Full Report --Anil Kumar reports from Manama.
Bahraini, Omani piolot error caused Gulf Air Crash of August 2000.
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Gulf Air Disaster Investigation Report Advises Oman Civil Aviation to improve Pilot Training Programmes
Gulf Air Crash --BBC picture.
Manama -- July 15, 2002. The Gulf Air disaster of was caused by a deadly combination of factors, mainly a piolot error an a report declared yesterday. "The investigation showed that no single factor was responsible for the GF072 accident," it says.The plane, en route from Cairo, smashed into the sea just off Muharraq at around 7.30pm on August 23, 2000, killing all 143 people on board.In the final seconds of the flight, Bahraini pilot Ihsan Shakeeb was so confused he pitched the plane into the sea, says the final crash report, released by the Accident Investigation Board.Captain Shakeeb may have thought the plane was pitching up when in fact it was pitching down.
He increased speed and thrust the plane into a dive for 11 seconds, before trying to pull up, but it was too late, says the damning report.Capt Shakeeb, aged 37 and his 25-year-old Omani co-pilot First Officer Khalaf Al Alawi, may have been spatially disorientated as they performed a tight orbit after a failed attempt to land at Bahrain International Airport, says the report.
They ignored repeated computer voice warnings to "pull up, pull up", in a tragic catalogue of safety violations and mistakes, it says.It cites fatal flaws in Gulf Air's organisational, management and training systems, leading up to the accident, combined with human error on the flight deck.Gulf Air failed to respond to safety warnings issued by its regulatory body, or to attend international safety meetings.
It also failed to provide adequate training in emergency procedures and to properly staff its flight safety department, says the report."The accident was the result of a fatal combination of many contributory factors, both at the individual and systemic levels."All of these factors must be addressed to prevent such an accident happening again."
A "lethal cocktail" of safety violations and mistakes put the ill-fated Gulf Air Flight 072 in peril, says the damning investigation report. Once in trouble the flight crew became confused and at one point Captain Ihsan Shakeeb put the plane into a dive instead of pulling up.
His co-pilot, First Officer Khalaf Al Alawi, should have taken control of the jet, but sat in silence as it plunged into the sea, killing all 143 people aboard. The Accident Investigation Board report found that Capt Shakeeb demonstrated "poor judgement, non-adherence to standard operating procedures (SOPs)" and committed an "exceptional violation".
He not only "attempted to solve the problem (of an initial unsuccessful approach) by taking an ad hoc decision to execute a non-standard and unplanned manoeuvre, an orbit" - but also failed to respond to repeated alerts by the aircraft's Ground Proximity Warning System (GPWS) in the seconds before it hit the water, said the report. Instead, Capt Shakeeb and his co-pilot commented only on dealing with the 'flap over-speed', which was not endangering the aircraft.
The pilots appeared to be suffering from spatial disorientation and thought that they were "pitching up", not descending. However, even though the aircraft's instruments were displaying accurate information, they did not respond to it. They may have been suffering from information overload and filtered out the information on the instruments, said the report.
The pair worked badly together as a team and Capt Shakeeb intimidated the co-pilot, it continued. This could have been the cause of Al Alawi's failure to challenge Shakeeb or attempt to take control of the aircraft, as he should have done. Shakeeb also acted unilaterally, without warning his co-pilot, who should have been aware of all plans. "(The orbit) was an unsafe act which had an immediate adverse effect upon the safety of the system," said the report.
"The captain performed this unsafe act without prior briefing to his first officer, and in the absence of any valid operational necessity, such as an unexpected emergency." Had Shakeeb adhered to the SOPs the accident could have been prevented, it continued. Even in the last seconds before the crash the disaster could have been averted, despite the mistakes made earlier.
"If the captain had executed the response to the GPWS warning in accordance with the SOP, recovery was still possible," found the report. Despite the fact that both flight crew members were properly certified and qualified, they may not have received vital training which could have prevented the accident, it said.
Shakeeb had been with the airline for 21 years, but had only been promoted to Airbus A320 captain two months before the crash. The report found that Gulf Air had not shown evidence of a strong emphasis on GPWS training, which would have made response to the warning "immediate" and "instinctive".
A number of possible explanations for the captain's sudden decision to execute an orbit, rather than to carry out a routine safety procedure, known as a go-around or missed approach, were put forward. The report noted that Shakeeb may have been unwilling to carry out the go-around because "a perception existed on the part of some company pilots that a missed approach would be regarded unfavourably by company operational management."
The airline has since instructed pilots that no disciplinary action will be taken against those who elect to carry out a go-around for safety reasons. There was also evidence that some Gulf Air pilots did not always comply with SOPs. The report suggested that Capt Shakeeb might have been unwilling to let Al Alawi see how much difficulty he was in. "The Cockpit Voice Recorder (CVR) showed that earlier in the flight the captain was demonstrating his knowledge of the A320 systems to the flight officer," it stated.
"This indicates that the captain was, understandably, keen to ensure that a relatively less experienced first officer should have every confidence in his abilities as a captain to operate the aircraft, and that the first officer could learn a lot from flying from him."
Capt Shakeeb also demonstrated signs of frustration with his own performance, such as swearing and clicking his tongue at key moments.The first officer performed a routine role but proved unable to take control when it became clear that the aircraft was about to crash.
"At no stage did he raise any issues with, or question the captain's decisions, even though the captain performed non-standard procedures and manoeuvres," continued the report. Evidence from the co-pilot's training records indicated that he was "shy" and "unassertive".
They also indicated that he had "difficulties meeting the required standards overall," and had on one occasion become "disoriented" going into Bahrain. "This first officer was unlikely to speak up and challenge a captain's authority," said the report. "It is also likely that the captain's overt demonstration of his knowledge earlier in the flight may have further dampened the first officer's tendency to speak up."
However, the report stressed that Capt Shakeeb had not utilised his first officer properly and that he had been kept out of the decision-making process.
Safety is top priority for Gulf Air
MANAMA -Gulf Air has beefed up its training schemes, to ensure maximum safety for passengers and aircraft, it declared yesterday. Its pilots are the best trained in the region, it said after the release of the final Accident Investigation Board report on the Flight 072 disaster. Passenger security and the safe operation of aircraft are Gulf Air's two main priorities, said the airline's new president and chief executive James Hogan. "That was the situation at the time of the accident and is the situation now," he said. "These are priorities that have not changed in more than 50 years of dedicated service.
"For Gulf Air, passenger safety is our principle motivating force and flight crew undergo high level training to internationally-recognised standards." The airline has further improved safety and training standards since the crash, said Mr Hogan. "We ensure that a high level of pilot training is achieved in accordance with the regulatory requirements and reflects the very latest in available technology and international aviation best practices," he said. "Gulf Air continues to lead the region in the training of its pilots and there will be no let-up in our commitment to ensure that this remains the case." Forward this article to a Colleague, Associate or Friend
Captain 'may have had a rush of data'
CAPTAIN Ihsan Shakeeb is believed to have been experiencing information overload due to the very high workload and stressful situation in the moments before the crash. The symptoms can include ignoring some signals or responsibilities, difficulties in processing information correctly, response delay, systematic omission of certain categories of information, reversion to a previously over-learned response pattern, less precise responses and giving up or failing to respond.
"With his conscious attention focused on the flap over-speed in the last moments before impact, the captain did not possess sufficient spare information processing capacity to perceive and respond to the information from the aircraft's instruments," according to the report issued yesterday.
"Information from the instruments was filtered out. The overall lack of situational awareness demonstrated by the captain was evidence of information overload on the part of the captain." Effective training could have prevented this from happening, according to the report.
"An important objective of flight training is to ensure that, in situations of potentially very high workload, such as critical emergencies, the tasks most vital to the survival of the aircraft are accorded the highest priority by the crew," it noted.
"When this priority system is incorrect or inappropriate, situations arise in which pilots concentrate on non-critical tasks, and filter out, or shed, critical information essential to the safety of flight, sometimes leading to accidents."
In Capt Shakeeb's case the situation had progressively deteriorated from the time of high speed initial approach, as his responses had not achieved the desired results.
"It is also probable that the captain's level of stress and anxiety had progressively increased as the initial approach, and then the orbit, did not go as he had intended," said the report.
"The captain visually flew an unplanned and unpractised manoeuvre; at low altitude with negligible external visual references; and in a high drag aircraft configuration.
"Following this orbit, the captain commenced to go-around at 1929:10.
"His immediate attention was then focused on the go-around procedure, performing the checklist, and at 1929:33 also upon querying the instructions from Air Traffic Control.
"Then, at 1929:41, the aural master warning (for flap over-speed) sounded, and his attention was concentrated on dealing with the flap over-speed situation.
"All these factors combined to create an extended time period of very high workload for this captain, as well as the first officer, which progressively increased following the initiation of the orbit up to the time of the accident."
SUMMARY OF GF-072 CRASH
Brief history of the flight
On August 23, 2000, at about 1930 local time, Gulf Air flight GF-072, an Airbus A320-212, a Sultanate of Oman registered aircraft A40-EK, crashed at sea at about three miles north-east of Bahrain International Airport.
GF-072 departed from Cairo International Airport, Egypt, with two pilots, six cabin crew and 135 passengers on board for Bahrain International Airport, Muharraq, Kingdom of Bahrain.
GF-072 was operating a regularly scheduled international passenger service flight under the Convention on International Civil Aviation and the provisions of the Sultanate of Oman Civil Aviation Regulations Part 121 and was on an instrument flight rules (IFR) flight plan.
GF-072 was cleared for a Very High Frequency Omnidirectional Range/Distance Measuring Equipment (VOR/DME) approach for Runway 12 at Bahrain.
At about one nautical mile from the touch down and at an altitude of about 600 feet, the flight crew requested for a left-hand orbit, which was approved by the air traffic control (ATC).
Having flown the orbit beyond the extended centre-line on a south-westerly heading, the captain decided to go-around.
Observing the manoeuvre, the ATC offered the radar vectors, which the flight crew accepted. GF-072 initiated a go-around, applied take-off/go-around thrust, and crossed the runway on a north-easterly heading with a shallow climb to about 1,000 feet.
As the aircraft rapidly accelerated, the master warning sounded for flap over-speed.
A perceptual study, carried out as part of the investigation, indicated that during the go-around the flight crew probably experienced a form of spatial disorientation, which could have caused the captain to falsely perceive that the aircraft was "pitching up".
He responded by making a 'nose-down' input, and, as a result, the aircraft commenced to descend.
The ground proximity warning system (GPWS) voice alarm sounded: "whoop, whoop pull-up ?".
The GPWS warning was repeated every second for nine seconds, until the aircraft impacted the shallow sea.
The aircraft was destroyed by impact forces, and all 143 persons on board were killed.
Conclusions
The factors contributing to the above accident were identified as a combination of individual and systemic issues.
The individual factors during the approach and final phases of the flight were: non-adherence to standard operating procedures (SOPs) by the captain; the first officer not drawing the attention of the captain to the deviations of the aircraft from the standard flight parameters and profile; the spatial disorientation and information overload experienced by the flight crew; and, the non-effective response by the flight crew to the ground proximity warnings.
The systemic factors that could have led to these individual factors were: a lack of a crew resources management (CRM) training programme; inadequacy in some of the airline's A320 flight crew training programmes; problems in the airline's flight data analysis system and flight safety department which were not functioning satisfactorily; organisational and management issues within the airline; and safety oversight factors by the regulator.
Any one of these systemic factors, by itself, was insufficient to cause a breakdown of the safety system. Such factors may often remain undetected within a system for a considerable period of time.
When these latent conditions combine with local events and environmental circumstances, such as individual factors contributed by "front-line" operators or environmental factors, a system failure, such as an accident, may occur.
The investigation showed that no single factor was responsible for the accident to GF-072.
The accident was the result of a fatal combination of many contributory factors, both at the individual and systemic levels. All of these factors must be addressed to prevent such an accident happening again.
The airline has taken a number of post-accident safety initiatives to address some of these individual and systemic factors.
The airline has reported that it is in the process of enhancing its flight crew training.
Safety recommendations
The safety issues in this investigation report focus on the above individual and systemic factors. In order to prevent a probability of such occurrence and increase the overall safety of the aviation system, the investigation report has made 12 safety recommendations concerning these issues.
They are addressed to: the Directorate General of Civil Aviation and Meteorology (DGCAM), Oman (seven); the owner-States of Gulf Air (two); Bahrain Civil Aviation Affairs (one) and the International Civil Aviation Organisation (two).
SAFETY RECOMMENDATIONS
In order to enhance the overall safety of the aviation system, the Accident Investigation Board makes the following recommendations to the regulatory authority DGCAM, Oman, the owner-States of the airline (Gulf Air), Civil Aviation Affairs, Kingdom of Bahrain and the International Civil Aviation Organisation (ICAO).
The board recommends to the DGCAM, Oman:
To review whether safety oversight surveillance is adequate to ensure airlines' timely compliance with all critical regulatory requirements.
To ensure that Gulf Air updates the crew resource management (CRM) programme, by integrating it in a Line Oriented Flight Training (LOFT) in accordance with DGCAM regulatory requirements and consider implementing a Line Operations Safety Audit (LOSA) programme.
To ensure that Gulf Air reviews and enhances, in accordance with DGCAM regulatory requirements, the A320 flight crew training programmes to ensure full compliance with the standard operating procedures and increase the effectiveness of the first officer.
The training in Controlled Flight Into Terrain (CFIT) avoidance and GPWS responses' should be augmented by including it in the recurrent training programme, with a detailed syllabus in accordance with DGCAM requirements.
The Approach-and-Landing Accident Reduction (ALAR) toolkit produced by the Flight Safety Foundation, with extensive airline industry input, could be a key element in the updated training programme.
To ensure that Gulf Air company's training and evaluation of flight crew performance consistently meets the required DGCAM standards.
To consider requiring Gulf Air to include in its flight crew training programmes (initial as well as recurrent) comprehensive information on spatial disorientation.
To ensure that Gulf Air reviews and improves the functioning and utilisation of the A320 flight data analysis system, in accordance with DGCAM regulatory requirements.
To consider requiring Gulf Air to augment the accident prevention strategies and adopt programmes, such as the Procedural Event Analysis Tool (PEAT), and implement a comprehensive integrated safety and risk management programme.
The Board recommends to the owner States of Gulf Air - Abu Dhabi, Bahrain, Oman and Qatar:
To ensure that the civil aviation regulatory authority for Gulf Air (DGCAM), Oman, has the full and continuing support of the governments of those States in implementing regulatory compliance by the airline.
To ensure that the management of Gulf Air complies with civil aviation regulatory requirements effectively and expeditiously
The Board recommends to Civil Aviation Affairs, Bahrain:
To enhance guidance to air traffic controllers for addressing requests from pilots to execute non-standard manoeuvres (such as an orbit) during the final approach.
When on final approach, requests from pilots to conduct non-standard manoeuvres should only be approved by controllers after they have ascertained the required safety parameters.
The Board recommends to the International Civil Aviation Organisation:
To consider making the following as a standard applicable in all classes of airspaces: "a speed limit of 250 knots below 10,000ft amsl (above mean sea level).
To consider prohibiting non-standard manoeuvres (such as orbit) when an aircraft is on the final approach, unless safety considerations demand otherwise.
CONCLUSIONS
Findings
1) The captain did not adhere to a number of SOPs, particularly during the approach and final phases of flight:
(a) During the descent and the first approach, flight GF-072 had significantly higher speed than standard.
(b) During the first approach, standard 'approach configurations' were not achieved and the approach was not stabilised on the correct approach path by 500ft.
(c) When the captain perceived that he was 'not going to make it' on the first approach, standard go-around and missed approach procedures were not initiated.
(d) Instead, the captain executed a 360-degree orbit, a non-standard manoeuvre close to the runway at low altitude, with a considerable variation in altitude, bank angle and 'g' force.
(e) A 'rotation to 15 degree pitch-up' was not carried out during the go-around after the orbit.
(f) Neither the captain nor the first officer responded to hard GPWS warnings.
(g) In the approach and final phases of flight, there were a number of deviations of the aircraft from the standard flight parameters.
2) During the approach and final phases of flight, in spite of a number of deviations from the standard flight parameters and profile, the first officer (PNF - pilot not flying) did not call them out, or draw the attention of the captain to them, as required by SOPs.
3) During the go-around after the orbit, it appears that the flight crew experienced spatial disorientation:
(a) During the go-around the aircraft was accelerating rapidly, as the captain was dealing with the flap over-speed situation, he applied a nose-down side-stick input that was held for about 11 seconds, resulting in a nose-down pitch of 15 degrees.
(b) A perceptual study conducted using FDR recordings of the accident flight indicated that while the aircraft was accelerating with TOGA power in total darkness, the somatogravic illusion could have caused the captain to perceive (falsely) that the aircraft was 'pitching up'. He would have responded by making a 'nose down' input.
As a result the aircraft descended and thereafter flew into the shallow sea.
4) Controlled Flight into Terrain:
(a) The GPWS 'sink rate' alert sounded, followed by the ground proximity warning 'whoop, whoop, pull up' which sounded every second for nine seconds until the impact.
(b) The analysis of flight data recorder (FDR) and cockpit voice recorder (CVR) recordings indicated that neither the captain nor the first officer perceived, or effectively responded to, the threat of the aircraft's increasing proximity to the ground in spite of repeated hard GPWS warnings, and continued addressing the comparatively low priority flap over-speed situation.
(c) The captain did not fully utilise critical information provided by the aircraft instruments during the final phases of the flight, where he was also experiencing 'information overload'.
5) During the approach and final phases of the flight, the captain did not consult the first officer in the decision making process and did not effectively use this (the first officer) valuable human resource available to him.
A lack of training in CRM contributed in the flight crew not performing as an effective team conducting the operation of an aircraft.
6) Gulf Air's Organisational Factors:
(a) Inadequacy was identified in Gulf Air's A320 training programmes such as adherence to SOPs, CFIT and GPWS responses.
(b) At the time of accident, Gulf Air's flight data analysis system was not functioning satisfactorily and the flight safety department had a number of deficiencies, which restricted the airline's awareness in many critical safety areas.
7) Safety oversight factors:
A review of about three years preceding the accident indicated the following:
(a) The regulatory authority DGCAM, Oman had identified cases of non-compliance and inadequate or slow responses in taking corrective actions to rectify them, on the part of Gulf Air in some critical regulatory requirements.
(b) Although the DGCAM was attempting to ensure regulatory compliance by Gulf Air, it could not accomplish it in some critical regulatory areas, due to inadequate response by the operator.
(c) The regulatory authority and the airline are expected to fulfil complementary roles in maintaining safety of aircraft operations.
The evidence indicated inadequacies in the fulfilment of the above and highlighted the systemic factors in the airline's mechanisms to respond to the regulatory requirements.
8) The airline has taken a number of post-accident safety initiatives in the areas such as:
go-around procedures, ab-initio training, CRM training, command upgrade training, A320 fleet instructions, recurrent training and checking, instructor selection and training, pilot selection, modification to the A320 automatic flight system, and the flight safety department.
Gulf Air has further reported that it is in the process of enhancing its flight crew training, particularly that of A320 aircraft and introducing more safety initiatives.
Contributory Factors
The factors contributing to the above accident were identified as a combination of the individual and systemic issues.
Any one of these factors, by itself, was insufficient to cause a breakdown of the safety system.
Such factors may often remain undetected within a system for a considerable period of time. When these latent conditions combine with local events and environmental circumstances, such as individual factors contributed by "front-line" operators (eg: pilots or air traffic controllers) or environmental factors (eg: extreme weather conditions), a system failure, such as an accident, may occur.
The investigation showed that no single factor was responsible for the accident to GF-072.
The accident was the result of a fatal combination of many contributory factors, both at the individual and systemic levels. All of these factors must be addressed to prevent such an accident happening again.
(1) The individual factors particularly during the approach and final phases of the flight were:
(a) The captain did not adhere to a number of SOPs; such as: significantly higher than standard aircraft speeds during the descent and the first approach; not stabilising the approach on the correct approach path; performing an orbit, a non-standard manoeuvre, close to the runway at low altitude; not performing the correct go-around procedure; etc.
(b) In spite of a number of deviations from the standard flight parameters and profile, the first officer (PNF - pilot not flying) did not call them out, or draw the attention of the captain to them, as required by SOPs.
(c) A perceptual study indicated that during the go-around after the orbit, it appears that the flight crew experienced spatial disorientation, which could have caused the captain to perceive (falsely) that the aircraft was 'pitching up'. He responded by making a 'nose-down' input and as a result, the aircraft descended and flew into the shallow sea.
(d) Neither the captain nor the first officer perceived, or effectively responded to, the threat of increasing proximity to the ground, in spite of repeated hard GPWS warnings.
(2) The systemic factors, identified at the time of the above accident, which could have led to the above individual factors, were:
(a) Organisational factors (Gulf Air):
(i) A lack of training in CRM contributing to the flight crew not performing as an effective team in operating the aircraft.
(ii) Inadequacy in the airline's A320 training programmes, such as: adherence to SOPs, CFIT, and GPWS responses.
(iii) The airline's flight data analysis system was not functioning satisfactorily, and the flight safety department had a number of deficiencies.
(iv) Cases of non-compliance, and inadequate or slow responses in taking corrective actions to rectify them, on the part of the airline in some critical regulatory areas, were identified during three years preceding the accident.
(b) Safety oversight factors:
A review of about three years preceding the accident, indicated that despite intensive efforts, the DGCAM as a regulatory authority could not make the operator comply with some critical regulatory requirements.
