Gulf Air Flight 072

Aircraft

Flight 073 was operated with a Airbus A320-212, serial number 481, registration A4O-EK. It was first flown on 16 May 1994, and was delivered new to Gulf Air on September 1994. The aircraft was powered by two CFM International CFM56-5A3 engines. It had accumulated more than 17,000 hours in 14,000 cycles before the crash. Its last maintenance was conducted on 17–18 August 2000. The aircraft was in compliance with all applicable airworthiness directives for the airframe and engines.

Passengers and crew

The aircraft was carrying 143 passengers, two pilots, and six cabin crew members from 17 countries, mostly from Egypt and Bahrain. One Egyptian was supposed to board the flight but did not because the immigration officials in Cairo found that his passport was not stamped with the necessary interior ministry permit for working abroad.

Crew

There were two pilots in the aircrew:

Passengers

Among the 135 passengers were 61 men, 37 women and 37 children (including eight infants). An additional set of remains was found to be a fetus that had been delivered during the impact, but this was not counted as a fatality in the final report.

Notable passengers

Accident

The A320 with 143 passengers and crew on board approached the landing at higher speeds than normal and carried out an unusual low altitude orbit in an attempt to correct the approach. The orbit was unsuccessful and a go around was attempted. While carrying out a turning climb, the aircraft entered a descent at 15 degrees nose down. The aircrew did not respond to repeated GPWS warnings and approximately one minute after starting the go-around the aircraft disappeared from radar screens. There were no survivors. There were 36 children on the aircraft. The accident investigation concluded that the primary cause of the crash was pilot error (including spatial disorientation), with a secondary factor being systemic organizational and oversight issues.

After the accident Hamad bin Issa al-Khalifa, the Emir of Bahrain, declared three days of national mourning.

Investigation

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.

1. The individual factors particularly during the approach and final phases of the flight were:
   1. The captain did not adhere to a number of SOPs, such as:
      1. significantly higher than standard aircraft speeds during the descent and the first approach
      2. not stabilising the approach on the correct approach path; performing an orbit, a non-standard maneuver, close to the runway at low altitude
      3. not performing the correct go-around procedure
      4. other related items
   2. In spite of a number of deviations from the standard flight parameters and profile, the first officer (PNF) did not call them out, or draw the attention of the captain to them, as required by SOPs.
   3. 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.
   4. 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:
   1. Organisational factors (Gulf Air):
      1. A lack of training in CRM contributing to the flight crew not performing as an effective team in operating the aircraft.
      2. Inadequacy in the airline's A320 training programmes, such as: adherence to SOPs, CFIT, and GPWS responses.
      3. The airline's flight data analysis system was not functioning satisfactorily, and the flight safety department had a number of deficiencies.
      4. 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.
   2. 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.

The chairperson of the accident investigation board adopted the report on 10 July 2002.

Aftermath

Gulf Air retired the Flight 072 (GF072) flight number and replaced it with Flight 070 (GF070) for inbound flights from Cairo to Bahrain.