Some key preliminary findings (direct quotes from the report):
- The crew did not follow standard callouts and did not observe CRMaspects during most parts of flight.
- “Karachi Approach” inquired “confirm track mile comfortable for descend” and later advised to take an orbit, so that the aircraft can be adjusted on the required descend profile. No orbit was executed and the effort to intercept the glide slope and localizer (of ILS) was continued. The FDR indicated action of lowering of the landing gears at 7221 ft at around 10.5 Nautical Miles from Runway 25L.
- “Karachi Approach” advised repeatedly (twice to discontinue the approach and once cautioned) about excessive height. Landing approach was not discontinued. However, FDR shows action of raising of the landing gears at 1740 ft followed by retraction of the speed brakes (at a distance slightly less than 05 nautical miles from the runway 25L). At this time, the aircraft had intercepted the localizer as well as the glide slope. Flaps 1 were selected at 243 knots IAS, the landing gears and speed brakes were retracted. Over-speed and EGPWS warnings were then triggered.
- According to the FDR and CVR recordings several warnings and alerts such as over-speed, landing gear not down and ground proximity alerts were disregarded. The landing was undertaken with landing gears retracted. The aircraft touched the runway surface on its engines. Flight crew applied reverse engine power and initiated a braking action.
- The “Aerodrome Control” observed the scrubbing of engines with the runway but did not covey this abnormality to the aircraft. It was conveyed to the “Karachi Approach” on telephone. Subsequently “Karachi Approach” also did not relay this abnormality to the aircraft.
- The landing was discontinued and a go-around was executed. FDR recording indicates a brief action of selection of landing gear lever to down position, which was immediately followed by its movement to up position.
Outside of the report, the Minister of Aviation stated the pilots were preoccupied by discussion of the coronavirus affecting them and their families.
Takeaways:
- Stress and uncertainty over coronavirus dominated the cockpit and distracted from proper crew resource management.
- Pilots dropped the gear to speed descent instead of descending in circles as instructed by ATC. Tenerife had a similar instance of outside stresses and disregard for ATC instructions.
- Pilots do not notice overspeed, ground proximity, and gear down warnings. This is not unusual when pilots do not focus on flying the airplane.
- Pilots forget to lower gear for landing. Lowering the gear to dump speed 10 nautical miles before may have satisfied this subconscious memory item.
- ATC bungles landing clearance and does not directly inform pilots of situation. Hopefully further investigation determines of coronavirus discussions dominated that workplace as well.
- Pilots applied brakes after landing, suggesting they thought the gear was down. They then moved the landing gear lever after initiating a go-around, as if to raise a gear they thought was down.