Investigation Summary
The investigation revealed a significant breakdown in Crew Resource Management (CRM) and technical proficiency. During pre-takeoff checks, the crew only manually verified the feathering mechanism for the right engine, skipping the required simultaneous check for both engines. Shortly after rotation, the right engine flamed out. The First Officer attempted to feather the propeller, but the crew became confused, misidentifying the failed engine to Air Traffic Control as the left engine (number one). Crucially, the crew never retracted the landing gear, which created excessive drag. The Beechcraft 1900C-1 is capable of climbing on a single engine, but the combination of extended gear, low altitude maneuvering, and the crew's failure to reach a safe altitude before attempting remedial actions led to a loss of control. The Captain's history showed consistent struggles with single-engine handling during simulator training, requiring coaching to pass mandatory checks.
Final Conclusions
The Pakistan Safety Investigation Board released its final report in December 2015, concluding the primary cause was the Captain's inability to handle a single-engine operation during a critical flight phase. Contributing factors included the crew's failure to retract the landing gear, the First Officer's premature remedial actions below the minimum safe altitude of 400 feet, and a general lack of situational awareness and adherence to manufacturer-prescribed emergency procedures.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Former Pakistan Air Force squadron leader; simulator records showed poor proficiency in emergency handling.
First Officer
Promoted to Captain in March 2010 but acting as co-pilot on this flight.
Systems & Failure Modes
Propeller Beta Valve
A component of the propeller governor system that controls blade pitch; a malfunction here can cause the propeller to move toward a flat pitch, creating high drag or leading to an engine flameout.
Auto-feather System
A system designed to automatically pitch propeller blades to a streamlined (feathered) position upon engine failure to reduce drag; it was turned off during this flight.
Landing Gear
The retractable undercarriage; failure to retract the gear after an engine failure on takeoff prevents the aircraft from achieving a positive rate of climb due to excessive aerodynamic drag.
Interesting Facts
- 01The aircraft was chartered by the Italian oil and gas company Eni to transport staff to the Bhit Shah gas field.
- 02The Captain had 8,114 total flying hours, but his simulator records showed he struggled to handle single-engine failures without coaching.
- 03The landing gear was found in the extended position in the wreckage, significantly increasing drag during the emergency.
- 04The auto-feathering system was selected to the 'Off' position, requiring manual intervention that the crew handled poorly.
- 05Investigators identified a malfunction in the propeller beta valve, likely due to fair wear and tear, as the trigger for the engine failure.
Safety Actions & Advisories
Enforcement of Safety Protocols
The accident led to calls for the Pakistan Civil Aviation Authority to more strictly enforce air safety protocols and pilot proficiency monitoring following two major crashes in 2010.