Eventually !!Probe Blames Captain for GF Jet Crash

[gulf_slf]

See original thread on GF 072 Crash below for new story .......

Sorry for the text being intertwined...see
http://www.gulf-daily-news.com/Artic...=27765&Sn=BNEW
http://www.gulf-daily-news.com/Artic...=27767&Sn=BNEW
for the news stories

[gulf_slf]

GDN 16/07/02 Report

The probe seems to confirm the speculation and assumption made for the past two years........Sad days ...but hopefully GF can now focus on improving standards all round and become an airline of note once more......

FINAL
TRAGICMOMENTSOFFLIGHTGFREVEALED... MANAMA

TheGulfAirdisasterwascausedbyadeadlycombinationoffactors,are portdeclaredyesterday.

"Theinvestigationshowedthatnosinglefactorwasresponsibleforth eGFaccident,"itsays.

Theplane,enroutefromCairo,smashedintotheseajustoffMuharraq ataround.pmonAugust,,killingallpeopleonboard.

Inthefinalsecondsoftheflight,BahrainipilotIhsanShakeebwas soconfusedhepitchedtheplaneintothesea,saysthefinalcrashrepor t, releasedbytheAccidentInvestigationBoard.

CaptainShakeebmayhavethoughttheplanewaspitchingupwheninfacti twaspitchingdown.

Heincreasedspeedandthrusttheplaneintoadiveforseconds,before tryingtopullup,butitwastoolate,saysthedamningreport.

CaptShakeeb,agedandhis-year-oldOmanico-pilotFirstOfficer KhalafAlAlawi,mayhavebeenspatiallydisorientatedastheyperform ed atightorbitafterafailedattempttolandatBahrainInternationalAi rport, saysthereport.

Theyignoredrepeatedcomputervoicewarningsto"pullup,pullup", inatragiccatalogueofsafetyviolationsandmistakes,itsays.

ItcitesfatalflawsinGulfAir'sorganisational,managementandtrai ning systems,leadinguptotheaccident,combinedwithhumanerroronthefl ight deck.

GulfAirfailedtorespondtosafetywarningsissuedbyitsregulatoryb ody,ortoattendinternationalsafetymeetings.

Italsofailedtoprovideadequatetraininginemergencyproceduresan d toproperlystaffitsflightsafetydepartment,saysthereport.

"Theaccidentwastheresultofafatalcombinationofmanycontributor yfactors,bothattheindividualandsystemiclevels.

"Allofthesefactorsmustbeaddressedtopreventsuchanaccidenthapp eningagain."

[Kubota]

maybeyoushouldtryandproofreadbeforecuttingandpastinganarticl eliketheoneabove.

(Maybe you should try and proofread before cutting and pasting an article like the one above.)

[PPRuNe Pop]

It would nice if you would re-post and make into some kind of English. Spacing would be a help!

On second thoughts I have done it myself

The Gulf Air disaster was caused by a deadly combination of factors, 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."

[Low-Pass]

So BOTH pilots were disorientated? Rather unfortunate for all concerned, n'est pas?

[Desertia]

Ooops

I should have said "passengers' relatives" of course, lest you all think there is some hideous conspiracy theory here, or possible something even more Machiavellian!

[Desertia]

More GDN Background

A SERIES of fatal flaws that led to the Gulf Air disaster had been ignored for years, says a final report on the tragedy.

The airline failed to respond to safety warnings issued by its regulatory body, to attend international safety meetings, to provide adequate training in emergency procedures and to staff its flight safety department properly, says the final report by the Accident Investigation Board.

"The investigation showed that all of the latent organisational and management conditions that precipitated the accident to GF072 were present long before the accident," states the report.

"They had been identified and should have been rectified long before it happened.

"If these deficiencies had not been rectified, similar accidents could occur again, for the same underlying systemic reasons."

The agency responsible for the overseeing flight operations, the Directorate General of Civil Aviation and Meteorology (DGCAM), Oman, had repeatedly warned Gulf Air about its lack of compliance with Civil Aviation Regulations (CARs), according to the report.

During the three years preceding the accident, the DGCAM "could not achieve compliance by Gulf Air with respect to some critical regulatory requirements."

This was due to "inadequate supervisory oversight within Gulf Air, rather than a deliberate disregard for the regulations", said the report.

It said the airline did not emphasise Ground Proximity Warning System (GPWS) training, which would have trained Captain Ihsan Shakeeb to respond instantly to the warning that he was about to crash into the sea.

This is despite the fact that such training was originally introduced in the industry as defence against such Controlled Flight into Terrain (CFIT) accidents, which still account for the greatest number of airline fatalities each year, according to the report.

Gulf Air's flight data analysis system was not "functioning satisfactorily" at the time of the accident and this could have warned them that some flight crew were not complying with Standard Operating Procedures (SOPs), said the report.

The airline could then have taken action to ensure that SOPs were followed.

If Capt Shakeeb had complied with these procedures the accident would not have happened, noted the report.

Crew Resource Management (CRM) training, which was implemented at other airlines to increase safety, was apparently stopped in 1996 or 1997, when there was a change of management said the report.

"One of the goals of CRM training is to provide crew members with the tools to foster co-operative collaborative teamwork and overcome counterproductive styles of leadership and group interaction," noted the report.

"Such tools include assertiveness training for First Officers and participative management training for captains.

"The evidence shows that CRM in the cockpit of GF072 was ineffective, and that this contributed to the non-adherence to SOPs by the flight crew, which initiated the sequence of events that led to the loss of the aircraft."

Capt Shakeeb was found to be taking the lead in the cockpit at the time of the crash, while his co-pilot did not raise any alarms, perhaps because he was intimidated.

"At the time of the accident there was no formal CRM training programme within Gulf Air. The accident was consistent with that organisational deficiency," added the report.

"The value of CRM training to operational safety should and could, have been recognised by the company a long time ago."

The airline also failed to provide adequate CFIT training.

Gulf Air had a one-man safety department from 1998 to the time of the accident.

"This lack of resources within the flight safety department and its inappropriate corporate status within the company was a serious deficiency," said the report.

The airline had stopped taking part in the International Air Transport Association (IATA) Safety Committee meeting years before the crash, it added.

"This greatly restricted the airline's awareness of new information and developments in areas such as accident investigation studies, safety and risk management programmes, training, safety information systems and safety management programmes."

It has now resumed its participation in the meetings.

[Desertia]

Yet more GDN Background

This pretty well covers everything, even if it is a long read. The interesting point to me is that the DGCAM had absolutely no power to enforce regulatory compliance. How useless are they?:

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.

[ironbutt57]

GF has lots of problms true, but it is far from a crap airline, and many good folks work there, so lets hope the new leaders are ALLOWED to **** in anybody's cheerios they need do, to fix it...will be interesting

[126.9]

Opinionated

Desertia Your views are that strong huh? Perhaps you should ask for a password protected, private forum of your own? That way the rest of us won't get so bored with your bullsh!t!

[sweeper]

to desertia

pompous style...
however my lot have used this accident to re inforce most of what you are saying...
if SOP,s break down, and the break down is not due to bad SOP,s
you get errors,like not following TCAS over germany/swiss airspace.
you are right..don,t lecture ,help[

[Desertia]

Dutch Elm disease at Gulf Air

I don't apologise for upsetting "126.9" or anyone like him, who prefers to stick his head up his arse and puff and bluster in the face of criticism, instead of accepting and addressing the huge flaws that lead the to deaths of these people, including friends of mine.
Here's hoping the down-to-earth Aussie approach satisfies the owners and at the same time clears out the dead wood!
Desertia

[autoflight]

My friend, Jim Dunn, died because airlines in the ME grill the captain if he makes a missed approach. Pax feel badly treated & write letters. Airlines do not make the effort to explain that its a normal & safe procedure. The [usually] simple solution is to make an orbit on final. Officially, not a missed approach. Thus no explaination required! Its all a half baked idea to save face. Well now there is some explaining to do. Let us not think for a moment that this is the only half baked idea residing in the heads of people who think such considerations are worthwhile. No wonder they need a few aussies, brits, SA etc to help them dilute the harmful influences of their own kind.

[ironbutt57]

An orbit at night, on a dark night flying from a lighted area to a dark area, is not an adviseable maneuver, as is evident by the very large altitude variations that occurred during the first orbit, spatial disorientation was present then as well, as was a loss of situational awareness, as is evidenced by the subsequent overshoot of the runway extended centerline, thus requiring the fateful go-around, which again was not flown to SOP's. daylight clear conditions are entirely another matter, as visual references would have been sufficient to preclude the onset of vertigo. In any case, it is clear that training crews to avoid these conditions that lead to spatial disorientation needs to be emphasised, no experience level can preclude the onset of spatial disorientation, it can and does happen to pilots of all experience levels, however, a more experienced pilot is more likely to realize the potential for this problem, and adhere strictly to standard operating procedures, and carry out a proper go-around...training...training...training...is the key. Let's all hope GF has risen to the occasion, and remedied the problem. I still fly as a pax with them, as does my family, and will continue to do so...but this accident was clearly a "private-pilot" type accident.

[Desertia]

"Private Pilot" type accident

It may appear to be a "private pilot" type accident, but unfortunately the opportunity for something like this to happen has been created by the environment, and from the many GF air crew and cabin crew I know, the only surprise is that it didn't happen earlier.
Of course GF would have you believe that passenger safety is uppermost in their mind, whereas in reality for several years now it's been about trying to survive on budgets slashed to pieces by people with their hands in the corporate pocket, placed there by their uncles/friends/other people in high places!
Many ex-GF'ers I know here point to the number of ex GF expat staff in management positions in Emirates to show what GF could have been now if it hadn't been ravaged over the years and turned into a local YOPS scheme.
But I work for the government and it's the same story there, too.
Conclusion: Jobs for the boys and passenger safety do not go hand in hand.
Cheers,
Desertia

[SLF3]

In the immediate aftermath of this accident many contributors to PPrune said the enquiry would be a whitewash and would exonerate Gulf Nationals.

Later, many said the report was delayed so that the appropriate number of coats of whitewash could be applied.

Perhaps a special thread is required so that those who made comments along these lines can tender their apologies?

[Desertia]

Spreading the blame

Interesting comments there. With Airbus obviously unwilling to take the blame, they really couldn't just turn round and say the pilot was a cowboy, because if he was, who let him fly?
The report, which is extensive, spreads the blame across a wide area, and I don't think it's a coincidence that senior management have been replaced in most if not all areas prior to it being released. After all, what better direction to point fingers than at the people you've just got rid of?
It's also interesting to note that there has been hardly a mention of this in the world's press, which is exactly what GF would prefer. And I don't think the way the report is constructed and the way it expertly obfuscates the key flaw - nationals being promoted too quickly - is any accident either.
Whitewash, maybe not. Quick lick of paint, most definitely

[ironbutt57]

bodstrup......yes it would have...hindsight is 20-20, but as you mentioned, you have to be aware of the potential problem to avoid it....it obviously was not emphasised enough at somepoint in his past training either at GF, or where he did his initial training.....

[Rananim]

I see the poor first officer had never flown anything other than the A320,and that the Captain started life as a F/E.Dangerous combination.It worries me that 200 hour pilots should go straight into an Airbus 320;where do they get the chance to build the basic flying skills?Perhaps if he'd done a bit of time on a proper aircraft,he would have known which way was up and which way down.As for the skipper,he had flown the 767(a fine a/c) and the L1011 but his first command was the 320.Add to this he only had 100 hours as 320 skipper.And there you have the reason for this crash.How were these two pilots allowed to operate together?This Captain needed a high-time First Officer who had good flying skills(2 years on a 767) but who was also experienced on the computerized Eurobus.

[Captain Sensible]

He "started" as a Ground Engineer in the hangar. He didn't "fly" the Tristar; he was a Flight engineer on it. But his "F/E" time was counted towards his Command flying time.