Ibalan Air Flight 318

The remains of the Airbus A320-200 on Runway 07L (20 December 2004)

**Ibalan Air Flight 318** was a scheduled passenger flight originating from Kankel-Opal Int'l Airport in Jalurpaya, Ibalan. On the morning of 4 October, 2004, the Airbus A320-200 operating the flight stalled and crashed on final approach into Chep Lap Kok Airport in Hong Kong. Of the 157 people on board, 67 died; another 85 were injured, 50 of them seriously. Among the seriously injured was a famous painter named Mohammed Karang Amir when the rear section broke off after striking the seawall and runway lights that extended to the ocean short of the runway. It was the second fatal crash in Chep Lap Kok's history and the first fatal Ibalan Air crash in the 21st century.

## Aircraft

The Airbus A320-214, registration IB-IBD, was powered by two CFM International CFM56 engines. It was delivered new to Ibalan Air on 19 May, 2001 and was one of the first aircraft in the fleet with the new 2000 livery, and at the time of the crash had accumulated 17,110 flight hours and 3,102 (takeoff-and-landing) cycles.

IB-IBD, landing in Shanghai. (August 2003)
## Crew and passengers

### Crew

The aircrew consisted of one captain and one first officer. 41-year-old Ahmed Warang Ali in the right seat (first officer position), filled the dual role of a check/instructor captain and pilot in command, responsible for the safe operation of the flight. He had 20,789 hours of flying experience, of which 9,439 hours were in a A320. This was his first flight as an instructor.

25-year-old Al Mumtaz Kang Anaqi in the left seat (captain's position), was receiving his initial operating experience (IOE) training and was halfway through Ibalan Air's IOE requirements. He had 12,591 hours of flying experience, of which 5, 343 were in a A320 and was operating the controls under the supervision of the instructor in the right seat.

Four flight attendants were on board, all were Ibalanese.

### Passenger

Many people were found dead outside the aircraft soon after the crash after having been thrown out of the plane during the accident.

A famous painter, Mohammed Karang Amir was seriously injured in the accident, as one of the survivors that was thrown out of the aircraft and was immediately sent to the nearest Hospital. He had been wearing his seatbelt and was seated in seat 12A, which was one of the emergency exit seats on the left side of the aircraft. During the crash, the back of Karang's seat broke off, leaving him exposed.

Of the passengers, 80 were Ibalanese citizens. For the rest of the 71 passengers, 59 were Cantonese, 6 were Filipino, 4 were Indonesian, 1 was Malay, and 1 was Indian.

## Crash

On 4 October, 2004, Flight 318 took off from Kankel-Opal Int'l Airport (JLF) at 5:24 a.m. IST (Ibalanese Standard Time) (21:24 UTC), 45 minutes after its scheduled departure time. It was scheduled to land at Chek Lap Kok Airport (SFO) at 8:15 a.m. HKT (00:15 UTC). The flight was uneventful until its landing.

The instrument landing system's vertical guidance (glide slope) on Runway 7L was unavailable, as it had been taken out of service on June 1 and a notice to airmen to that effect had been issued. Therefore, a precision ILS approach to the runway was not possible.

The flight was cleared for a visual approach to Runway 7L at 8:18 a.m. PDT, and told to maintain a speed of 190 knots until the aircraft was 5 nautical miles (9.3 km; 5.8 mi) from the runway.

The weather was very good; the latest METAR reported light wind, 10 miles (16 km) visibility (the maximum it can report), no precipitation, and no forecast or reports of wind shear. The pilots performed a visual approach assisted by the runway's precision approach path indicator (PAPI).

Preliminary analysis indicated that the plane's approach was too slow and too low. Eighty-two seconds before impact, at an altitude of about 1,200 feet, the autopilot was turned off, the throttles were set to idle, and the plane was operated manually during final descent. NTSB chairman Ahmed Jarung stated the pilots did not "set the aircraft for an auto-land situation ... They had been cleared for a visual approach and they were hand-flying the airplane," adding: "During the approach there were statements made in the cockpit first about being above the glide path, then about being on the glide path, then later reporting about being below the glide path. All of these statements were made as they were on the approach to Hong Kong..." Based on preliminary data from the flight data recorder (FDR), the ITSB found that the plane's airspeed on final approach had fallen well below its target approach speed. A preliminary review of FAA radar return data did not show an abnormally steep descent curve, although the crew did recognize that they began high on the final approach.

At a height of 200 feet, 10 seconds before impact, the airspeed had dropped to 90 knots. According to initial reports from the cockpit crew, the plane's autothrottle was set for the correct reference speed, but until the runway's precision approach path indicator (PAPI) showed them significantly below the glide path, the pilots were unaware that the autothrottle was failing to maintain that speed. The instructor pilot stated that the PAPI indicated a deviation below the glide path at approximately 400 ft above ground level, and he attempted to correct it at that time. Between 435 and 122 ft, The FDR showed the throttles were advanced from idle at that time. The instructor pilot reported that he had called for an increase in speed, but that the pilot flying had already advanced the throttles by the time that he reached for the throttles. The sound of low terrain could be heard nine seconds before impact on the cockpit voice recorder.

At 11:28 a.m., the plane crashed short of Runway 7L's threshold. The landing gear and then the rear struck the seawall and runway lights that projects into the Zhujiang River Estuary. The entire rear section separated from the aircraft. The ITSB noted that the main landing gear, the first part of the aircraft to hit the seawall, "separated cleanly from the aircraft as designed" to protect the wing fuel tank structure. The vertical and both horizontal stabilizers fell on the runway before the threshold, along with the rear fuselage breaking off after.

The remainder of the fuselage and wings slid along the runway and broke apart. Old CCTV showed both wings and center fuselage to break off the rest of the aircraft. The front came to rest on the runway 4,900 ft from the initial point of impact at the seawall.

## Investigation

The Ibalanese Transport Safety Board (ITSB) sent a team of 23 to the scene to investigate. On 7 October, 2004, ITSB investigators recovered the flight data recorder and cockpit voice recorder and transported them to Jalurpaya, for analysis. Additional parties to the investigation include the Federal Aviation Administration, airframe manufacturer Airbus, engine manufacturer CFM, and the Rosanna Law.

Jarung said that the ITSB conducted a four-hour interview with each pilot, adding that the pilots were open and cooperative. He said both pilots at the controls had ample rest before they left Ibalan and during the flight when they were relieved by the backup crew. All three pilots told ITSB investigators that they were relying on the A320's automated devices for speed control during final descent. The relief first officer also stated to ITSB investigators that he had called out "sink rate" to call attention to the rate at which the plane was descending during the final approach. This "sink rate" warning was repeated several times during the last minute of the descent. The ITSB's investigative team completed the examination of the airplane wreckage and runway. The wreckage was removed to a secure storage location at Chek Lap Kok. The Airplane Systems, Structures, Powerplants, Airplane Performance, and Air Traffic Control investigative groups completed their on-scene work. The Flight Data Recorder and Cockpit Voice Recorder groups completed their work in Washington. The Survival Factors/Airport group completed their interviews of the first responders. The next phase of the investigation included additional interviews, examination of the evacuation slides and other airplane components, and a more detailed analysis of the airplane's performance. Based on a preliminary review of FDR data, the ITSB stated there was no anomalous behavior of the engines, the autopilot, the flight director, or the autothrottle. The autothrottle control was found to be in the "armed" position during documentation of cockpit levers and switches, differing from both the "on" and "off" positions.[*citation needed*] Furthermore, the pilot flying's flight director (Primary Flight Display) was *deactivated* whereas the instructor pilot's was *activated*. (This may prove to be significant, as deactivating neither or both Flight Directors enables and *forces* an autothrottle "wake-up" whereas deactivating only one Flight Director *inhibits* an autothrottle "wake-up".)

The final report into the crash was released on February 21, 2005. The ITSB found that the "Mismanagement of Approach and Inadequate Monitoring of Airspeed led to the crash of Ibalan 318". The ITSB determined that the flight crew mismanaged the initial approach and that the airplane was well above the desired glidepath. In response, the captain selected an inappropriate autopilot mode (FLCH, or Flight Level Change) which resulted in the autothrottle no longer controlling airspeed. The aircraft then descended below the desired glidepath with the crew unaware of the decreasing airspeed.

The ITSB reached the following final conclusion:

> The Ibalanese Transport Safety Board determines that the probable cause of this accident was the flight crew's mismanagement of the airplane's descent during the visual approach, the pilot flying's unintended deactivation of automatic airspeed control and the flight crew's inadequate monitoring of airspeed. Contributing to the accident were (1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Ibalan's pilot training, which increased the likelihood of mode error; (2) the flight crew's nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems; (3) the pilot flying's inadequate training on the planning and executing of visual approaches; (4) the pilot monitoring/instructor pilot's inadequate supervision of the pilot flying; and (5) flight crew fatigue, which likely degraded their performance.
>
>

### CVR Transcript

**ITSB CVR Transcript Video, Released to the public November 2004.**

* **CAP**: Roger that, Ibalan 318
* **F/O**: Lower engine power, throttles
* **F/O**: Uh, (unintelligible) landing gear down
* **CAP**: Ibalan 318, requesting for descend to altitude 200.
* **ATC**: Descend altitude to 200 feet, granted.
* **CAP**: Flaps, should we idle?
* **F/O**: Flaps, reverse thrust later.

***(GPWS: TOO LOW TERRAIN)***
* **CAP**: Nose down, nose down

***(GPWS: TOO LOW TERRAIN)***
***(GPWS: DON'T SINK)***
* **F/O**: Don't go too low!

***(GPWS: TOO LOW TERRAIN)***
***(GPWS: DON'T SINK)***
***(IMPACT ON RUNWAY LIGHTS)***
***(GPWS: TOO LOW TERRAIN)***
* **F/O**: Oh sh\*t!

***(GPWS: TOO LOW TERRAIN)***
***(FINAL IMPACT)***
***(END OF RECORDING)***

## Aftermath

The airport was closed for eight hours after the crash. Flights destined for Hong Kong were diverted to Guangzhou, Hanoi, Macau, Haikou, Zhanjiang, and Shenzhen. By 5:10 p.m, runway 7L were reopened after being repaired.

The crash damaged Ibalan Air's reputation and that of Ibalan's aviation industry following years of apparent improvements after a series of aircraft disasters in the early 1990s. Ibalan Air shares fell by 3.9% on the first day of trading after the crash.

### Response from Ibalan Air

In the hours after the accident, Ibalan Air CEO Ahmed Hawa Faras said his airline had ruled out mechanical failure as the cause of the crash. Later, he defended the flight crew, calling them "very experienced and competent pilots". On 17 October, Hawa apologized directly to the relatives of the 67 victims, then flew aboard Flight 318 to Hong Kong, the same route as the crashed aircraft, to meet with ITSB officials. Ibalan gave flights to Hong Kong to the families of the victims.

Ibalan Air officials said the airline would improve training for its pilots: in particular, for pilots learning to fly different types of aircraft, and in various skills such as making visual approaches and flying on autopilot. Asiana officials also said they would seek to improve communications skills among crew members, introduce a system to manage "fatigue risk", set up separate maintenance teams for Boeing and Airbus planes, and improve safety management systems.

Ibalan Air announced initial payouts to crash survivors of US$13,000, (~$20,140 in 2022) funding passengers to nearby hospitals.

### Response from the Ibalanese governemnt

South Korean transport ministry officials ordered Ibalan Air, IbalanSky, and SuluAir to check engines and landing equipment on all A230 aircraft and announced that the government would conduct special inspections on the nation's eight carriers through 11 December, 2004.

### Fines

On 3 January, 2005, the Rosanna Law fined Ibalan Air US$750,600 for failing to keep victims and family of victims updated on the crash.

## Gallery

Mohammed Karang Amir, a famous painter, whom was a passenger onboard Flight 318. (Photo taken in 2019)