DH121
Thanks for that, my point being though that on approaches like this (I go to Samos regularly) you need a bit more thought and briefing because you aren't necessarily going to go around from the point you describe heading north!
Monarch Man's comments are as frank as mine, with some additional comments such as the fact that the GIB missed approach is also available in the FMC. I refrained from suggesting that as it wasn't mentioned in the AAIB report and I have not been to GIB, but if we want to learn something from this it is important to ask WHY did this situation develop, HOW did they get the missed approach so wrong and WHY did the crew stop operating effectively?
As there is no complete answer in the AAIB report one can only speculate.
1. Why did the situation develop? Possibly due to several previous benign arrivals into GIB as Monarch Man suggests. But the fact that you have to get specially checked out to go there and (presumably) an extensive airfield brief is enough to remind you each time you go there that it is somewhere to give extra consideration and respect to. The report says that there was a lack of a comprehensive brief prior to the approach. This could indeed lead to perhaps the plan not being fully complete in the mind of at least one of the flight crew. Having been somewhere lots of times before can lead to the temptation to underbrief.
2. How did they get the missed approach so wrong? I think they lost visual and elected to go around. The workload was high and an action error occurred, namely forgetting to press the TOGA switch. The unexpected had happened, they were late in the approach and the brain would have been thinking about rolling out onto final, searching and looking for the visual reference and the all of a sudden this was lost. Once the missed approach was actioned incorrectly I think this is what caused the loss of SA; thrust was manually increased and the nose was rising to the go around pitch attitude. The PNF was on the radio and then noticed no annunciation of G/A on the FMA. He called this to the PF which was not something that he would be ready for or expecting to hear. He pressed the TOGA switch and the flight directors popped back up. This distraction drew attention away from the MAP display which would have been showing that they were not lined up with the runway, not positioning towards the runway extended centreline or following the LNAV missed approach (if displayed on the map). A brief moment of confusion (we've all been there) and the prioritisation breaks down. After the G/A had been initiated, the G/A attitude selected, the flaps set for the G/A and the gear retracted the next priority would be to get onto the required track. This didn't occur and SA was lost with them heading towards the high ground.
3. Why did the crew stop operating effectively? Workload management I would suggest. Thorough brief perhaps missing and then the unexpected happened. The workload then goes up even more and the overload was not recognised (forgetting how to initiate the missed approach using the TOGA button), this leads to loss of SA in at least the PF, but by the sounds of the report the PNF too as nothing was said about the tracking. Then a radio call to say going around which was not the priority, followed by the PNF pointing out that G/A was not annumnciated. This was correct, but could possibly have become a distraction for the PF, taking his mind away from the tracking (MAP display) and onto the EADI. Pressing the TOGA switch then caused the flight directors to pop up and to show current ground track, which was not following the missed approach procedure. The flight directors are very powerful stimuli and it can be difficult to ignore them. I think this compounded the loss of SA. The PF was still turning when he thought he was in wings level flight, so he would have been diverging from the flight director commanded heading too. And during this high workload the PNF didn't mention anything about the lack of correct missed approach tracking. I suspect his SA was lost too in the confusion that was happening VERY quickly. Then the controller recognised the problem and told them to keep their turn going onto 180 degrees as the best way of avoiding terrain. Once the heading was selected to 180 degrees and HDG SEL taken the PNF obviously regained his SA and prompted the PF that the high terrain was on their left from his terrain display.
My airline have a CRM Skills List, which was developed using one of the industry's leading lights on CRM together with our training department. The whole thing centres around WORKLOAD, with sub headings in that area of 'recognises high workload', 'takes or makes time', 'deals with overload and prioritises' and 'avoids distraction and distracting'. We use the list to debrief sim performances and line checks etc. It is a VERY USEFUL tool and I have worked through it with this scenario and it is very helpful.
Now I may be wildly wrong with my speculation about how it happened, but that's how I read the report and those are the lessons I have taken from it.
PP