JS Air B190 at Karachi on Nov 5th 2010, engine failure on takeoff

Last Update: December 18, 2015 / 19:36:03 GMT/Zulu time

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Incident Facts

Date of incident
Nov 5, 2010

Classification
Crash

Airline
JS Air

Aircraft Registration
AP-BJD

Aircraft Type
BEECH C-12J

ICAO Type Designator
B190

Airport ICAO Code
OPKC

A JS Air Beech 1900C, registration AP-BJD performing a charter flight from Karachi to Bhit Shah (Pakistan) with 19 passengers and 2 crew, had just taken off Karachi's Jinnah International Airport when the crew reported the right hand engine failed and attempted to return to Karachi. The airplane impacted terrain at about 07:15L (02:15Z) about 2 minutes after becoming airborne.

The airplane was to carry oil workers for Italian company ENI to oilfields at Bhit Shah.

On Dec 18th 2015 Pakistan's Safety Investigation Board (SIB) released their final report concluding the probable causes of the crash were:

Detailed investigation and analyses of the examinable evidence confirmed that the aircraft had developed some problem with its Engine No.2 (Right) immediately after takeoff which was observed by the cockpit crew as propeller feathering on its own. No concrete evidence could be found which would have led to the engine’s propeller malfunction as observed. The only probable cause of propeller feathering on its own could be the wear & tear of the beta valve leading to beta system malfunction. However, this anomaly at the most could have led to the non availability of one engine and making a safe landing with a single engine since the aircraft was capable of landing with a single engine operation. Some of the actions by the cockpit crew before takeoff and subsequent to the observed anomaly in the Engine No.2 were not according to the QRH / FCOM which aggravated the situation and resulted into the catastrophic accident.

Factors leading to the Accident

- The aircraft accident took place as a result of combination of various factors which directly and indirectly contributed towards the causation of accident.

- The primary cause of accident includes, inappropriate skill level of Captain to handle abnormal operation of engine No 2 just after takeoff, failure of cockpit crew to raise the landing gears after experiencing the engine anomaly, execution of remedial actions by FO before the attainment of minimum safe altitude of 400 ft AGL resulted in non conformance and non compliance of cockpit crew to OEM recommended procedures to handle such situations.

- The lack of situational awareness and CRM failure directly contributed towards ineffective management of the flight deck by the cockpit crew.

- The contributory factors include inadequate cockpit crew simulator training monitoring mechanism both at operator and CAA Pakistan levels in respect of correlation of previous / current performance and skill level of cockpit crew during the simulator training sessions along with absence of conduct of recurrent / refresher simulator training between two annual simulator checks in accordance with ICAO Annex-6 guidelines and CAA Pakistan (applicable ANOs) requirements for specific type of aircraft in a year.

Finalization

- A number of non conformances and non adherences to Beechcraft 1900C aircraft OEM recommended QRH, FCOM procedures and remedial actions by the cockpit crew, their lack of situational awareness, CRM failure and unprofessional handling of the anomaly in one of the engines’ operation (Engine No 2 propeller feathering without any cockpit crew input) aggravated the situation and caused the accident.

- The cause of Engine No 2 propeller feathering on its own is attributed to probable wear & tear of the beta valve during its service life leading to beta system malfunction.

The SIB reported that the aircraft was at maximum takeoff weight. The aircraft was cleared for takeoff from Karachi's runway 25L, the captain (53, ATPL, 8,114 hours total, 1,820 hours on type), pilot flying, queried the first officer (33, ATPL, 1,746 hours total, 1,338 hours on type, rated as captain on the B-1900), pilot monitoring, regarding autofeather and announced "autofeather off", the SIB annotating that according to standard operation procedures the autofeather should be in position "ARM", not OFF. The autofeather switch was set to "OFF" and the autofeather light illuminated. Takeoff power was set while the aircraft began accelerating, the aircraft began to rotate at 113 KIAS.

While rotating through 4.63 degrees of pitch, at 119 KIAS, the cockpit voice recorder recorded reduced engine sounds instantly followed by the remark "Oh no!" by the first officer and the captain asking "What has happened?" 3 seconds later the first officer reported "right engine propeller has gone", at this time the airspeed was 123 KIAS, pitch was +6.66 degrees and the aircraft was just about to become airborne.

Another 5 seconds later, at about 40 feet AGL, 7.49 degrees nose up and 121 KIAS, the first officer queried whether he should select the right propeller into feather position, the captain affirmed.

3 seconds later the first officer queried whether he should put the propeller into feather, captain responded "What?", airspeed was 119 KIAS at 7.34 degrees nose up about 70 feet AGL. The landing gear was still down.

The captain indicated to bring the power (lever) back, 117 KIAS, 85 feet AGL, 7.57 degrees nose up.

The captain subsequently instructed the first officer to tell ATC about the failure of the #1 (left) engine, although all discussion and crew actions concerned the #2 engine, 116 KIAS, 110 feet AGL, 7.87 degrees nose up.

The first officer, although knowing engine #2 was malfunctioning, advised ATC of the #1 engine failure and received clearance to join a right downwind for runway 25L, 185 feet AGL, 112 KIAS, 9.75 degrees nose up, 13.08 degrees right bank.

The first officer queried "Is it under control?", 300 feet AGL, 109 KIAS, 8.96 degrees nose up, 12.28 degrees right bank.

The first officer acknowledged the instruction to join right downwind for runway 25L, which proved to be the last transmission from the aircraft, 106 KIAS, 10 degrees nose up, 12 degrees right bank.

The captain queried the first officer "what are you doing?", 102 KIAS, 280 feet AGL, 9.2 degrees nose up, 17 degrees right bank. The SIB annotated: "At this stage, it is considered that FO was moving the engine No 2 feather control lever."

The first officer advised: "It is not feathering", 102 KIAS, 280 feet AGL, 9.02 degrees nose up, 18 degrees right bank.

The captain instructed "Wait a minute", 98 KIAS, 300 feet AGL, 10.24 degrees nose up, 22 degrees right bank. Engine sound on the CVR reduces further, SIB annotates: "it is considered that at this stage FO feathered the propeller as the reduction in engine noise was observed at this stage in CVR recording."

Further reduction in engine sounds was noticed on the CVR, 83 KIAS, 330 feet AGL, 7.95 degrees nose up, right bank 28 degrees. SIB annoted: "It is important to note that the aircraft at this stage was flying at very low airspeed which was close to the stalling speed with landing gears down and at maximum all up weight."

Sounds consistent with two engine surges were recorded, 94 KIAS, 300 feet AGL, 7.42 degrees nose up, 22 degrees right bank. The SIB annotated: "Probably at this stage, cockpit crew advanced the power on serviceable engine No 1 to recover out of unsafe set of conditions which resulted in two surges being recorded on CVR."

About 45 seconds after becoming airborne a high pitch tone similiar to a stall warning became audible and continued until end of recording, 95.8 KIAS, 300 feet AGL, 9.91 degrees nose up, 22 degrees right bank.

2 seconds later the captain exclaims "bismillah bismillah" (with the name of Allah), 85.6 KIAS, 320 feet AGL, 38 degrees right bank, 6.96 degrees nose up.

50 seconds after becoming airborne the GPWS issued aural "whoop! whoop!", 88 KIAS, 320 feet AGL, 2.3 degrees nose up, 50 degrees right bank. The "Whoop! Whoop!" continued until end of recording.

The SIB annotated: "The aircraft was continuously losing altitude under stalled state" as the aircraft descended through 300 feet AGL at 73.9 KIAS, 270 feet AGL at 66 KIAS. The last recording was at 190 feet AGL at 80 KIAS, 15.12 degrees nose down, 42.65 degrees right bank, gear was still down.

Examination of the wreckage showed the right hand propeller was in its feathered position at the time of impact, all blades, beta rod end, feather stop screws and blade clamp screws indicating the mechanism had reached the feathered position.

The SIB analysed: "The Beechcraft 1900C-1 at its full all up weight is capable of sustaining safe flight after experiencing non availability of one engine provided the OEM recommended procedures as per QRH and FCOM are followed. The first recommended action after experiencing engine failure after V1 or takeoff is having positive control of aircraft and raising the landing gears in order to reduce the drag immediately so that aircraft can quickly achieve minimum safe flying parameters ie altitude 400 ft above ground level while maintaining minimum single engine safety speed. The cockpit crew after experiencing the engine No 2 anomaly, never discussed and raised the landing gears after takeoff. This is one of the very important factor due to which the mishap aircraft could not achieve the minimum safe flying parameters and crashed after experiencing one engine un-serviceability."

The SIB analysed with respect to reporting the #1 engine failing: "The cockpit crew were experiencing engine No 2 propeller going to feathered position and not problem with engine No 1. The engine No 1 performance parameters were observed well within the design parameters of the engine and very close to the cockpit crew desired parameters as well. Therefore, it is considered that the cockpit crew transmitted the incorrect information due to the anxiety / stress of flying in abnormal set of conditions while operating at low airspeed and below minimum safe altitude."

The SIB analysed: "The FO was a qualified Captain on Beechcraft-1900C aircraft, however his actions and assistance available to the Captain of aircraft was not at optimum level. He failed to retract the landing gears after takeoff and undertook remedial actions well below the defined minimum safe altitude contrary to the recommended procedures as per QRH and FCOM which shows his pre-occupation, anxiety and stress in handling abnormal situation. Due to these non conformances, the mishap aircraft failed to achieve the safe flying parameters despite having a serviceable engine. Therefore non conformances of the recommended remedial actions by both the cockpit crew resulted into the in-effective management of flight deck causing the aircraft to lose initially airspeed and then altitude after takeoff."

The SIB analysed:

The Captain during two simulator training check flights was observed achieving the satisfactory standard of performance after briefing (SB) in safely handling the single engine operation of aircraft. It points to the fact that despite being instructor on various types of aircraft, the Captain was not confident and lacked the required proficiency level / skill to independently handle the aircraft operations with single engine during critical phases of flight.

FO as PM was exposed to serious level of stress and anxiety when he observed the propeller feathering of No 2 (right) engine. The situation was aggravated due to the fact that the auto feathering was selected to “Off” which entailed the cockpit crew to manually manage feathering of Propeller in case of any anomaly. He did communicate to the Captain correct information, however, Captain did not register engine No 2 and told him to inform ATC Tower that they were experiencing problem with engine No 1 and FO communicated the same without questioning Captain or correcting himself. He got mentally pre-occupied to a level where he could not perform the recommended remedial actions as per the QRH and FCOM. Thus, he did not effectively contribute towards handling of abnormal set of conditions.

The cockpit crew could not effectively and efficiently employ CRM tools and techniques to achieve safe flying parameters of aircraft for executing safe recovery back to JIAP, Karachi.

With respect to the uncommanded feather the SIB analysed: "A review of the engine’s relevant Technical Manuals and the experience indicate that the beta valve is the only part in the propeller governing system that has the authority to bring the propeller into a coarse or feather pitch in such a quick manner as observed in this accident. There are two possibilities of beta valve malfunction; mis-rigging after some maintenance work or fair wear & tear during routine service. Unfortunately, the beta system’s integrity and rigging status could not be verified because the propeller governor had been completely consumed in the post ground impact fire. However, it was confirmed from the documented history and the engineering staff that there was neither any reported defect related to the beta system nor was there any scheduled or unscheduled maintenance performed in the recent past. Therefore, the only probable cause of occurrence could be fair wear and tear of the beta valve."

Metars:
OPKC 050330Z 03003KTS 3000 FU SKC 22/18 Q.1014 NOSIG
OPKC 050328Z 03003KTS 3000 FU SKC 22/18 Q.1014 NOSIG
OPKC 050230Z 05003KT 3000 FU FEW030 18/15 Q1014 NOSIG
OPKC 050200Z 04003KT 3000 FU SKC 18/15 Q1013 NOSIG
OPKC 050130Z 00000KT 4000 FU SKC 18/16 Q1013 NOSIG
OPKC 050100Z 36002KT 5000 FU SKC 18/16 Q1013 NOSIG
OPKC 050030Z 05003KT 5000 FU SKC 18/16 Q1013 NOSIG
OPKC 050000Z 02002KT 5000 FU SKC 18/16 Q1012 NOSIG
Incident Facts

Date of incident
Nov 5, 2010

Classification
Crash

Airline
JS Air

Aircraft Registration
AP-BJD

Aircraft Type
BEECH C-12J

ICAO Type Designator
B190

Airport ICAO Code
OPKC

This article is published under license from Avherald.com. © of text by Avherald.com.
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