On 5 November 2010, JS Air Flight 201, a Beechcraft 1900 passenger aircraft on a charter service from Karachi to the Bhit Shah gas field in Sindh, Pakistan, crashed near Karachi's Jinnah International Airport, after suffering an engine malfunction at take-off. All 21 people on board were killed.
The investigation by Pakistan's Civil Aviation Authority concluded that the primary cause of the accident was the "inappropriate skill level" of the captain in dealing with the malfunction, and more generally the flight crew's non-adherence to the procedures prescribed by the aircraft manufacturer in such abnormal circumstances.
Accident
The aircraft had been chartered to fly 17 personnel of Italian oil and gas company Eni from Jinnah International Airport in Karachi to the Bhit Shah gas field. Three crew members and one airport security guard were also on board. At 01:55 UTC, the flight crew contacted Karachi Ground for take off. The Karachi Ground Controller replied "copied JS-201 start up approved runway two five left" and this was acknowledged by cockpit crew. The Captain cleared the area towards left side and began start up procedure for Engine No 1.
Following this the crew contacted Karachi Ground requesting taxi instructions which were given. Having received this the pilots conducted the pre-take off checklist. Cockpit Voice Recorder (CVR) data shows that the right engine propeller feathering system was checked as being in manual position. As per procedure, run up checks are supposed to be carried out and the feathering function of both engines is to be checked simultaneously. However, the pilots in this case only checked No 2 engine's feathering mechanism serviceability manually, contrary to the documented procedures.
At 02:03 UTC, the aircraft was cleared for takeoff and left the runway. Shortly thereafter the right engine flamed out, and the airspeed started to decrease slightly. The First Officer then put the failed engine into feathered position. At this stage, it is considered likely that the pilot monitoring (PM) may have observed only partial feathering. Having made the Pilot Flying (PF) aware of this, the PM made further attempts to fully feather engine number two. This both wasted precious time and, despite being authorised by the captain, was contrary to the documented procedures that no remedial action be taken below above ground level. Both airmen are recorded discussing the issue pertaining to Engine No 2, despite this the captain goes on to request the First Officer inform Air Traffic Control (ATC) of an engine failure on takeoff, with the failure in the number one engine. This mistake is indicative of a high stress level within the cockpit, and the breaking down of situational awareness.
The air traffic control gave immediate clearance for an emergency return to Karachi, which was acknowledged by the flight crew. This acknowledgment would be the last contact with the stricken aircraft. Cockpit Voice Recorder (CVR) and Flight Data Recorder (FDR) data indicates that, after the last radio message, the captain observed the First Officer moving the feather control for engine number two, asking "What are you doing?" The first officer replied that the engine was not feathered properly. It seems likely that the first officer became fixated on this one goal, removing all other situational awareness and to the exclusion of other tasks. By this point, the speed of the aircraft was with increasing pitch attitude and right angle of bank.
On the CVR recording further reduction in engine sound was observed. Flight Data Recorder (FDR) information showed that bank angle continually increased. The high stress levels of both pilots resulted in near overload and loss of situational awareness. This meant that the asymmetrical thrust caused by full power application to the functional number one engine and lack of thrust from number two, went unnoticed and was not corrected. Landing gear remained extended and airspeed continued to bleed off, rapidly approaching stalling speed.
The cockpit voice recordier noted the beginning of continuous stall warning alerts. The captain is recorded calling out Holy verses from the Quran and "Bismillah (In the name of God)". The ground proximity warning alert, "whoop, whoop", could be heard until the end of the recording.
Aircraft
The aircraft involved was a twin-turboprop Beechcraft 1900C-1, with Pakistani registration AP-BJD. It was built in 1991 and at the time of the accident had accumulated around 18,000 flight hours.
Passengers and crew
On board the aircraft were 17 passengers, 2 pilots, 1 technician and 1 security guard.