Pakistan International Airlines Flight 8303

On 22 May 2020, Pakistan International Airlines Flight 8303, a scheduled domestic passenger flight from Lahore to Karachi, crashed while on approach to Jinnah International Airport, killing 97 out of the 99 people on board as well as an additional person on the ground. The aircraft, an Airbus A320 with 91 passengers and 8 crew members on board, was on an unstable approach to Jinnah International Airport, with an excessively high airspeed and altitude. The aircraft subsequently belly landed nearly half-way down the airport runway before the flight crew conducted a go-around. During the go-around, both engines started to fail due to damage sustained during the belly landing. Whilst attempting to land back on the runway, the aircraft lost airspeed and crashed into buildings in Model Colony. All 8 crew members and 89 out of the 91 passengers on board were killed by the impact and post-crash fire. One person who was inside the buildings died ten days after the crash due to burn injuries.

The investigation, conducted by the Aircraft Accident Investigation Board of Pakistan, determined that both the captain and first officer made multiple errors over an extended period during both the approach and landing. The crew lacked crew resource management, which led to unsafe flight operations and a lack of adherence to standard operating procedures. The investigators determined that the crew's actions resulted in the aircraft being significantly above the required glide slope approach path for the runway. The flight crew disregarded air traffic control instructions and continued an unstable approach. The improper position of the approach path and the configuration of the aircraft then caused the autopilot to disengage. In response to the high descent rate and numerous warnings from the ground proximity warning system, the first officer raised the landing gear and speed brakes in an attempt to go around. He did not verbalise his actions to the captain, nor did he follow up with the proper go-around procedure. The captain continued with the landing, and the aircraft contacted the surface of the runway multiple times. This resulted in severe damage to the engines, which led to a failure of both engines and electrical generators as the aircraft then climbed away from the runway. The crew were now attempting to return to the airport, but with damaged engines and at a critical altitude, the plane was simply too low and too slow to go around for a successful landing. The aircraft continued to lose airspeed before crashing into a row of buildings 4,410 ft from the threshold of the runway.

Flight operations

During the flight, the investigation found that the crew displayed disregard to several safety regulations. During cruise, the CVR revealed that the flight crew engaged in casual conversation, especially about the COVID-19 pandemic. Conversations not relevant to the safety of the flight are not allowed below 10,000 ft (the sterile cockpit rule), but the flight crew continued to converse in violation of the rule. The required approach briefing was never conducted. The AAIB determined that their conversations also resulted in a failure to verbalize changes to the flight mode annunciator (FMA) and the temporary loss of radio contact.

The AAIB deemed that the crew demonstrated a lack of situational awareness and crew resource management (CRM) several times during the descent. The crew did not notice the two indications of the holding pattern at SABEN: one on the navigation display and one on the multi-function control and display unit. The AAIB determined that this resulted in their failure to notice the indicated track miles was greater than the amount the aircraft flew. The investigation also stated that crew was overconfident and complacent as they did not communicate or crosscheck with each other with the position of the aircraft.

The AAIB determined that the crew did not follow standard operating procedures (SOPs), which showed when they engaged open descent mode on final approach despite it being prohibited during that phase of flight. When ATC told the flight about their position, the crew disregarded their suggestions of taking an orbit and continued with the unstable approach. The investigators found that the crew failed to properly consider their options, which was in violations of SOPs, and were focused in on the approach without considering their altitude, showing a lack of situational awareness. When the autopilot disconnected due to excessive nose down pitch, the CVR indicated that crew failed to verbalize the master caution warning or the FMA caution, and did not establish who was in control of the aircraft. Despite the required procedure after a GPWS activation being to initiate a terrain escape manoeuvre to climb away from the terrain, the recorders showed that the crew failed to do so after the GPWS activated. The AAIB deemed this to be demonstrating their lack of situational awareness in relation to the position of the aircraft.

After First Officer Azam raised the landing gear and speed brakes, the CVR showed that he did not communicate his action with Captain Gul, who remained insistent on landing the aircraft. Neither recorder showed the crew acknowledging the master caution warnings after the extension of the flaps, the "landing gear not down" ECAM warning, or them conducting an orbit at the instruction of ATC. Despite being on an unstabilized approach, the CVR recorded no callouts about the aircraft's position, a violation of SOPs according to the AAIB. Gul assuming control over the aircraft without any callouts showed improper CRM as the CVR showed there was no conversation about who was actually in control of the flight.

During the landing attempt, full reverse thrust was selected on both engines despite the aircraft still being airborne, against SOPs. The flight crew then initiated a go-around despite being on the ground for 18 seconds. This was against standard procedure, which dictates that flight crews must not go-around after reverse thrust selection. The AAIB deemed that the crew demonstrated poor airmanship by deciding to go-around after the engine two fire warning rather than trying to stop on the runway. After the go-around, the investigators determined that the crew failed to properly discuss the gear-up landing or a second approach to Runway 25L, demonstrating a lack of situational awareness. The lack of situational awareness was also shown when the DFDR recorded the crew reducing power to the still functional engine two rather than the failing engine one.

Flight crew performance

The investigation highlighted several factors in relation to the performance of the flight crew and their past in aviation. Captain Gul had a history of excessive flight hours; an analysis of his flying hours between 2017 and 2019 showed that he flew 33% more than the average for all other PIA A320 captains and he was issued a notice by the Pakistan Civil Aviation Authority (PCAA) about exceeding duty time limitations. In 2014, he was considered for a supervisory position on ATR aircraft but was not recommended due to lack of technical knowledge and general awareness. An analysis of Gul's flights in the twelve months prior to the accident showed multiple high-speed approaches, excessively high approaches, high rates of descent, long flare distances, GPWS warnings, a lack of go-arounds, and unstabilized approaches. As part of the investigation, an aviation psychologist wrote, "He was of bossy nature, firm, dominant and overbearing. He had below average intelligence. He [tended] to have little regard for the authority. He had low mechanical comprehension with low comprehension of space relations. His level of stress tolerance was also quite inadequate." During Gul's first psychiatric evaluation, he was not recommended for a cadet pilot position by the panel at PIA. Subsequently, he got declared fit for cadet pilot by five other psychiatrists. The PIA psychiatric panel initially denied Gul's application, but after he filed a petition to the Wafaqi Mohtasib, they sided with him and he was declared fit.

First Officer Azam also had difficulties in his past. During initial simulator checks on ATR aircraft in July 2014, he passed with three "satisfactory with briefing" remarks on engine failure after V1, emergency procedures, and procedure execution and adherence. Later during his initial line check in December, he passed with two more satisfactory with briefing remarks. As a result, he was placed under supervision by a Pakistan Civil Aviation Authority (PCAA) inspector the next year which withheld his promotion to an A320 first officer in February 2016.

The AAIB determined that the flight crew failed to adhere to standard operating procedures and apply proper crew resources management. They listed Gul's history of having problems with approaches as a finding related to flight operations and the crash.

As the crash occurred during the Islamic holy month of Ramadan, the AAIB conducted tests and research to discover whether fasting might have impaired the flight crew's performance. During Ramadan, Muslims abstain from eating or drinking from sunrise to sunset. Fasting can affect the normal human day-night routine, circadian rhythms, levels of hydration, and blood sugar levels. PCAA regulations state that pilots shall not fly while under the effects of fasting. The AAIB conducted two studies in flight simulators in relation to the effects of fasting: one to study the performance of dehydrated pilots against a control group; and one to compare the performance of pilots with low blood sugar levels against pilots with excessive blood alcohol levels, pilots exposed to excessive noise, and a control group. For the first study, results showed that dehydrated pilots had worse flight performance and spatial cognition compared to properly hydrated pilots. For the second study, results showed that pilots with low blood sugar levels deviated the most from a set vertical axis, horizontal axis, and airspeed, followed by pilots with excessive blood alcohol levels. The flight crew on Flight 8303 were likely fasting during flight; the CVR showed that a flight attendant offered them snacks, but they refused the offer. The AAIB concluded that the judgment of the flight crew was likely impaired due to the effects of fasting, although they did not determine the full extent of the consequences of this impairment. Additionally, manuals at PIA did not make it clear what the regulations on fasting were at the airline.