Gulf Air A320 Accident - Case Study Example

Gulf Air A320 Accident, August 23, 2000 Air travel is considered as one of the safest means of transport in the world. This of affairs has beenthe case considering the contributions that have arisen from developments in technology, standards, maintenance, education and operational procedures in the aviation industry. In spite of the relative safety and worth of the industry, human error is believed to cause about 70 percent of all accidents in the world’s aviation industry (Bagshaw, 2002). In order to reduce the accidents caused by human error, it is important to understand both the psychological and physical human limitations and capabilities of human beings. This paper will analyze the Gulf Air A320 accident of august 23rd, 2000 with a focus on human factors and error. I. Possible Factors Contributing To the Accident A. Age, Experience, Personality, Health of the Crew The leading to the accident were found to be as a result of systematic and individual issues (Civil Aviation Affairs Report, 2001). The captain was said not to have adhered to the standard operating procedures. The first officer failed to draw the captain’s attention to the aircraft’s deviation from the set parameters and profile. The 37-year old Captain Ihsan Shakeeb and had a lot of experience as a pilot. He had logged 4,416 hours of pilot time and a further 2, 402 hours as flight engineer. His co-workers described his personality as being “responsible, knowledgeable and open to suggestions, happy, very helpful, professional and sharp” (Civil Aviation Affairs Report, 2001, 11). His age and vast experience may have contributed to his over-confidence which led to fatal errors. The captain had also failed his captain upgrade check ride. It is therefore possible his errors were due to lack of competence. It seems that the captain had an overbearing personality since no one was bold enough to question some of the faulty decisions that he made during the flight. The first officer, though disciplined, was very shy and reserved. He could not confront the captain when it was clear that he was making the wrong choices. The first officer, who had been upgraded to that position just four months prior to the accident, may have lacked the experience needed to deal with emergency situations. He had logged only 608 hours (Sparaco and Dornheim). B. Fatigue, Body Rhythms or Other Physiological Factors Fatigue is another factor that may have played a role in the accident. According to the captain’s duty logs, he had not worked for 24 hours prior to the flight take off. However, for the previous 7 days, he had logged a duty time of 24 hours and 35 minutes. He was on flight duty for 17 hours and 5 minutes. Since he had been on leave before this flight, he might not have been ready to take on this flight after having worked for 24 hours before that. However, none of the flight crew’s activities, mannerisms or conversations showed any weariness. The captain appeared to have been fully alert throughout the journey. The captain and the crew might also have experienced 12 degrees pitch up which prompted the captain to apply a forward side-stick input, which in turn made the aircraft to pitch down at the maximum angle of 15 degrees (Civil Aviation Affairs Report, 2001, 76). C. Single Channel Processing, Cognition Single channel processing and cognition (Brooks, nd) might have directly or indirectly contributed to the aircraft accident. Some of the people who had served as the captain’s first officers have said that he was sometimes overbearing. The first officer in this case was a shy 25 year old, who might have found it difficult to offer his thoughts on some of the manoeuvres that the captain was making. This means that the entire decision making was left to the captain, who went ahead and made several errors which might have been avoided had there been some dialogue between the two. Single channel processing may have been the cause of the faulty decisions made by the captain. It may be possible that due to information overload in the cockpit, the captain did not hear what the first officer said or did not see the warning signs on the control board. This might have led to him choosing to make some dangerous manoeuvres even though they were not necessary at that point. Since there is no proof that the captain and his crew members were fatigued before or during the flight, there is only one explanation for the single channel processing in the cockpit – stress and anxiety (Brooks, nd). D. Weather The accident occurred about one hour after sunset. The engulfing darkness may have contributed to the misperception of the pilot of the plane’s pitch orientation. The darkness could also have contributed to somatogravic illusion which made the crew members to perceive a false sense of pitching up. This could have made the captain to make a nose-down input which made the aircraft to descend into the water at 280 kt. Since it was dark, it was also possible for the captain and other crew members not to see how close to the ground the plane was when making the nose-down input. However, according to the Accident Investigation Report, the weather was an unlikely contributory factor to the accident (Civil Aviation Affairs Report, 2001, 101). There was a visibility of about 10 km and there were no signs of clouds below 1500m. The speed of the easterly surface wind was 8 knots (Civil Aviation Affairs Report, 2001). E. Spatial or other Disorientation According to information retrieved from the flight’s data recorder, it is possible that crew members had suffered from spatial disorientation before the fatal crush. Since there were a number of standard operating procedures violated by the captain, all the flight crew members could have been in a situation of spatial disorientation (Whitaker and Dawoud, 2000). The captain was relying heavily on external visual cues and seemed to pay little or no attention to the information on the display instruments. However, the visual cues were not sufficient enough and this may have led the captain to experience a false perception of the plane’s altitude. The end result was spatial disorientation. According to the flight path study, the captain lost all visual cues at around 1929:41. He then made a nose-down side-stick at 1929:43 at which point there was complete darkness around the aircraft. This condition may have created a somatogravic illusion which may explain why the captain did not act on the information on the display instruments showing that the plane was descending at a fast rate. He may not have been consciously perceiving this information as he was busy dealing with the flap over speed warning (Whitaker and Dawoud, 2000). F. Any other Considerations The captain may have been experiencing information overload moments before the accident occurred. Considering the circumstances inside the cockpit a well as the captain’s actions, it is possible that the captain was having difficulties processing all the information bombarding from all directions. Due to this information overload, the captain may have responded using omission, error, approximation or filtering (Sparaco and Dornheim, 2002). If he responded through omission, it means that he chose to ignore some important signals. If he responded using the error kin of response, he might have processed the information he had incorrectly. On the other hand, if he responded in a filtering manner, then he systematically omitted some categories of information. If he used approximation, then he made the wrong decisions which led to the accident. The circumstances in the cockpit may have increased the captain’s anxiety levels, leading to several errors that might have been avoided had the situation been calmer. Conclusion The workload in the cockpit also became unmanageable at a certain point when the captain was trying to make some “unplanned and unpractised manoeuvres” at dangerous altitudes with poor visuals (Civil Aviation Affairs Report, 2001). All this contributed to the captain’s and first officer’s work overload as they tried to take control of the aircraft. This added to the stressful situation in the cockpit which caused the captain not to act on the warning signs on the display instruments. References Brooks, C, J, nd, Knowledge of Human Behaviour Under Stress and Sleep Deprivation will Enable you to Prevent Accidents and Death. Accessed 12 October 2010, http://ftp.rta.nato.int/public//PubFullText/RTO/AG/RTO-AG-HFM-152///AG-HFM-152-06.pdf Civil Aviation Affairs, 2001, Accident Investigation Report: Gulf Air Flight GF-072, Accessed 12 October 2010, http://www.bea.aero/docspa/2000/a40-ek000823a/htm/a40-ek000823a.html Sparaco, P and Dornheim, M, 2002, Gulf Air Crash Probe Spotlights Disorientation, Training Issues, Aviation Week. Accessed 12 October 2010, http://www.iasa.com.au/folders/Safety_Issues/others/GF072Final.html Whitaker, B and Dawoud, K, 2000, Faulty Landing Gear Blamed for Crash, The Guardian. Manchester. Read More