Eventually !!Probe Blames Captain for GF Jet Crash
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I remember this fatal night like nothing else in my aviation career,
landing just before them. I was probably at the gate pointing my tail to all that happened. Arriving from the west we were held high (7000 ft is normal) until passing the Saudi coast. Changing to APP. we were asked if we could accept 12 for landing (ATIS was 30). Ofcourse then you are high, asked for surface wind, it was around 130/8. I just thought why bother to go for 12 with new setup, breefing, loosing considerable amount of altitude, VOR app. etc, etc. Just take a bit of tailwind, I am not an ace, I want to relax. My guess is that the guy had been bragging to the F/O about his skills from way up, and when he saw he was going to lose out he felt so embarrassed ( loss of face) he tried to make up for it by trying to show more skills, fatal skills. It is an enormous tragedy that should not have happened on this clear but dark night.
landing just before them. I was probably at the gate pointing my tail to all that happened. Arriving from the west we were held high (7000 ft is normal) until passing the Saudi coast. Changing to APP. we were asked if we could accept 12 for landing (ATIS was 30). Ofcourse then you are high, asked for surface wind, it was around 130/8. I just thought why bother to go for 12 with new setup, breefing, loosing considerable amount of altitude, VOR app. etc, etc. Just take a bit of tailwind, I am not an ace, I want to relax. My guess is that the guy had been bragging to the F/O about his skills from way up, and when he saw he was going to lose out he felt so embarrassed ( loss of face) he tried to make up for it by trying to show more skills, fatal skills. It is an enormous tragedy that should not have happened on this clear but dark night.
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Instrument Survival Instincts
There is a cure for spatial disorientation: As a last resort, look only at the SAI, avoid sensory overload by ignoring flashing lights, voice alerts, bells, horns, clackers, tones, chimes and whistles, then level the wings, raise the nose ten degrees, add a handful of power and maintain attitude. It works in a dark cockpit, with CADC and static system failure, and with all generators gone on vacation, in IMC.
If each recurrent simulator training session would include just 30 consecutive minutes of nothing but "hands on" flying during complete electrical failure, with one engine inoperative (without A/P, without F/D, without glide slope)....One would not lose the magic touch of raw data instrument flying during extreme circumstances.
If each recurrent simulator training session would include just 30 consecutive minutes of nothing but "hands on" flying during complete electrical failure, with one engine inoperative (without A/P, without F/D, without glide slope)....One would not lose the magic touch of raw data instrument flying during extreme circumstances.
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One should not be teached basic flying skills in an airliner.....You learn them during your training on props.
You do not need to have a 1000 hours before you can fly.....and unusual attitudes are part of your first 100 hours of flying!!!!
In europe it is common to have F/Os on an airliner with 300H TT. And by my knowledge nothing severe happend because of that untill now. Also lots of guys immediatly start out on the Airbus....again, nothing wrong with that! You do not need a 767 to learn how to fly an airplane!
But when flying an airliner it is dangerous to team up two inexperienced pilots in a cockpit....and thats probably what happend here and to my concern, that was the major cause of this tragedy.....
You do not need to have a 1000 hours before you can fly.....and unusual attitudes are part of your first 100 hours of flying!!!!
In europe it is common to have F/Os on an airliner with 300H TT. And by my knowledge nothing severe happend because of that untill now. Also lots of guys immediatly start out on the Airbus....again, nothing wrong with that! You do not need a 767 to learn how to fly an airplane!
But when flying an airliner it is dangerous to team up two inexperienced pilots in a cockpit....and thats probably what happend here and to my concern, that was the major cause of this tragedy.....
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Gulfpilot76.....
I see the GF 072 Captain did not fly the full Vor approach from overhead the Vor as per the published approach plate.
He accepted the baited invitation from ATC to self position at night from the non turn side to a short FAF from a large intercept angle when already high and fast plus under stress being inexperienced on type with a similar configured FO.
He did not have a STAR arrival or gate speeds to guide him off of a Saudi navigation beacon to a sensible distance initial final fix for Rw 12.
I had hoped the accident investigation team would have recommended a Star for RW12 now be published.
When I joined GA/GF in 1974 there was an SOP rule that pilots would always use an ILS if available and within wind and aircraft landing limitations.
This Sop rule was introduced because two Air France aircraft had crashed in one week on Black Hole Night approaches into RW12 Bahrain.
What happened to this Sop
What happened to the inexperienced pilots Sop
GF 072 A320 loss $36million
Back to the drawing board
I see the GF 072 Captain did not fly the full Vor approach from overhead the Vor as per the published approach plate.
He accepted the baited invitation from ATC to self position at night from the non turn side to a short FAF from a large intercept angle when already high and fast plus under stress being inexperienced on type with a similar configured FO.
He did not have a STAR arrival or gate speeds to guide him off of a Saudi navigation beacon to a sensible distance initial final fix for Rw 12.
I had hoped the accident investigation team would have recommended a Star for RW12 now be published.
When I joined GA/GF in 1974 there was an SOP rule that pilots would always use an ILS if available and within wind and aircraft landing limitations.
This Sop rule was introduced because two Air France aircraft had crashed in one week on Black Hole Night approaches into RW12 Bahrain.
What happened to this Sop
What happened to the inexperienced pilots Sop
GF 072 A320 loss $36million
Back to the drawing board
Last edited by scanscanscan; 18th Jul 2002 at 08:55.
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This accident was a "system" error, the system being Gulf Air and the DGCAM (civil aviation authority of Oman). This has been clearly highlighted in the report and the appropriate reccomendations made. Lets hope that there is a shake up within these bodies to tidy up an ongoing, festering problem. The crew were the end product of a poorly administered aviation system and whilst it can be seen by some that they directly caused the accident, they were in fact indirectly put there by poor administration and regulation. I am sure this type of situation is not unique to Guilf Air, many aviation bodies can learn from this to avoid another catastrophe of this magnitude.
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Triple Scan,
To my knowledge there is no SOP in effect nowadays that requires pilots to use an ILS app. when available / suitable.
There is however a SOP / fleetinstruction dealing with a stabilized approach before 1000ft in IMC and 500 ft in VMC. As far as rostering rules for blue line captains, there must be one in effect.
Although from what I heard this captain considered himself as 'experienced'. A STAR for VOR 12 is not in force, but it might be better in this case for BAH/ACC to negotiate their jurisdiction in the DMM airspace ( lower altitude) in case RWY 12 is in use. The full procedure could have been an option, but then in this case ILS 30 was still available with around 8 kts steady tailwind. Hope this answers your questions. Good luck.
GP76.
To my knowledge there is no SOP in effect nowadays that requires pilots to use an ILS app. when available / suitable.
There is however a SOP / fleetinstruction dealing with a stabilized approach before 1000ft in IMC and 500 ft in VMC. As far as rostering rules for blue line captains, there must be one in effect.
Although from what I heard this captain considered himself as 'experienced'. A STAR for VOR 12 is not in force, but it might be better in this case for BAH/ACC to negotiate their jurisdiction in the DMM airspace ( lower altitude) in case RWY 12 is in use. The full procedure could have been an option, but then in this case ILS 30 was still available with around 8 kts steady tailwind. Hope this answers your questions. Good luck.
GP76.
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Two-pilot Simultaneous Disabilities
It's a dangerously dismissive attitude to start talking about visual disorientation, unusual attitudes, vertigo and sensory illusions all at the same time - as if they are interchangeable terms for much the same phenomenon.
Some of these Human Factors phenomena are much more attention-getting, alarming and confusing than others. The somatogravic illusion is unique inasmuch as it can and does affect both pilots simultaneously. That fact explains much of what didn't happen in the GF072 cockpit at that crucial time.
So if you experience it, don't expect that your oppo will be much help - or that you will exit it successfully. Long-term USN experience and a wealth of "unexplained" accidents bear out that morbid fact.
If you read on from this 31 Aug 2000
http://www.pprune.org/ubb/NonCGI/For...009550-15.html
Belgique post, you might observe that apparently few people had at that time heard of the "pitch-up illusion". Hopefully that's now changed. You cannot practice it in a sim but you can ensure that it's not something you'd fail to recognise when it comes your turn.
Some of these Human Factors phenomena are much more attention-getting, alarming and confusing than others. The somatogravic illusion is unique inasmuch as it can and does affect both pilots simultaneously. That fact explains much of what didn't happen in the GF072 cockpit at that crucial time.
So if you experience it, don't expect that your oppo will be much help - or that you will exit it successfully. Long-term USN experience and a wealth of "unexplained" accidents bear out that morbid fact.
If you read on from this 31 Aug 2000
http://www.pprune.org/ubb/NonCGI/For...009550-15.html
Belgique post, you might observe that apparently few people had at that time heard of the "pitch-up illusion". Hopefully that's now changed. You cannot practice it in a sim but you can ensure that it's not something you'd fail to recognise when it comes your turn.
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really.....when was the ILS installed? and belgique....you are missing the point...we are all aware of the pitfalls of spatial disorientation....but an education and an acute awareness of the situations that favor such perceptions are what need to be avoided...thus the need for training...not only what to do if and when it happens to you, but how to recognize/avoid the onset of the vertigo...
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And what about the aircraft?
Despite the Analysis, Findings and conclusions, readable at http://www.bahrainairport.com/GF072i...ionreport.htm, the factual information had previously lead to point some comments about an hypothetical malfunction of the aircraft systems, specifically the well known hard limit "fly-by-wire" conception.
According to the readouts of the DFDR, it appears that, despite the effective actions of the PIC, the aircraft did not respond and continued descending. In fact, TRIM and elevators were consistently in opposite positions, up and down respectively, until the moment of impact.
Some experts have talked about an APC phenomenon, caused by overcommand on the sidestick from the PIC.
Surprisingly, any comment is done about this. Even to say that everything worked out properly ...
According to the readouts of the DFDR, it appears that, despite the effective actions of the PIC, the aircraft did not respond and continued descending. In fact, TRIM and elevators were consistently in opposite positions, up and down respectively, until the moment of impact.
Some experts have talked about an APC phenomenon, caused by overcommand on the sidestick from the PIC.
Surprisingly, any comment is done about this. Even to say that everything worked out properly ...
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Ironbutt
Er, I think that's what I said. In fact I first said it about this accident two years ago... and if you go back to those old threads you will note that even a Chief Pilot piped up and said he'd never heard of it (the somatogravic illusion). In this respect it is an area (like hypoxia and altitude chamber training) where the old military hands have a distinct advantage in their background. Most Western Military pilots still undergo AVMED Refresher Lectures every few years .... including a very real hypoxia experience and disorientation training in a spin-chair or centrifuge.
The point that I was making is that until it happens to you, you tend to treat it as a bit of mythology (a bit like retreating blade stall, dynamic rollover and vortex ring for the rotary brethren). You cannot have a somatogravic illusion ("pitch-up") experience in a simulator and I'm quite sure that you won't have it in any airplane's conversion syllabus. It remains as one of those silent deadly gotchas. One cannot guarantee that you will remain clear of it; it's not like avoiding coffin corner. It's potentially there in any light-weight go-round. There are many pilots on this forum who will tell you that they have experienced it as an overpowering sensation. Many of them will have been high performance mil-jet operators, but some will not. It even happens very regularly to sailplane pilots on winch and auto-tow launches. Derek Piggott wrote a book about it about 20 years ago.... after a series of unexplained UK glider launch accidents in VMC.
But I reiterate that it is the most dangerous illusion because it normally affects both pilots at once (from a USN Study). That makes it deadly and derates much of what has been said about those latter failures of CRM in GF072.
Without that phenomenon the GF072 accident chain wouldn't have been complete.
Er, I think that's what I said. In fact I first said it about this accident two years ago... and if you go back to those old threads you will note that even a Chief Pilot piped up and said he'd never heard of it (the somatogravic illusion). In this respect it is an area (like hypoxia and altitude chamber training) where the old military hands have a distinct advantage in their background. Most Western Military pilots still undergo AVMED Refresher Lectures every few years .... including a very real hypoxia experience and disorientation training in a spin-chair or centrifuge.
The point that I was making is that until it happens to you, you tend to treat it as a bit of mythology (a bit like retreating blade stall, dynamic rollover and vortex ring for the rotary brethren). You cannot have a somatogravic illusion ("pitch-up") experience in a simulator and I'm quite sure that you won't have it in any airplane's conversion syllabus. It remains as one of those silent deadly gotchas. One cannot guarantee that you will remain clear of it; it's not like avoiding coffin corner. It's potentially there in any light-weight go-round. There are many pilots on this forum who will tell you that they have experienced it as an overpowering sensation. Many of them will have been high performance mil-jet operators, but some will not. It even happens very regularly to sailplane pilots on winch and auto-tow launches. Derek Piggott wrote a book about it about 20 years ago.... after a series of unexplained UK glider launch accidents in VMC.
But I reiterate that it is the most dangerous illusion because it normally affects both pilots at once (from a USN Study). That makes it deadly and derates much of what has been said about those latter failures of CRM in GF072.
Without that phenomenon the GF072 accident chain wouldn't have been complete.
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Belgique
I am not talking about disorientation, I am saying that some facts (see the DFDR readouts) may lead to consider the possibility of an aircraft malfunction, a lack of proper response to the out of doubt energic nose up PIC command after the GPWS warning.
It's probably a safe bet that neither pilot was proficient at hand flying raw data. The gyrations described are very similar to what I have witnessed in the simulator when pilots have experienced a situation where a quick disconnect of the automatics and hand-fly would have saved the day. Unless they retain currency on raw data flying (which few do) they are all over the sky - especially IMC or at night.
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That is exactly the reason why a skill test is now obligatory once a year during an Jar checkride....
More and more companies are allowing their pilots to fly raw data when the conditions permit to do so. This is a very good evolution....
More and more companies are allowing their pilots to fly raw data when the conditions permit to do so. This is a very good evolution....
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What's all this nonsense about raw data hand flying, if the automatics were engaged then this would not have happened, they don't get disorientated, fight amongst themselves or get into p.i.o. It was the pilots playing 'pilots' that caused this accident, much safer to 'operate' the airoplane.
Scanscan scan, i'd stick to flightsim if I were you.
Scanscan scan, i'd stick to flightsim if I were you.
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Okay, you have got a point......BUT
I have been flying the A320 for three years now within an airline environment . So I have done quit a few Go Arounds in this airplane and I have to say that very little of those where executed using the AP......
Why? My guess is that pilots still feel more at ease taking controlls themselves. In those situations it is easier to do so because the use of the automatics in those situations can be really confusing. Besides that a G/A does not always require the TOGA thrust/follow procedure things programmed in the FMA. A lot of times the controllers give you an ammended procedure with an altered height to level off which makes the automatics way more difficult to use.
A third tought is that Airbus itself is still advising pilots that if they should get lost in the automatics they should disconnect everything and fly raw data!
So your comment about using automatics is very correct indeed but only in an ideal standardisized world....which does not exist.
It is my firm belief that everybody who flies an airlinere should be able to perform every manoever/procedure that exists 100%perfectly flying raw data as well as using automatics!!!!
Any pilot who is not able doing so, being that because a of lack of training or lack of skills, should not be allowed to fly these airplanes!!!!
I have been flying the A320 for three years now within an airline environment . So I have done quit a few Go Arounds in this airplane and I have to say that very little of those where executed using the AP......
Why? My guess is that pilots still feel more at ease taking controlls themselves. In those situations it is easier to do so because the use of the automatics in those situations can be really confusing. Besides that a G/A does not always require the TOGA thrust/follow procedure things programmed in the FMA. A lot of times the controllers give you an ammended procedure with an altered height to level off which makes the automatics way more difficult to use.
A third tought is that Airbus itself is still advising pilots that if they should get lost in the automatics they should disconnect everything and fly raw data!
So your comment about using automatics is very correct indeed but only in an ideal standardisized world....which does not exist.
It is my firm belief that everybody who flies an airlinere should be able to perform every manoever/procedure that exists 100%perfectly flying raw data as well as using automatics!!!!
Any pilot who is not able doing so, being that because a of lack of training or lack of skills, should not be allowed to fly these airplanes!!!!
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The use of the automatics should obviously be encouraged to "off load" pilot workload.
The problem arises where the flight crew don't understand what the automatics are doing. This creates unintended confusion particularly in critical flight phases. Coupled, perhaps, with crews who may be fatigued, or who are new on type, this can develop rapidly into an undesirable situation.
For this reason, the all engine go around manoeuver must be practiced regularly in BOTH manual and automatic modes up to a SAFE altitude. It must be second nature to pilots.
Unfortunately, we just do not seem to practice this enough.
The problem arises where the flight crew don't understand what the automatics are doing. This creates unintended confusion particularly in critical flight phases. Coupled, perhaps, with crews who may be fatigued, or who are new on type, this can develop rapidly into an undesirable situation.
For this reason, the all engine go around manoeuver must be practiced regularly in BOTH manual and automatic modes up to a SAFE altitude. It must be second nature to pilots.
Unfortunately, we just do not seem to practice this enough.
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Airbus automatics and configuration details aside, it seems to me that the critical bad decision came about when the GF crew realized their original approach was not going to work. At that point they knew (because it was obvious) they were behind the aircraft, and yet they still had all the good options wide open ahead.
Even with the motive to avoid having an official 'missed approach' on the record, the decision to do a tight 360 close to the ground in pitch darkness seems unsupportable. As long as one is playing fantasy - land with the nomenclature, why not climb a few thousand feet and standardize the turn so there's time and room to improve the layup - or better yet, fly the MA Procedure anyway, to the letter, and just call it 'manoeuvering'?
In a more perfect world, the crew observation that Plan A had not worked should have inspired some moments of introspection and then a change to MORE conservative plan B requiring less artful manoeuvering and simpler procedure, rather than the increasingly nonstandard and uncontrolled flying that ensued.
When you abandon SOP, decisionmaking becomes a philosphical thing. At such times, one had better have the right philosophy.
Even with the motive to avoid having an official 'missed approach' on the record, the decision to do a tight 360 close to the ground in pitch darkness seems unsupportable. As long as one is playing fantasy - land with the nomenclature, why not climb a few thousand feet and standardize the turn so there's time and room to improve the layup - or better yet, fly the MA Procedure anyway, to the letter, and just call it 'manoeuvering'?
In a more perfect world, the crew observation that Plan A had not worked should have inspired some moments of introspection and then a change to MORE conservative plan B requiring less artful manoeuvering and simpler procedure, rather than the increasingly nonstandard and uncontrolled flying that ensued.
When you abandon SOP, decisionmaking becomes a philosphical thing. At such times, one had better have the right philosophy.