InitRef
12th Apr 2001, 00:44
Apologies for the lengthy cut and paste from Aviationnow.com, but it contains excerpts from the factual report.
Bahrain Probe Triggers Changes At Gulf Air
By Sean Broderick
10-Apr-2001 4:24 PM U.S. EDT
Gulf Air changed key training and flight operations guidelines after investigators found that events preceding the August 2000 crash of a Gulf Air A320 in Bahrain included several procedural errors by the plane's crew as it attempted a go-around, a preliminary report on the crash revealed.
The airline made several changes to its pilot training programs and criteria, issued several new A320 Standard Operating Procedures (SOPs), including banning 360-degree turns as part of a go-around, and stopped hiring "ab-initio" pilot candidates pending a review of its training programs.
Gulf Air altered several training programs to make them reflect line operations more closely, the report said. For example, its simulator program will include more sessions with captain trainees in the left seat and first-officer trainees in the right seat, rather than placing trainees who are on the same level in the cockpit together. A similar initiative was put into place in Gulf Air's Command Line Training program that gives prospective captains about 20 added cycles with a first officer in the right seat.
The airline also began screening rising first officers "to assess their suitability for command," the report said. Similar tests already had been done on new hires.
Other new instruction initiatives include more go-around scenarios in the recurrent training program, and a cockpit crew resource management (CRM) program that started Nov. 1. CRM training was supposed to be under way when the accident happened but was delayed because of "contract negotiations" between the pilots and management, according to the report. All Gulf Air pilots are expected to complete initial CRM training by July.
In October, Gulf Air modified its A320 SOPs, limiting speed to 250 knots below 10,000 feet (FL100) "for normal operations." An exception can be made at air traffic control's (ATC) request, but the limit must be observed below 5,000 feet and at "higher altitude airports."
The carrier also barred "360-degree turns and other maneuvers for descent profile adjustment" once the plane is on final approach.
The SOP mandate also "assured" Gulf Air pilots "that no disciplinary action whatsoever will be taken" for crews that elect to go-around "for safety-related reasons, including inability...to stabilize an approach by the applicable minimum height."
Gulf Air is looking at its ab initio training program, especially the simulator phase, the report said, "in order to assess it against industry standards and recent changes to regulatory requirements."
Several safety officials praised Gulf Air's actions in the wake of the tragedy. "This is the best thing that can come out of an accident investigation," one official told AviationNow.com. "If potential deficiencies are identified and the responsible organization takes the initiative to address them, that shows the aviation safety process works."
Missed Approach
Gulf Air Flight 072 crashed after missing an approach to Bahrain International Airport (BAH) on Aug. 23 at about 1930 local time. The flight, carrying 135 passengers and eight crewmembers including the pilot and first officer, was en route to Bahrain from Cairo. All 143 people on the plane died.
Weather at the time of the crash was clear, with a visibility of at least 10 kilometers and few, if any, clouds. Sunset on Aug. 23 in the area of the island of Bahrain was at 1806. Moonrise was 2345 local time, meaning there was no moon in the sky at the time of the crash.
At 1921:48, Flight 072 was cleared for a "self-navigation" approach to BAH Runway 12 using the strip's VOR/DME (very-high-frequency omnidirectional range/distance measuring equipment) when the aircraft was at 14,000 feet and some 30 nautical miles from the airport. The first officer was the pilot flying.
During the next five minutes, the plane descended to 1,000 feet as it approached Runway 12, flying as fast as 313 knots after descending through 2,000 feet above ground level (AGL), the flight data recorder (FDR) showed.
At 1927:06, with the A320 about 2 nm from the runway threshold and at an altitude of about 600 feet, the plane's cockpit voice recorder (CVR) tape revealed that the captain told the first officer, "We're not going to make it." The captain told the first officer to do a 360-degree left turn and line the plane up for another approach attempt.
The plane began its left turn at 584 AGL. It banked away from the shoreline lights of BAH, turned to the northeast, over the Persian Gulf, and back around. During the turn, the plane's altitude was as high as 965 AGL and as low as 332 AGL. The minimum altitude for the maneuver based on Gulf Air procedures was 1,000 feet AGL, the report said.
The maximum bank angle during the circle was 36 degrees, and flap settings went from two to three and then to full. About halfway through the turn, the first officer said, "Landing checklist completed."
Go-Around
At 1928:57, as Flight 072 was coming out of the circle heading southwest and approaching the Runway 12 centerline, the captain said, "We overshot it." The A320 then began another left turn, and 10 seconds later, the captain said to the first officer, "tell him [ATC] going around" as the engine thrust increased to maximum takeoff/go-around (TOGA).
Gulf Air's SOPs indicate the first four steps for A320 two-engine go-arounds are to set thrust levers to TOGA, issue a verbal call for flaps to be retracted one step, retract flaps one step, and rotate the plane to a 15-degree nose-up attitude.
When the go-around was announced, ATC told the first officer to fly "heading three zero zero" and climb to 2,500 feet on the go-around. The first officer acknowledged the transmission. "During this time, the flaps were retracted to position 'three,'" the report said.
At 19:29:41, with the A320 flying at 191 knots and 1054 feet AGL, the aural master warning sounded, indicating a flap overspeed condition. Maximum speed for an A320 in "flaps-three" configuration is 185 knots, the report noted.
Two seconds after the warning, the FDR showed that the captain's sidestick moved forward and was held there for about 11 seconds. Maximum forward deflection during that time was 9.7 degrees, the report said. (The A320 sidestick can be moved a maximum of 16 degrees fore and aft.) With the sidestick pushed forward, the plane's pitch angle changed from about five degrees nose-up to 15.5 degrees nose down.
At 1929:51, with the plane descending through 1000 feet AGL and flying at 221 knots, the ground proximity warning system (GPWS) sounded an aural "sink rate" warning, indicating an excessive rate of descent, followed by a "whoop, whoop, pull up" warning that would continue until the CVR tape ended. By this time, the A320 had circled back over the runway and was facing northeast with the airport and the island of Bahrain behind it, and nothing but the Persian Gulf ahead and below.
GPWS Procedures
At about 1929:53, the captain's sidestick moved aft of neutral, reaching a maximum aft position of 11.7 degrees. "However, the FDR data showed that this nose-up command was not maintained and that subsequent movements never exceeded 50% of full-aft availability," or eight degrees, the report said. FDR data showed the first officer's sidestick did not move during this sequence, the report said.
Gulf Air's procedures for response to a GPWS warning call for "full back stick...to be employed and maintained, and that during night conditions, the response should be immediate," the report noted.
At 1929:59, the captain called for "flaps all the way," and the first officer verified the command. FDR data showed that at 1930:00, Flight 072 was 105 feet from the Persian Gulf's surface, traveling at 282 knots with a nose-down attitude of 6 degrees. Two seconds later, the CVR stopped.
Investigators seem to be looking at several aspects of the accident to analyze what happened, the report indicated. The nighttime, moonless conditions at the time of the crash meant Flight 072's pilots had few visual clues to lean on once they broke off their first approach, so several sets of flight tests were done to determine what a crew would feel during maneuvers like those done by the Gulf Air pilots after the first missed landing attempt.
Investigators also monitored an Airbus Industrie flight test crew in an A320 simulator set up to recreate Flight 072's final moments, with an emphasis on the GPWS warning.
In one scenario, the captain pulled back fully on the sidestick (16-degree aft deflection) when the warning sounded and was able to recover the simulator after 300 feet of altitude loss. The same scenario with half-back stick (eight-degree aft deflection) allowed the simulator to recover after 650 feet of altitude loss.
A third scenario called for the first officer to take over after realizing the captain was not responding to the GPWS warning. The first officer took control of the simulator and, using full aft deflection, pulled it out of its dive with 400 feet of altitude loss.
A review of Gulf Air's controlled flight into terrain (CFIT) training showed that briefings are done during conversion and initial simulator CFIT training, and simulator work is done during recurrent training. "The content of the CFIT simulator training is left to the discretion of the instructor," the report said. "There was no detailed syllabus for CFIT training."
The manufacturer's course syllabus for the A320 includes a GPWS "pull-up demonstration," the report said, but the carrier's A320 flight training manager "indicated that there was no similar syllabus for Gulf Air, and no requirement to execute such demonstration" for A320 pilots.
The factual report on the crash, released late last month, contains no analysis of the findings. The probe is being led by a Bahrain accident investigation board, with assistance from a dozen or so other organizations and companies, including France's Bureau Enquetes-Accidents (BEA) and the U.S. National Transportation Safety Board (NTSB). A representative from the U.S. body is acting as the investigator-in-charge.
Bahrain Probe Triggers Changes At Gulf Air
By Sean Broderick
10-Apr-2001 4:24 PM U.S. EDT
Gulf Air changed key training and flight operations guidelines after investigators found that events preceding the August 2000 crash of a Gulf Air A320 in Bahrain included several procedural errors by the plane's crew as it attempted a go-around, a preliminary report on the crash revealed.
The airline made several changes to its pilot training programs and criteria, issued several new A320 Standard Operating Procedures (SOPs), including banning 360-degree turns as part of a go-around, and stopped hiring "ab-initio" pilot candidates pending a review of its training programs.
Gulf Air altered several training programs to make them reflect line operations more closely, the report said. For example, its simulator program will include more sessions with captain trainees in the left seat and first-officer trainees in the right seat, rather than placing trainees who are on the same level in the cockpit together. A similar initiative was put into place in Gulf Air's Command Line Training program that gives prospective captains about 20 added cycles with a first officer in the right seat.
The airline also began screening rising first officers "to assess their suitability for command," the report said. Similar tests already had been done on new hires.
Other new instruction initiatives include more go-around scenarios in the recurrent training program, and a cockpit crew resource management (CRM) program that started Nov. 1. CRM training was supposed to be under way when the accident happened but was delayed because of "contract negotiations" between the pilots and management, according to the report. All Gulf Air pilots are expected to complete initial CRM training by July.
In October, Gulf Air modified its A320 SOPs, limiting speed to 250 knots below 10,000 feet (FL100) "for normal operations." An exception can be made at air traffic control's (ATC) request, but the limit must be observed below 5,000 feet and at "higher altitude airports."
The carrier also barred "360-degree turns and other maneuvers for descent profile adjustment" once the plane is on final approach.
The SOP mandate also "assured" Gulf Air pilots "that no disciplinary action whatsoever will be taken" for crews that elect to go-around "for safety-related reasons, including inability...to stabilize an approach by the applicable minimum height."
Gulf Air is looking at its ab initio training program, especially the simulator phase, the report said, "in order to assess it against industry standards and recent changes to regulatory requirements."
Several safety officials praised Gulf Air's actions in the wake of the tragedy. "This is the best thing that can come out of an accident investigation," one official told AviationNow.com. "If potential deficiencies are identified and the responsible organization takes the initiative to address them, that shows the aviation safety process works."
Missed Approach
Gulf Air Flight 072 crashed after missing an approach to Bahrain International Airport (BAH) on Aug. 23 at about 1930 local time. The flight, carrying 135 passengers and eight crewmembers including the pilot and first officer, was en route to Bahrain from Cairo. All 143 people on the plane died.
Weather at the time of the crash was clear, with a visibility of at least 10 kilometers and few, if any, clouds. Sunset on Aug. 23 in the area of the island of Bahrain was at 1806. Moonrise was 2345 local time, meaning there was no moon in the sky at the time of the crash.
At 1921:48, Flight 072 was cleared for a "self-navigation" approach to BAH Runway 12 using the strip's VOR/DME (very-high-frequency omnidirectional range/distance measuring equipment) when the aircraft was at 14,000 feet and some 30 nautical miles from the airport. The first officer was the pilot flying.
During the next five minutes, the plane descended to 1,000 feet as it approached Runway 12, flying as fast as 313 knots after descending through 2,000 feet above ground level (AGL), the flight data recorder (FDR) showed.
At 1927:06, with the A320 about 2 nm from the runway threshold and at an altitude of about 600 feet, the plane's cockpit voice recorder (CVR) tape revealed that the captain told the first officer, "We're not going to make it." The captain told the first officer to do a 360-degree left turn and line the plane up for another approach attempt.
The plane began its left turn at 584 AGL. It banked away from the shoreline lights of BAH, turned to the northeast, over the Persian Gulf, and back around. During the turn, the plane's altitude was as high as 965 AGL and as low as 332 AGL. The minimum altitude for the maneuver based on Gulf Air procedures was 1,000 feet AGL, the report said.
The maximum bank angle during the circle was 36 degrees, and flap settings went from two to three and then to full. About halfway through the turn, the first officer said, "Landing checklist completed."
Go-Around
At 1928:57, as Flight 072 was coming out of the circle heading southwest and approaching the Runway 12 centerline, the captain said, "We overshot it." The A320 then began another left turn, and 10 seconds later, the captain said to the first officer, "tell him [ATC] going around" as the engine thrust increased to maximum takeoff/go-around (TOGA).
Gulf Air's SOPs indicate the first four steps for A320 two-engine go-arounds are to set thrust levers to TOGA, issue a verbal call for flaps to be retracted one step, retract flaps one step, and rotate the plane to a 15-degree nose-up attitude.
When the go-around was announced, ATC told the first officer to fly "heading three zero zero" and climb to 2,500 feet on the go-around. The first officer acknowledged the transmission. "During this time, the flaps were retracted to position 'three,'" the report said.
At 19:29:41, with the A320 flying at 191 knots and 1054 feet AGL, the aural master warning sounded, indicating a flap overspeed condition. Maximum speed for an A320 in "flaps-three" configuration is 185 knots, the report noted.
Two seconds after the warning, the FDR showed that the captain's sidestick moved forward and was held there for about 11 seconds. Maximum forward deflection during that time was 9.7 degrees, the report said. (The A320 sidestick can be moved a maximum of 16 degrees fore and aft.) With the sidestick pushed forward, the plane's pitch angle changed from about five degrees nose-up to 15.5 degrees nose down.
At 1929:51, with the plane descending through 1000 feet AGL and flying at 221 knots, the ground proximity warning system (GPWS) sounded an aural "sink rate" warning, indicating an excessive rate of descent, followed by a "whoop, whoop, pull up" warning that would continue until the CVR tape ended. By this time, the A320 had circled back over the runway and was facing northeast with the airport and the island of Bahrain behind it, and nothing but the Persian Gulf ahead and below.
GPWS Procedures
At about 1929:53, the captain's sidestick moved aft of neutral, reaching a maximum aft position of 11.7 degrees. "However, the FDR data showed that this nose-up command was not maintained and that subsequent movements never exceeded 50% of full-aft availability," or eight degrees, the report said. FDR data showed the first officer's sidestick did not move during this sequence, the report said.
Gulf Air's procedures for response to a GPWS warning call for "full back stick...to be employed and maintained, and that during night conditions, the response should be immediate," the report noted.
At 1929:59, the captain called for "flaps all the way," and the first officer verified the command. FDR data showed that at 1930:00, Flight 072 was 105 feet from the Persian Gulf's surface, traveling at 282 knots with a nose-down attitude of 6 degrees. Two seconds later, the CVR stopped.
Investigators seem to be looking at several aspects of the accident to analyze what happened, the report indicated. The nighttime, moonless conditions at the time of the crash meant Flight 072's pilots had few visual clues to lean on once they broke off their first approach, so several sets of flight tests were done to determine what a crew would feel during maneuvers like those done by the Gulf Air pilots after the first missed landing attempt.
Investigators also monitored an Airbus Industrie flight test crew in an A320 simulator set up to recreate Flight 072's final moments, with an emphasis on the GPWS warning.
In one scenario, the captain pulled back fully on the sidestick (16-degree aft deflection) when the warning sounded and was able to recover the simulator after 300 feet of altitude loss. The same scenario with half-back stick (eight-degree aft deflection) allowed the simulator to recover after 650 feet of altitude loss.
A third scenario called for the first officer to take over after realizing the captain was not responding to the GPWS warning. The first officer took control of the simulator and, using full aft deflection, pulled it out of its dive with 400 feet of altitude loss.
A review of Gulf Air's controlled flight into terrain (CFIT) training showed that briefings are done during conversion and initial simulator CFIT training, and simulator work is done during recurrent training. "The content of the CFIT simulator training is left to the discretion of the instructor," the report said. "There was no detailed syllabus for CFIT training."
The manufacturer's course syllabus for the A320 includes a GPWS "pull-up demonstration," the report said, but the carrier's A320 flight training manager "indicated that there was no similar syllabus for Gulf Air, and no requirement to execute such demonstration" for A320 pilots.
The factual report on the crash, released late last month, contains no analysis of the findings. The probe is being led by a Bahrain accident investigation board, with assistance from a dozen or so other organizations and companies, including France's Bureau Enquetes-Accidents (BEA) and the U.S. National Transportation Safety Board (NTSB). A representative from the U.S. body is acting as the investigator-in-charge.