Date: 20th July 2019
Location: Gilgit Airport, Pakistan
Aircraft: ATR-42-500, registration AP-BHP
Operator: Pakistan International Airlines (PIA)
Flight Number: PK-605
Route: Islamabad (ISB) to Gilgit (GIL), Pakistan
Occupants: 53 (48 passengers, 5 crew)
Injuries: None reported
Damage: Substantial damage to right main landing gear, right wing, and right engine
Summary of Events
On 20th July 2019, PIA flight PK-605, an ATR-42-500, landed on Gilgit Airport’s runway 25 but overran the runway’s end, veered to the right, and came to rest in a ditch with the right main gear collapsed. While no injuries were reported among the 53 occupants, the aircraft sustained significant structural damage.
The Pakistan Safety Investigation Board (SIB) conducted a thorough investigation and released their final report on 12th December 2024, identifying multiple lapses in standard operating procedures (SOPs) and flight crew performance as the primary causes of the accident.
Sequence of Events
1. Approach and Landing Phase:
• The captain, serving as the pilot flying (PF), conducted a high-speed approach and landing contrary to SOPs.
• The first officer, the pilot monitoring (PM), failed to assertively intervene despite observing deviations from SOPs.
• Key warnings, such as “Too Low Gear” and “Terrain,” were ignored by the captain.
2. Landing and Overrun:
• The aircraft touched down approximately 2,000 feet down the runway at a ground speed of 170 knots, significantly higher than the recommended 115 knots.
• The captain failed to use thrust reversers and relied solely on brakes, which proved insufficient to stop the aircraft on the remaining runway.
• The captain veered the aircraft to the right at 75 knots to avoid overrunning into obstacles but lost control as the right main gear collapsed.
3. Post-Landing Actions:
• The aircraft came to a stop in a ditch.
• The captain shut down the engines and instructed the cabin crew to prepare for evacuation, which proceeded without injury.
Investigation Findings
Primary Causes:
1. High-Speed Approach and Landing: The captain intentionally conducted a high-speed approach, leading to runway excursion.
2. Failure to Follow SOPs: The flight crew deviated from established operational protocols.
Contributing Factors:
1. Inadequate Crew Resource Management (CRM): The PM failed to assertively challenge or correct the PF’s actions.
2. Lack of Supervision: PIA’s Flight Data Analysis (FDA) program failed to identify and address the captain’s habitual non-compliance with SOPs.
Key Findings
• Flight Crew: The captain had a history of high-speed approaches, but no prior actions were taken to address this behavior.
• Aircraft Performance: No technical faults were found with the aircraft or its systems.
• Operational Environment: Weather was fair, with calm surface winds and occasional gusts.
• Regulatory Oversight: PIA’s FDA program was inadequately monitored by the Civil Aviation Authority (CAA), contributing to systemic lapses in safety practices.
Safety Risks
1. Runway Excursion Hazards: High-speed approaches and insufficient braking increase the likelihood of runway overruns.
2. CRM Deficiencies: Ineffective communication and lack of assertiveness between crew members compromise decision-making.
3. Regulatory Gaps: Poor oversight of safety practices by the airline and regulatory authority perpetuate non-compliance with SOPs.
Recommendations
1. Enhanced Crew Training:
• Reinforce adherence to SOPs through regular training and simulator sessions.
• Improve CRM training to ensure effective communication and assertiveness among crew members.
2. Stronger Oversight:
• Strengthen the FDA program with more frequent debriefs and corrective measures for SOP violations.
• Ensure regulatory authorities regularly audit airline safety practices.
3. Operational Revisions:
• Introduce stricter monitoring of high-speed approaches and implement automated systems to flag violations in real-time.
4. Retirement and Replacement:
• Following the damage sustained, PIA permanently retired and deregistered the aircraft.
Safety Lessons
This accident highlights the critical importance of adhering to SOPs, effective CRM, and robust oversight mechanisms. Regular FDA reviews and proactive regulatory audits are essential to identify and address systemic safety issues before they result in accidents.
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Our investigation reports are based on all the evidence and facts we have at the time of writing and posting. We apologise if any details are missed or are not fully accurate.
