Gulf 072 report out next week?

[newswatcher]

From the Gulf Daily News - Bahrain(2/8)

"The release of the final accident report on the Gulf Air crash which killed 143 people last year is imminent.

An aviation official told the GDN yesterday that the Accident Investigation Board had scheduled meetings with concerned individuals and agencies next Wednesday and Thursday at the Civil Aviation Affairs (CAA) headquarters in Muharraq.

It will review its conclusions on the accident of August 23 last year, when Gulf Air Flight 072 en route from Cairo plunged into the sea less than a mile from the airport runway, killing all 135 passengers and eight crew members.

The final report could be released to the public as early as August 10, added the official.

The final report "will definitely" include the cause of the accident, he said.

However, a Gulf Air spokesman said the report was not expected to be published until early next month.

The 90-page factual report of the crash was released on April 1, and contained all aspects of the investigation, but drew no conclusions. However, it did not find any fault with the aircraft or the engines.

The report was submitted in mid-December to National Transportation Board (NTSB) assistant deputy director Frank Hilldrup, who heads the investigation, and included the board's Technical Investigation Committee's (TIC) cockpit voice recorder/flight data recorder, air worthiness and operations sub-group findings.

It was compiled by more than 25 sub-group committees representing the NTSB, CAA, Gulf Air, Oman Civil Aviation, Bureau Enquetes-Accidents, Airbus Industrie and CFMI (the engine manufacturer"

[Hogwash]

We wait with baited breath!!!!!

[oneilas]

The local news paper suggested that it'll be out on the 10th of August but wasn't the case.
Probably in the next few weeks.
Member of the Civil Aviation Borad said truth will be published,whatever it maybe .
At the same time, a few prominent members of the state have also lost their families on that accident and have a keen eye out with warnings in the local paper that they are going full throttle for the actaual excepts.
No wonder the heads of state from the outset had insisted that the NTSB carry out the report,without prejudice.

[newswatcher]

This from today's Bahrain "Gulf Daily News", which gives little confidence that the report will be released soon.

"Meanwhile, the Accident Investigation Board held its final briefing after two days of meetings which concluded on Thursday, at Civil Aviation Affairs (CAA) headquarters.

Aviation sources said the final accident report had been ready "for some time" and that the board planned to release it on September 10.

However, a CAA spokesman told the GDN yesterday he could not confirm whether or not the final accident report was finished or when it would be released."

[GF_001]

guys be passion, it will be one year this this month, and we all want to know what happen? god bless all those poeple who were on that flight.. so let hope BAHRAIN CIVIL AVIATION will put it public sooner rather than later.

[THUD]

The Cause:
http://members.ozemail.com.au/~aupa/PDF_files/DNT.pdf

as discussed (on this page and later) in this thread:
http://www.pprune.org/ubb/NonCGI/Forum1/HTML/009550-15.html

[L1011]

Report's out people.

Available at http://www.bahrainairport.com/GF072Factualinformation.htm

[Konkordski]

L1011,

Think you'll find that's the factual report which has been out for several months. Bahrain has yet to release the final report which will derive conclusions about the root cause(s) of the GF072 accident.

[L1011]

Konkordski

You are right, that is only the "factual report". No probable cause though deriving one is a no-brainer.

I stand corrected - if anyone was misled my apologies.

[scanscanscan]

L1011...O.K... I'm a "no brainer," what was the probable cause?

[hal3]

scanscanscan


DISORIENTATION !!!! :confused:

[ia1166]

You really are a no brainer

[twitchy]

what is there in the report to see, both the P1 and P2 fu**ed it well.......that is moral of the story :( :( :(

No airline has any business to employ these kind of people to be in the cockpit

[partagas]

About five years ago I operated into BAH from time to time as SFO for an Asian carrier. One evening the Capt, a former F4 carrier pilot, gave be a quick briefing that I have always tried to keep in mind regarding the grave dangers of disorientation when manoeuvring at low level at night over water. Take offs and go arounds being especially harzardous due to the significant forces of acceleration being horribly misinterpreted by the brain ,in such a compelling manner as to lead to tragic consequences.

[ironbutt57]

Strictly adhereing to sop's minimize the chances of these types of accidents occurring...

[shogunsina]

All things left aside,A first officer should be still a second officer till he can speak up at least to the captain,that'll save the day for most of these types of accidents where the captain is mr "I know". :cool:

[scanscanscan]

Thank you chaps for your proffesional opinions.
I am still going to stick with Belgique's posts and his Somatogravic illusion paper.

Further I would ask you, could this Somatogravic illusion have been a factor in the Staines Trident crash?

The concern is that three 320 qualified pilots present on the GF072 and the four qualified Trident pilots on the Stains were "all" struck by the same inability to recognise or fly manually correct pitch and power.

Maybe it is not as simple as all our dead collegues (7) simply Fu..ed Up.
Or their airline had no business employing such types.

Maybe Somatogravic illusion is a real killer as Belgique continues to warn, and it goes unrecognised on the tapes and today is not documented by the crash investigators.

Is it the silent killer that incapacitated all our collegues?

Also for your consideration..
The 737 in Idia.
The latest Russian.

[exeng]

ScanScanScan,

The tragic loss of the Trident at Staines was caused by the inadvertant (presumably) retraction of the L.E. droop at an inappropriately low I.A.S. This caused the A/C to stall. The stall on a 'T' tail A/C such as this resulted in an irecoverable stall known as a 'super stall' due to turbulent airflow from the wings reducing the effect of the elevator. This was a known problem on the Trident.

As usual in any A/C accident there were many other factors that contibuted to the outcome. C.R.M., unheard of in those days, was likely to be a factor in it's absence. (An impending industrial dispute had divided many crew in BEA). False stall warnings were common at the time on 'ground grippers', (hence the dumping of the 'stick push' in reponse to the stall). It was found that the Captain had suffered a heart attack, (who wouldn't if you were about to hit the ground and perish in a few seconds) but it may have been a causal factor if the heart attack occurred at the start of the event.

However I don't believe it was anything to do with a Somatographic Illusion as was likely, amongst other factors, to be at the root of the GF072 tragedy.


Regards
Exeng

[Belgique]

In Explanation (for those who may have come in late)
Quest
During my IR training I can recall being told about all the instrument errors that occur during various situations but I can't remember anything about this. I've been trawling through my memory ever since the GF accident and the first discussions of the somatogravic effects on Pprune and just can't recall this problem yet it seems such an important physiological phenomena to be ignorant of.

Did these guys get themselves into trouble ONLY because they did NOT stay on the instruments and flew visually without any visual references - or am I missing something?
http://members.ozemail.com.au/~aupa/PDF_files/DNT.pdf
http://www.pprune.org/ubb/NonCGI/Forum1/HTML/009550-15.html

Barry

Answer
Barry
They were turning 360 degrees to try and recapture the centre-line on short finals - always a challenge that's best left unattempted - when they shot through the centre-line and so had to declare a missed approach and reposition for another approach. Instead of a wings-level missed approach to a safe height, levelling off, stabilising and only then turning to a good repositioning heading, they were given a clearance by ATC that had them doing it all at once (overshooting, cleaning up, accelerating, climbing, turning, communicating and levelling). All these significant accelerations and distractions in a light and frisky aircraft posed a physiological mish-mash of sensations that then had suddenly superimposed upon them the complete loss of visual cues. This critical loss of "visual" was caused by their ATC-instructed immediate left turn away from the bright lights of Manama and the island of Bahrein into the dark-pool of the inky blackness of the overwater Gulf. You could NOT have set up a better scenario for that pitch-up somatogravic illusion. And of course the real killer with that one is that both the PF and PNF get it simultaneously. The powerful and instinctive reflex response to the sudden onset of the pitch-up illusion is to forcefully lower the nose (which causes greater acceleration and stimulates an even stronger instinctive reflex). It has been the cause of more night and IMC accidents than it has ever been given credit for. Low experience levels in the flight-deck don't help. Neither does an airline culture (within GulfAir and elsewhere) that calls for the captain to file a report on why a missed approach became necessary. The pressure upon pilots to then abbreviate the procedure (and ATC to comply) is a given and would have been a cause factor in this accident. None of the built-in alpha-floor protection features of the FBW Airbus were going to stop them from falling for this trap.

Since I raised the issue of somatogravic illusion, I have sensed in local Gulf News reports and the interim Official factual report, that they are trying to decry or dispute this, and find some other aspect that downplays the human error angle and seeks to either lay blame elsewhere (misleading instrumentation) - or leave the cause safely "unknown". The Final Report's due out now, so I guess we shall see if those suspicions are correct.

I'd have to agree with you that there is scant training carried out for airline pilots in avmed and physiological pitfalls. This will become even more significant as the number of military-trained airline pilots decreases in future. It's not something that can be done effectively or induced in a simulator. Significanty I had an email from an airline Chief Pilot (and a Pprune-post) thanking me for highlighting the phenomenon, simply because he'd never heard of it. It makes you wonder - particularly as there's no shortage of academic writings upon the subject.

To answer your second para question, the dichotomy for "contact" non-IMC night-flight in VFR conditions has always been that it must be an instrument/visual "mix" (i.e. instrument flight but necessarily utilising visual contact cues). That was brought home to me very effectively when another Vampire first night solo just ahead of me forgot about the runway change for that second wave of jets and turned fatally left off 18 into the Darling Ranges at Pearce (instead of right). Fatal oversight, like hindsight, is easily come by.
**************************
Ques
It's starting to come back to me. I remember reading about a crash in Canada
where a light a/c , a potent turbocharged c210 from memory, took off from a dark country airport and just flew into the ground a mile or two upwind not far off the extended centre line of the runway. The investigation did mention something
about an illusion which I didn't understand at the time.

I seem to have lost the link to the Canadian civil aviation site, do you have any URL's as I'd like to try and find it and re-read it in the light of my new found knowledge. Obviously someone is well aware of the problem but it's not public enough. Barry

Answ:
Barry
It will be one of those accessible via http://www.tsb.gc.ca/ENG/
(actually http://www.tsb.gc.ca/ENG/reports/air/RptAvi_Indx.html )
So could you be a mate and, if you look through them, pass me the URLs of:
a. Any other somatogravic-related accidents

Belcheek

SomatoGravic Illusion http://www.tsb.gc.ca/ENG/reports/air/earlier/ea93c0169.html somatogravic illusion suspected
"Somatogravic illusion may have adversely affected the pilot's performance during the acceleration stages of the take-off and initial climb. "
2.6 Behavioral Factors - Illusions and Disorientation
The forward acceleration of the Cessna 310 aircraft is sufficient to produce a powerful illusion of increasing pitch. Under extremely dark night conditions, with restricted outside visual references, a somatogravic illusion could cause the pilot to erroneously conclude that the aircraft was rotating to an increasingly high pitch angle. This illusion would be intensified if the pilot were denied accurate visual information because of a weak instrument scan, degraded eyesight, or poor ambient external lighting.
also http://www.tsb.gc.ca/ENG/reports/air/1996/ea96c0002.html

I think this somato...... illusion is so insidious it should be part of the pre takeoff briefing before every flight into night/ IMC in multi crew ops just as you turn onto the runway. Wouldn't have helped the poor chap in the URL above.

Barry

Barry
Research has shown that pilots are easily overtaxed by (and don't interpret) audio alarms - in particular when things are already coming unglued. It doesn't help to have a real tyro first officer who was overawed by his captain (and likely suffering the same sensory overload and selective radial scan breakdown). My experience of Arabs especially was that they were sometimes prone to throwing in the towel and leaving the outcome to the Supreme Being (with suitable incantations). That's why Arab students are never allowed to spin solo. In the finite time that you must take to permit spin recovery actions to take effect, an Arab cadet was always likely to suffer an attack of doubt, take hands and feet off and decide that it was Kismet that he should die. Nothing racist about this, it's purely an innate cultural and religious belief that they lean upon heavily when stressed. I saw it often.

When a very powerful sensory impulse is calling for an instinctive reflex reaction (which will unfortunately compound the problem) you can expect that the accompanying audio alarm is going to be beyond the stressed pilot's recognition and response threshold. You cannot "freeze-frame" a dynamic situation like they do regularly (for discussion) in a simulator. Which means of course that you have to look at this particular accident in terms of the time-scale of occurrence, recognition and the time available for reaction/recovery at the profile height, speed, altitude and attitude that they were at. It's easy to say that "surely they'd have been taught to wholly trust their instruments". That's a great concept of course, but it requires absolute self-discipline and some prior exposure to the sensations of entrapment. They would have had neither of these pre-conditioning absolutes. I call them "absolutes" because in reality, without this sensory training and a solid avmed understanding of the process...... well it is all so much lip-service. There is evidence in the DFDR readout of an attempted recovery, however it ended up being quite half-hearted and to me simply reflects the totally abject confusion that reigned once they had lost visual cues and were suddenly struck dumb and essentially powerless by that overwhelming physiological illusion. That's simply, factually and historically how it happens. CRM is no help when it's highly likely that both pilots were riding that same phenomenon.

Thanks for the research offer Barry. I always value your insightful inputs. I think that perhaps you are starting to realise and recognise one of the really basic truths about developing trends in airline aviation and crew quals. Aircraft are designed to be increasingly forgiving and reliable but once things start coming off the rails, it better be a very straightforward malfunction or you will soon be beyond your training, experience and limited systems knowledge - and in the province of confusion, despair and improvisation. That's what begets the typical, nowadays, pilot-error induced accident outcome, moreso than any overconfidence, negligence or risk-taking. And I guess I'd have to add that, like the GF072 crew, you don't really need a malfunction to qualify you for a visit to Never-Never Land (as in "never done this before - so what's it doing now?"). You only have to stick your neck out a little bit - to suddenly find that you shouldn't have.

If you read the speech (URL below) by Benoit Bouchard (Head of Canada's Transportation Safety Board), you will see that that is what he is saying in a nutshell, whilst still trying to put a positive spin on that admission.
http://www.ntsb.gov/events/symp%5Frec/proceedings/May_4/transcript_bouchard.htm

[newswatcher]

From today's Gulf Daily News(Bahrain):

"Gulf Air yesterday promised a "full and frank account" of the crash that killed 143 people, exactly a year ago today.

Safety is the airline's first priority, said president and chief executive Ibrahim Al Hamer.

"We wish to express our sorrow and sympathies on this sad occasion," he said in an open letter issued yesterday afternoon.

Mr Al Hamer said the airline and all its employees were profoundly affected by the crash of Flight 072 from Cairo, which smashed into the sea just off Muharraq, on August 23 last year, killing all on board.

"Our thoughts and sympathies are still with the victims, and their families and friends, a year later," he continued.

Mr Al Hamer said that as long as a need existed, the airline would continue to extend to those most affected every assistance through its Family Care office, which was set up immediately after the incident and is staffed full time during office hours.

"Gulf Air also continues to make every effort to ensure a satisfactory conclusion to any outstanding issues, such as the compensation of victims' families," he added.

"This, in particular, has been both a complex and emotive matter. We hope that, through continued co-operation and dialogue with all the various parties involved, it can be resolved."

Mr Al Hamer said Gulf Air had continued to give its full co-operation to the Accident Investigation Board and was "committed to the publication of a full and frank account" of the causes of the crash.

He reiterated that safety remained a priority issue, in which Gulf Air had and would continue to strive for higher standards in all aspects of air passenger travel.

"Through the appointment of specialist consultants, such as Lufthansa Consulting, in February 2000, Gulf Air has set new safety standards in flight operations and procedures," said Mr Al Hamer.

He said Gulf Air was the first airline in the region to include the evaluation of non-technical abilities as an essential element in pilot selection procedures.

"Through a contractual arrangement with German-based DLR, one of the world's foremost independent organisations involved in the selection of operational aviation personnel, Gulf Air has adopted similar systematic pilot selection procedures to those of some of the world's leading airlines," said Mr Al Hamer.

A similar facility is to be provided from a base in Bahrain and will offer its services to airlines in the region.

"The principles of assessment and training that have been adopted for pilots will be extended to apply to other personnel as part of a broader programme within the airline to promote Crew Resource Management," he added.

Mr Al Hamer said the process was aimed at developing organisational activities through human resources management as opposed to technology driven management.

"This will help all our staff, who are already technically well trained, to be better mentally equipped to operate in high pressure and often critical situations, hence further improving safety and proficiency," he remarked.

Mr Al Hamer said Gulf Air's safety and operational standards were higher than international levels.

"But I must stress that there can and will not be any complacency - the continual process of improvement in our activities and operations will never stop," he added.

Mr Al Hamer thanked the governments of all the owner states of Gulf Air "for their understanding and support", as well as staff and passengers "for their loyalty and commitment during the past year"."

[scanscanscan]

ExEng...Thank you for your post. I have read the Trident report and have it here.
IMHO...I feel the Somatogravic illusion kills by rendering all the flightdeck incapable of action and it requires a number of steps into its jaws.
I agree with Ironbutt that the way to avoid taking these steps is to stick closely to Sop.
However this assumes the Sop and training are correct??
If not the sops provide and assist the first step closer to a Somatogravic illusion and accident.

In the Trident case I suggest dumping the droops and getting the stick push and the auto pilot disconecting, all in IMC, accelerating,then not, climbing rapidly then not, were sufficient to render four of Britains most highly trained low vis pilots, well used to instrument scan incapable of redeploying the droops, or comprehending what they had actually done, what was happening and simply reversing their last actions i.e. redploy the droops, reconnect the autopilot,and reset the stick push override.

Had a stick push ever killed a Trident crew?

I feel something sinister overtook this entire highly trained crew, and it also overtook the 3 Gulf Air A320 pilots on GF072.

I do not accept (yet) "They F....d up" or "They never should have been hired" as a worthy or concluding tribute to these seven pilots.

There were three A320 pilots on the Gf072 flight deck and a series of events I feel also took them well into the Somatogravic jaws.
They were all,(like all of the Trident crew) rendered incapable of proper flap action, autopilot engagement, or manual instrument flying when overtaken by this illusion.

On a positive note I hope Gulf Air will now discourage high speed below ten requests in the speed restricted airspaces.
Will go back to the 1974 company sops regarding the acceptence of night nonprecision approaches around the Gulf which were introduced after two similar fatal accidents on the RW12 Vor Bah.
Hold a seminar for their pilots on the "Black Hole" effect and the "Somatogravic" illusion on aircrew and aircraft operation.
Brief Atc on the dangers of multiple,high speed, instructions and questioning crews at low altitude during approaches and go arounds and immediatly on main gear touchdown on landings, especially in bad weather or at night.
Introduce a Star arrival from Saudi airspace to intercept the Rw 12 Vor final.
Or better still put an ILs onto RW12 as suggested by an Australian flight safety
proffesional.
Put an ILs on RW16 at Doha which is also a trap in low vis.
All of the above IMHO will be helpful to any remaining Gulf Air pilots.

[Ghostflyer]

If you want to find out about Samatographic illusions, go and talk to any military fighter pilot that has been involved in low-level intercepts at night or in a cloud over the sea.

A routine part of military instrument training and civilian (I hope) is to stress that the instruments do not lie. In addition, the Military's Aviation Medicine specialists brief their pilots about the effects of Samatographic Illusions. By the time you reach the front-line, you have seen the video and got the tee-shirt. If you follow the wise words you will be ok.

Teaching egg-sucking, illusions do happen, so you fly attitude and then check the performance instruments to make certain that you are flying the required profile whilst monitoring the radar. On a typical intercept profile the aircraft could be descending from 8 or 9000' to 1000', whilst in a 70 Degree banked turn, pulling around 3-4g and accelerating from 300 to 550+ knots in full reheat. Trust me, from personal experience, the pitch up sensation is immense, far worse than you could ever experience in a commercial aircraft. Therefore, you believe the instruments as you were taught to do.

When you can't crack it, you roll off the bank and recover the aircraft, aborting the intercept (or approach?), because you are smart enough to realise that it is your little pink body that is at stake if you screw up.

Do not get me wrong, I have full sympathy for all of those involved in the Bahrain tragedy. However, a samatographic illusion is just that. Yes, it could occur off Bahrain in the blackhole over the Gulf but not if the crew are flying a sensible safe commercial profile. And even then, if the pilot has been correctly trained and carries out an effective instrument scan it is not an issue.

From what I have said above, it would be easy to assume that Aviation Medicine training (or lack of) might be a root cause of this incident. It might be a contributary factor but perhaps it would be more pertinent to look at the decision making of the Captain. I know of few commercial pilots (yes I am one now) that when they have screwed up the approach would then try to visually reposition for another go rather than taking ATC vectors downwind and setting up again. We are all human, we all make mistakes but the key is to trap the errors and to have the humility to take corrective action before the snowball gets rolling.

I hate all the speculation that surrounds the cause of the accidents before the board releases its findings. Lets let the men with the facts come up with their report and then feel free to dispute them. You never know, they might actually admit what really happened...

May they all rest in peace.

[llamas]

Well, llamas was just a cria when the Staines wreck happened, but I do seem to recall that evidence given at the inquiry indicated that Captain Keyes had been involved in an argument with a fellow employee (in relation to the impending industrial action) less than an hour before take-off - described, as I recall, by an observer, as the most violent argument he'd ever seen.

Was it not suggested at the time that either

a) the confrontation that Capatin Keyes engaged in was so violent that it led to the heart attack that he later suffered? or

b) the First Officer, whose name, I fear, escapes me, but who witnessed the entire incident, was so intimidated by what he saw that he was inhibited from questioning Captain Keyes' actions during the climb-out, specifically, the incorrect manipulation of the slats?

Looking to learn.

llater,

llamas