SELECTED AND A/SKID-NOSE WHEEL STEERING SWITCH ON ........................................................................... 69 FIGURE 62 – RAT................................................................................................... 69 FIGURE 63 – OVERVIEW THROUGH THE DOOR (LEFT) AND OPPOSITE SIDE (RIGHT) ......................................................................................................... 70 FIGURE 64 – FAN BLADES DAMAGED AND BENT ............................................. 70 FIGURE 65 – ENGINE LIFTED FROM ROOF TOP AND ENGINE AT WRECKAGE STORAGE SITE ................................................................................ 70 FIGURE 66 – TGB HOUSING CONDITION ............................................................ 71 FIGURE 67 – HEAVY RUBBING ON END FITTING INSTALLED ON HOSE ......... 71 FIGURE 68 – ECU IS MISSING .............................................................................. 72 FIGURE 69 – FRONT VIEW OF FAN BLADES NOT BENT. NO INDICATION OF SOFT BODY (I.E. BIRDS) IMPACT DAMAGE .................................................. 72 FIGURE 70 – RUBBING ON ABRADABLE COATING BETWEEN 9 TO 12 O'CLOCK (AFT LOOKING FORWARD) ASSUMED DUE TO DISPLACEMENT OF THE ENGINE DURING RESCUE OPERATION ..................................................... 72 FIGURE 71 – FAN BLADE’S FIRE FOAM AGENT TRACES.................................. 72 FIGURE 72 – FEW TIP CURLS, NO BENT BLADES. INDICATION OF NO OR LOW ROTATION DURING CRASH ........................................................................ 72 FIGURE 73 – DAMAGED TGB ............................................................................... 72 FIGURE 74 – ENGINE’S TGB WITH MISSING PART ON NEW ENGINE (IN GREY SHADE) .................................................................................................. 72 FIGURE 75 – ENGINE’S TGB AND AGB WITH MISSING PART ON NEW ENGINE (IN GREY SHADE) ................................................................................... 73 FIGURE 76 – TGB CONICAL GEAR: ACCIDENT CASE VS NEW ........................ 73 Final Report – Accident of PIA