Airbus A320 Bahrain

8/14/2019 Airbus A320 Bahrain

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26 FLIGHT SAFETY AUSTRALIA NOVEMBERDECEMBER 2003

COVER STORY

Can courtesy

kill?


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FLIGHT SAFETY AUSTRALIA NOVEMBERDECEMBER 20 03 27

ACAPTAINS FEARS that his

company would frown on him

if he conducted a missed

approach is one possible factor

in the fatal crash of a Gulf Air

A320 into the shallow waters of the

Arabian Gulf.

The failure of the first officer, a shy,

polite type, to take issue with the captains

decision to execute a 360-degree orbit

instead of a missed approach and go

around, is another possible factor in the

accident, near Bahrain International

Airpor t on August 23, 2000.

However, as with many aviation disas-

ters, the crash of GF-072 represents a

failure of the aviation system. The inves-

tigation revealed a complex series of

human, organisational and management

influences that combined to set the scene

for the accident, which culminated in thecrews failure to respond to insistent

warnings to pull up from the aircrafts

ground proximity warning system

(GPWS).

A multinational team of accident inves-

tigators set up by the Kingdom of Bahrain

in accordance with international civil

aviation agreements found no technical

deficiencies in the aircraft or its systems.

The investigators attr ibuted the tragedy

mainly to human factors at the individual

and organisational level.They turned up

evidence of errors and procedural viola-tions committed by the flight crew, and of

long-standing organisational and manage-

ment problems that had been identified

but not rectified.

GulfAir has since acted on many of the

recommendations made in the Accident

Investigation Boards report on the crash

and plans to implement the rest.

It is establishing a new integrated safety

management system, and has beefed up

its safety department, while stepping up

internal safety promotion.

Gulf Air flight GF-072 was a scheduledservice from Cairo International Airport

to Bahrain International Airport (BAH).

It was operated by an Airbus Industrie

Embarrassment about making a mistake, reluctance to

challenge a captains decision and spatial disorientation

are possible factors in an accident that killed 143 people.

But, as John Mulcair and Rob Lee report, there is much

more to the story.

PH

OTO:AAP


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DIETMARSCH

REIBER

A320-212. There were two pilots, six cabin

crew and 135 passengers on board.

When GF-072 was about one nm from

touchdown and at an altitude of about 600

ft, Bahrain air traffic control approved the

crews request for a 360-degree left-hand

orbit.

On completion of this manoeuvre, the

aircraft was about parallel to but beyond the

extended centreline of the landing runway,

and the crew initiated a missed approach.

With a radar vector offered by ATC, GF-072

overflew the runway in a shallow climb to

about 1,000 ft.

The aeroplane crashed into the sea about

four kilometres north-east of the airport at

about 1930, Bahrain local time. The debris

field was 700 m long and 800 m wide. Most

of the aeroplane was recovered, along withall significant structural components, flight

control surfaces and both engines. There was

no evidence of pre-crash failure or fire

damage.

The crew GF-072s last flight began with thearrival of its crew at the gate 25 minutes

before the scheduled departure time of 1600.

The airliner was under the command of a

37-year-old captain who had joined GulfAir

in 1979 as a cadet flight engineer. He had

later retrained as a pilot, flying on the Boeing

767 and Airbus A320 as a first officer, and,

since 1996, as a supervisory first officer.He was promoted to captain on the Airbus

A320 on June 17, 2000. He had logged total

pilot time of 4416 pilot hours, 86 of which

were as pilot in command on the A320.

Gulf Air pilots who had flown with him

described him as responsible, knowledge-

able,open to suggestions,happy,very helpful,

professional and sharp. They differed on

whether he was overconfident.

Gulf Air hired the first officer, aged 25,

as a cadet on July 4, 1999, after he attended

its ab-initio training program. He was

promoted to A320 first officer on April 20,

2000.

He had accrued a total of 608 pilot hours,

made up of 200 hours in training, and 408

hoursrs as an A320 line pilot with Gulf Air.

Gulf Air pilots who had flown with the

first officer described him as timid, meek,

mild, polite, shy and reserved in social situ-

ations, and keen to learn.

While most felt his reserved nature would

not stop his speaking up dur ing flight oper-

ations, others felt he might have been too

reserved to challenge a captain.The crash After an uneventful flight fromCairo, the aircraft was prepared for a visual

approach and landing on Runway 12 at

Bahrain. At the time, Runway 12 had no

instrument landing system.The weather was

fine, and the night was clear and dark with

no moon.

The conversation and sounds in the

cockpit for the 30 minutes before the acci-

dent were recorded on the cockpit voice

recorder (CVR).

At 1926:37,the captain stated:OK,visual

with airfield. Seconds later, the flight datarecorder (FDR) showed that the autopilot

and flight director were disengaged.

At 1926:49 and about 2.9 nm from the

runway, the aircraft descended through

1,000ft. At 1926:51, with GF-072 about 2.8

nm from the runway, at an altitude of 976 ft

and a speed of 207 knots, the captain said:

Have to be established by 500 feet. Flaps

two were selected.

As the approach to Runway 12 continued,

the captain said at 1927:06, and again at

1927:13,.were not going to make it.

At 1927:23,he instructed the first officer to

tell him to do a 360 (degree) left (orbit).

Bahrain tower approved the request. The left

turn was initiated about 0.9 nm from the

runway, at an altitude of 584 ft and an

airspeed of 177 knots.

During the left turn, the flap configura-

tion went from flaps two to flaps three and

then to flaps full. At 1928:17, the captain

called for the landing checklist.

At 1928:28, with the Airbus about halfway

through the left turn, the first officer advised

that the landing checklist was complete.After completing about three-quarters of

the 360-degree turn , the aircraft rolled wings

level.

The Airbus altitude during the left turn

ranged from 965 ft to 332 ft, while its bank

angle reached a maximum of about 36

degrees.

At 1928:57, after being cleared again by

Bahrain tower to land on Runway 12, the

captain stated:We overshot it.

The aircraft began to turn left again,

followed by changes consistent with an

increase in engine thrust. At 1929:07, thecaptain said:Tell him going around. The

FDR indicated an increase to maximum

take-off/go around (TOGA) engine thrust.

Bahrain tower provided radar vectors,

with instructions to fly heading three zero

zero (300 degrees), climb (to) 2,500.

COVER STORY

The A320 that crashed into the Arabian Gulf in 2000, pictured a year before the accident.


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The auto thrust remained active throughout

the approach until TOGA was selected.

The flaps were moved to position three

and the landing gear was selected up. The

gear remained retracted until the end of the

recording.

At 1929:41,with the aircraft at an altitude

of 1,054 ft and an airspeed of191 knots,and

having just crossed over Runway 12, the

CVR recorded the beginning of 14 seconds

sounding of the repetitive chime of the auralmaster warning consistent with a flap over-

speed followed by the first officer saying,

speed, overspeed limit

About two seconds after the master

warning began, and with the aircraft still

accelerating under TOGA power, the FDR

data indicated movement of the captains

side stick, which was held forward of the

neutral position for some 11 seconds, with a

maximum forward deflection of about 9.7

degrees.

During this time the aircrafts pitch atti-

tude decreased from about five degrees noseup to about 15.5 degrees nose down. The

recorded vertical acceleration decreased

from about +1.0 to about +0.5 G, while

airspeed increased from about 193 to about

234 knots.

About 1929:51, with the aircraft

descending through 1,004 ft at an airspeed of

221 knots, a single aural voice warning of

sink rate from the GPWS was recorded,

followed by the repetitive GPWS aural

warning whoop whoop, pull up, which

continued until the end of the CVR

recording.

At 1929:52, the captain requested, flapsup. About 1929:54, the CVR indicated that

the master warning ceased for about one

second but began again and lasted about

three seconds.

Two seconds after the GPWS warnings

began, the captains side stick was moved aft

of the neutral position, with a maximum aft

deflection of some 11.7 degrees.

These data showed this nose-up

command was not maintained and subse-

quent movements never exceeded 50 per

cent of full-aft availability, and the aircraft

continued to descend. FDR data indicatedno movement of the first officers side stick

throughout the approach and accident

sequence.

At 1929:59, the captain requested, Flaps

all the way and the first officer responded,

Zero!

This was the last comment from the crew

recorded on the CVR, which stopped

recording at 1930:02.

The FDR data showed continuous move-

ment of the flap position toward the zero

position after the captains Flaps up

command. The last flap position recorded on

the FDR was about two degrees ofextension.

The investigation To find out what visualcues the pilots had, investigators retraced

the flight path of GF-072 in a helicopter.The

flight was carried out at night, in meteoro-

logical and visual conditions similar to those

on the night of the accident. The recon-

structed flight path was recorded on video.

The cockpit view calculations of the fieldof view from the A320 cockpit, supported by

the video reconstruction of the flight path,

indicated that all external visual cues were

lost about 1629:41 as the last lights on the

ground passed under the nose ofthe aircraft.

The forward sidestick input by the captain

started at 1629:45, when the aircraft was

accelerating into complete darkness.

Somatogravic illusion The crew would havebeen vulnerable to a kind of spatial disori-

entation known as the somatogravic illusion.

The absence of visual cues combined with

rapid forward acceleration and the force of

gravity create a powerful pitch up sensation.

In such cases, particularly on dark night

takeoffs, pilots often respond by lowering

the nose. In some cases,the aircraft descends

and hits the ground, usually at a shallow

angle of impact.

The US Naval Aerospace Medical Research

Laboratory used the FDR data from GF-072

in a perceptual study. At the time of the

captains forward sidestick input at 1929:45,

he would have experienced a pitch-up sensa-

tion of about 12 degrees, the study showed.

The application of forward sidestick input

by the captain for 11 seconds resulted in theaircraft pitching down to an angle of 15

degrees, which is the maximum pitch-down

angle allowed by the A320 flight control

system. This would have almost cancelled

out the perceived pitch-up sensation. In the

absence of any external visual cues, and with

its attention probably focused on the flap

overspeed, the crew probably believed it was

in near-level flight.

The cockpit instruments would have been

displaying the true pitch attitude of the

aircraft. However, the captain, as pilot flying,

did not use this source of information,suggesting that he did not perceive the att i-

tude information from his Primary Flight

Display.


COVER STORY

Perceived pitch versus actual pitch Just before the captain pushed the sidestick

forward (t=1929:43). Source: Accident investigation report Gulf Air Flight GF-072. See

http://www.bahrainairport.com/caa/gf072.html.

Perceived pitch Actual pitch


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Other research after the accident included

studies to determine the effects of certain

variables on altitude loss during GPWS

recovery, simulations of the approach,orbit

and go-around of GF-072 at BAH, and a

series of flight tests.

Variables examined in the GPWS recovery

study were the amount of the pilots pitch-upcommand, the time between the GPWS

warning and the pilots reaction to it, and the

duration of the pitch command input.

An A320 fixed-base engineering simulator

at Airbus Industries facilities at Toulouse,

France was used to simulate the approach,

orbit and go-around of GF-072.

The simulator also allowed investigators

to fly the approach to Runway 12 and to

observe cockpit warnings during flap over-

speed and GPWS warnings.

During one of the simulator sessions, the

360-degree turn and go-around manoeuvreswere performed to approximate the flight path

and the sequence and timing of events recorded

on the FDR recovered from the aircraft.

The team considered several scenarios:

The pilots were instructed to recover with

full aft stick movement at the onset of the

GPWS alert. The simulator recovered with

about 300 ft altitude loss.

Half back stick was applied instead of

full back stick. The delay between th e

GPWS warnin g and the stick commandwas approximately four seconds. The

simulator recovered with about 650 ft alti-

tude loss.

The co-pilot performed a recovery after he

had verified that the captain had taken no

action to recover from the GPWS alert. The

co-pilot depressed the priority button on his

side stick, announced his control override,

and applied full aft side stick input. The

simulator recovered with about 400ft of alti-

tude loss.

The 360-degree turn was performed but

the pilots were instructed to make no furthercontrol inputs after selection of TOGA

power. The simulator tr immed nose down

to counter the noseup effect due to the thrust

increase and to maintain +1.0G, the target

when the side stick is in the neutral position

in Normal Law. The pitch remained positive

and the aircraft climbed slowly.

The 360-degree turn was initiated to match

the flight path and sequence and timing of

events recorded on the FDR. But instead of

rolling wings level upon reaching a headingof about 211 degrees magnetic, as the

captain of GF-072 had done, the 360-degree

turn was continued at a moderate bank

angle at the pilots discretion to align with

Runway 12, and the approach and landing

were continued. The pilots were able to

successfully land on Runway 12 from the

360-degree turn.

In th is final scenario, the pilots noted that

the approach was not stabilised and little

time was available to successfully complete

the final approach and landing.

On September 27, 2000 a flight demon-stration in an A320 test aircraft observed

various conditions similar to the flight

profile flown on August 23, 2000. It was


COVER STORY

A

CCIDENTINVESTIGATIONREPORTGULFAIRFLIGHTGF-0

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flown in daylight in visual meteorological

conditions.

Additional tests were performed to simu-

late the 360-degree orbit of the accident

flight, but continuing to turn at the end of

the orbit instead of rolling out.

Several scenarios were flown, with a

similar flap configuration sequence to that

in GF-072, or with full flaps.

The pilots were able to align the aircraft

with the runway and perform low

approaches down to 50ft where a go-around

was performed.

With no evidence that the accident was

caused by aircraft technical problems, the

investigation focused on human factors.

Investigators analysed the role and

performance of individuals as components

of a system.The considered systemic factors, such as

training deficiencies, inadequate procedures,

faulty documentation, lack of currency, poor

equipment design, poor supervision, failure

on the part of the company to take action on

previous violations and commercial pres-

sures to take shortcuts.

On the night of the accident, there was no

evidence the approach briefing in keeping

with standard operating procedures (SOPs)

had been carried out aboard GF-072.

Although the aircraft was established on

the VOR-radial of 301 degrees at the FAF

(final approach fix), other parameters were

far from the required standard for a

stabilised approach: the speed was 223 knots

instead of 136 knots; the flap position was

one instead of full, and the altitude was 1,662

ft rather than 1,500.

Unless the speed was reduced, the captain

could not have selected landing flaps to full.

Excessive speed was one reason for not

achieving the required stabilised approach

configuration.

Although the captain used speed brakes

three times from 1922:49 to 1926:13, he

could not achieve the required approachconfiguration before reaching the FAF. The

aircrafts speed of 223 knots at the FAF was

87 knots greater than the target speed.

However, rather than initiating a missed

approach, the captain decided to continue

with the approach, during which the speed

remained excessive.

Investigators suggested the reason for the

excessive speed could be the planning of the

descent, or the omission of the descent clear-

ance from the descent profile.

The GF-072 simulation and flight tests

showed that, based on the aircraft configu-ration, speed and altitude at the FAF, a

successful landing could have been achieved,

especially if the speed brakes had been

deployed continuously.

To do so would have involved manoeu-

vring with a steep approach angle and rapid

deceleration, however, and this would have

unsettled the passengers.

The captain did not stabilise the approach

on the correct path at 500 ft in the required

landing configuration, as required by

company SOPs.

When he apparently concluded that the

landing could not be made, the captain

elected to carry out a Three Six Zero to the

left. This was non-standard procedure.

Following the accident, Gulf Air issued a

fleet instruction that: Once an aircraft is

established and descending on the final

approach to the runway of intended landing,

360-degree turns and other manoeuvres for

descent profile adjustments are notpermitted.

The investigators concluded that the

circumstances in the cockpit and the behav-

iour of the captain indicated that he prob-

ably experienced information overload.

Departure from SOPs Even though GPWSvoice warnings to pull up sounded every

second from 1929:51, neither flight crew

member responded according to SOPs.

Instead, the captain concentrated on

dealing with the flap over-speed which, at

that stage, was not a critical emergency situ-

ation endangering the aircraft.The investigators said the accident could

have been prevented if the pilot flying had

adhered to SOPs.

Departures from SOPs, particularly

during the approach and final phases of

flight, included:

During the descent and the first approach,

the aircraft had significantly higher speeds

than standard.

During the first approach, standard

approach configurations were not

achieved, and the approach was not

stabilised on the correct approach path by

500ft. When the captain perceived that he was

not going to make iton the first approach,

standard go-around and missed approach

procedures were not initiated. Instead, the

captain executed a 360-degree orbit close to

the runway at low altitude with considerable

variations in altitude, bank angle and g

force.

A rotation to 15 degrees pitch up was not

carried out during the go around after the

orbit.

Neither the captain nor the first officer

responded to hard GPWS warnings. In the approach and final phases offlight,there

were several deviations of the aircraft from the

standard flight parameters and profile.

During the approach and final phases of

flight, the first officer did not call out or draw

the captains attention to several deviations

from the standard flight parameters and

profile.

Big questions The investigators regardedtwo questions as critical:Why did the captain

violate the SOPs, and why was there no chal-

lenge or comment from the first officer?

The captains sudden decision to execute

an orbit was apparently aimed at avoiding

the need for a standard missed approach

procedure. A missed approach is a perfectlyroutine safety procedure, although in prac-

tice it is relatively rare. However, there could

be reasons why a captain might be reluctant

to carry out such a procedure.

At the time of the accident, a go-around

required the submission to the company of

an air safety report describing the circum-

stances.Although Gulf Air said its policy was

not to take action against pilots who had

conducted missed approaches, the investi-

gation found that some pilots at the time

believed, rightly or wrongly, that company

management would view such actions

unfavourably.As a post-accident safety initiative, Gulf

Air issued a fleet instruction, stating: All

pilots are further assured that no discipli-

nary action whatsoever will be taken against

any crew that elects to carry out a go around

for safety-related reasons, including inability,

for whatever reason, to stabilise an approach

by the applicable minimum height.

Another factor could be that captains

might have feared losing the respect of rela-

tively junior first officers if they executed

missed approaches.

Investigators said the CVR showed thatthe first officer performed his routine role

of communicating with ATC, reading the

checklist and carrying out the checks.

COVER STORY

The investigators regarded

two questions as critical:Why did the captain violate

the SOPs, and why was

there no challenge or

comment from the first

officer?


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However, it also revealed that he played

little effective part in flight deck manage-

ment and decision making. He did not raise

any issues with the captain or question his

decisions, even though the captain

performed non-standard procedures and

manoeuvres.

Crew resource management Evidence fromthe training records of the first officer indi-

cated that he was seen as shy and

unassertive, and that his operational

performance overall was marginal.

However, investigators also observed that

at no stage during the approach did the

captain consult the first officer on any oper-

ational decisions. The first officer was a valu-

able, but untapped, resource available to the

captain, and crew resource management was

virtually non-existent in the cockpit of GF-072.

Although Gulf Air had been required by

Sultanate of Oman regulations to provide a

formal CRM training programme since June

1999, the original company CRM

programme, established in 1992 and active

unt il early 1997, appeared to have been

discontinued with a change ofmanagement.

The acting manager of human factors at

the time of the accident said that his prede-

cessor had resigned in frustration over his

attempts to re-establish the program.

Another factor contributing to the depar-

ture from SOPs could be that a company might not emphasise strongly enough the

importance of, the reasons for and the need

to adhere to SOPs.

And although Gulf Air had a flight datamonitoring and analysis system in place, the

system was not functioning satisfactorily at

the time of the accident. Such systems can

help identify the level of compliance with

SOPs by detecting events including unsta-

bilised approaches or times when an aircraft

had exceeded specific pre-programmed

parameters, such as airspeed, in a particular

configuration.

CFIT training CFIT (controlled flight intoterrain) accidents account for the highest

proportion of fatalities in commercial aviation.

The CFIT training in the A320 fleet in GulfAir was severely limited at the time of the

accident. Airbus Industr ies A320 normal

course syllabus includes a GPWS pull-up

demonstration. However, there was no

similar syllabus for Gulf Air and no require-

ment to execute such a demonstration for its

A320 fleet.

Nor did Gulf Airs A320 training program

emphasise GPWS response training. The

Airbus training program requires an instant,

instinctive side stick response when a hard

GPWS warning occurs.

Organisational deficiencies: The investiga-

tors found that from 1998 to the time of theaccident, the manager of flight safety was the

only person in his department, and he did

not report directly to the highest executive

level within the company. They labelled this

a serious organisational deficiency.

They also noted that for many years Gulf

Air had not participated in the regular six-

monthly meetings of the International Air

Transport Associations safety committee, at

which the latest safety information is shared

freely and confidentially between airlines,

manufacturers and safety specialists.

This had greatly restricted GulfAirs aware-ness of developments in areas such as acci-

dent investigation case studies,safety and risk

management, training and safety information.

COVER STORY

.. .airlines with positive

safety cultures, strongly

motivated towards

compliance with the

regulations, are in the

interests of the regulator.

Grim search Wreckage from Gulf Air Flight 072 is recovered from the Arabian Gulf.

PHOTO:AAP


8/8


The regulator: The investigators also exam-ined the relationship between Gulf Air and

its regulator,the Sultanate of Omans Direc-

torate General of Civil Aviation and Meteo-

rology (DGCAM).

A review of correspondence between

DGCAM and GulfAir revealed letters citing

non-compliance with civil aviation regula-

tions (CARs). In some areas, GulfAir did not

rectify problems identified by DGCAM.

The company lacked several programs

required by CARs. And it did not meet

regulations in areas including crew

resource management, quality manage-

ment, safety awareness and other areas of

crew training.

An evaluation of Gulf Air carried out by

the International Civil Aviation Organisa-

tion for DGCAM in October 1998 turned upevidence of delayed or non-compliance with

regulatory requirements.

The ICAO review concluded that, except

for isolated incidents, most of the infrac-

tions could be traced to inadequate super-

visory oversight within Gulf Air, rather

than a deliberate disregard for the regula-

tions.

DGCAM was well aware of this situation,

and had made many unsuccessful efforts to

correct it, including imposing various sanc-

tions on the airline.Despite this,GulfAir did

not implement many changes sought by

DGCAM.

A review of relevant information and

documentation covering the three years

preceding the accident indicated that, despite

intensive efforts,DGCAM could not get Gulf

Air to comply with some critical regulatory

requirements.

The investigators said regulatory authori-

ties and airlines had complementary roles in

maintaining the safety of the aviation system.

Strong and effective regulators are in the

interests of airlines because they provide an

independent means of quality control in

airline operations.

Conversely, airlines with positive safety

cultures,strongly motivated towards compli-

ance with the regulations, are in the interestsof the regulator.

At the time of the accident, this was not

the case with the DGCAM and Gulf Air.The

regulator needs to check that airline

resources,structures and processes necessary

to ensure regulatory compliance are

adequate, the investigators said. It also needs

the political support of the government to

fulfill its safety role. This broader issue was

the subject of a specific recommendation in

the GF-072 investigation report.

Meanwhile,James Hogan, GulfAirs pres-

ident and chief executive, says a lot has

changed since the accident. The airline has

enhanced regular fleet instructions and

improved crew training, he says.

The airline now electronically analyses

flight data to ensure adherence to standard

operating procedures, while all GulfAir crew

must be trained intensively in CRM, says

Hogan,who took up his position at the helm

of the airline after the accident.

Gulf Air has incorporated into its flight

crew training program modules driving

home the risks posed by spatial disorienta-

tion, a problem also addressed in the first

issue of the companys upgraded safety

magazine.

And during the accident investigation,

Gulf Air reviewed its A320 flight trainingprogram. This led to the reorganisation of

the companys operations division, a move

Hogan says ensures a high level of pilot

training.

John Mulcair is a journalist based in Sydney.

Rob Lee is an international aviation safety

consultant and former director of the Australian

Bureau of Air Safety Investigation. He was a

consultant to the Kingdom of Bahrain GulfAir

Bahrain investigation team.

COVER STORY

Documents

Airbus A320 Bahrain