Gulf Air Flight 072

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Gulf Air Flight 072
Airbus A320-212, Gulf Air AN0212197.jpg
A Gulf Air A320 similar to the aircraft involved in the crash
Accident
Date 23 August 2000 (2000-08-23)
Summary Controlled flight into terrain due to pilot error, spatial disorientation, somatogravic illusion
Site Persian Gulf, Bahrain
26°17′51″N 50°38′49″E / 26.297500°N 50.646944°E / 26.297500; 50.646944Coordinates: 26°17′51″N 50°38′49″E / 26.297500°N 50.646944°E / 26.297500; 50.646944[1]
Aircraft
Aircraft type Airbus A320-212
Operator Gulf Air
Registration A4O-EK
Flight origin Cairo International Airport, Cairo, Egypt
Destination Bahrain International Airport, Muharraq, Bahrain
Passengers 135
Crew 8
Fatalities 143

Gulf Air Flight 072 (GF072/GFA072)[a] was a scheduled international passenger flight from Cairo International Airport in Egypt to Bahrain International Airport in Bahrain, operated by Gulf Air. On 23 August 2000 at 19:30 Arabia Standard Time (UTC+3), the Airbus A320 serving the flight crashed minutes after executing a go-around upon failed attempt to land on Runway 12. The flight crew suffered from spatial disorientation during the go-around and crashed into the shallow waters of the Persian Gulf 5 km (3.1 mi) from the airport.[3] All 143 on board the aircraft were killed.

The crash of Flight 072 remains the deadliest aviation accident in Bahraini territory,[4] and was the deadliest accident involving an Airbus A320 at the time, which was later surpassed by TAM Airlines Flight 3054, which crashed on 17 July 2007 with 199 fatalities.[5]

The final report was issued on 15 August 2002,[6] concluded that the individual factors contributed to the accident was non adherence to a number of SOPs and loss of spatial and situational awareness by the aircraft crew during the approach and final phases of the flight. A number of systemic factors were also contributed to the accident, including deficiency in crew resource management training by Gulf Air and safety oversights by the Directorate General Of Civil Aviation and Meteorology of Oman.

Aircraft

Flight 072 was operated with an Airbus A320-212, serial number 481, registration A4O-EK. It was first flown on 16 May 1994, and was delivered new to Gulf Air in September 1994.[7] The aircraft was powered by two CFM International CFM56-5A3 engines.[8] It had accumulated more than 17,000 hours in 14,000 cycles before the crash.[4][9] 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.[10]

Passengers and crew

People on board by citizenship[11][12][13]
Nationality Passengers Crew Total
 Australia 1 0 1
 Bahrain 34 2 36
 Canada 1 0 1
 China 3 0 3
 Egypt 63 1 64
 India 0 1 1
 Kuwait 1 0 1
 Morocco 0 1 1
 Oman 1 1 2
 Palestine 9 0 9
 Philippines 0 1 1
 Poland 0 1 1
 Saudi Arabia 12 0 12
 South Korea 1 0 1
 Sudan 1 0 1
 United Arab Emirates 6 0 6
 United Kingdom 2 0 2
 United States 1 0 1
Total (17 nationalities) 135 8 143

The aircraft was carrying 143 passengers, two pilots, and six cabin crew members from 17 countries, mostly from Egypt and Bahrain.[3] 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.[14]

Crew

There were two pilots in the aircrew:[15]

  • The Bahraini pilot in command was 37-year-old Captain Ihsan Shakeeb.[16] He joined Gulf Air as a cadet pilot in 1979 and, after training he was promoted to First Officer of the Lockheed L-1011 in 1994, First Officer of the Boeing 767 in 1994, First Officer of the Airbus A320 in 1998 and to Captain of the Airbus A320 in 2000. Shakeeb had 4,416 hours of flying experience,[9] of which 86 were as captain.
  • The Omani co-pilot was 25-year-old Khalaf Al Alawi.[16] He joined Gulf Air as a cadet pilot in 1999 and promoted to First Officer of the Airbus A320 in 2000. Al Alawi had 608 hours of flying experience.[9]

Passengers

Among the 135 passengers were 61 men, 37 women and 37 children (including eight infants).[17] An additional set of remains was found to be a fetus that had been delivered during the impact,[18] but this was not counted as a fatality in the final report.

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.[19][20] 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[21] and approximately one minute after starting the go-around the aircraft disappeared from radar screens.[22] Seconds later, the aircraft crashed into the sea. There were no survivors. There were 36 children on board the aircraft.[23] 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.[24]

Group of U.S Navy assisting the salvage operations of Gulf Air Flight 072

After the accident Hamad bin Isa al-Khalifa, the Emir of Bahrain, declared three days of national mourning.[25]

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.[26] The investigation showed that during the go-around, as the captain was dealing with the flap over-speed situation, he applied a nose-down side-stick input, resulting in a nose-down pitch. 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. The aircraft descended and flew into the sea.[27]

Aftermath

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

See also

Notes

  1. ^ GF is the IATA designator and GFA is the ICAO airline designator.[2]

References

  1. ^ AIB Final Report – Section 1.12 – Page 34
  2. ^ "Gulf Air. Airline code, web site, phone, reviews and opinions". Airlines Inform. Retrieved 5 June 2016. 
  3. ^ a b "Bodies recovered from Gulf Air crash". BBC. 24 August 2000. Retrieved 7 June 2016. 
  4. ^ a b "ASN Aircraft accident Airbus A320-212 A4O-EK Bahrain International Airport (BAH)". Aviation Safety Network. Retrieved 5 July 2016. 
  5. ^ "23 August 2000 - Gulf Air 072". tailstrike. Retrieved 5 July 2016. 
  6. ^ "Pilot's family fight to clear his name". Gulf Daily News. 7 April 2015. Retrieved 5 July 2016. 
  7. ^ "Clue to Gulf Air crash". BBC News. BBC. 25 August 2000. Retrieved 25 May 2016. 
  8. ^ "Airbus's reliability record". BBC News. BBC. 24 August 2000. Retrieved 7 July 2016. 
  9. ^ a b c "Crash of an Airbus A320 in Bahrain: 143 killed | B3A Aircraft Accidents Archives". Bureau of Aircraft Accidents Archives. Retrieved 5 July 2016. 
  10. ^ AIB Final Report – Section 1.6 – Pages 15–16
  11. ^ Starr, Barbara; Masterman, Sue; Chang, Andrew (23 August 2000). "143 Bodies Recovered From Persian Gulf". ABC News. American Broadcasting Company. Retrieved 5 July 2016. 
  12. ^ "143 Passengers Killed in Gulf Air Plane Crash off Bahrain". Al Bawaba. 24 August 2000. Retrieved 5 July 2016. 
  13. ^ Menon, Kesava (24 August 2000). "Indian crew member among victims in Gulf Air crash". The Hindu. Retrieved 5 July 2016. 
  14. ^ "Relief amid Gulf crash tragedy". BBC News. BBC. 25 August 2000. Retrieved 5 July 2016. 
  15. ^ AIB Final Report – Section 1.5 – Pages 9–12
  16. ^ a b "One of Bahrain's biggest tragedies" (PDF). Gulf Daily News. 23 August 2010. Retrieved 5 July 2016. 
  17. ^ AIB Final Report – Section 1.6.8 – Page 26
  18. ^ AIB Final Report – Section 1.13 – Page 35
  19. ^ "Airbus A320 A40-EK accident record". Aviation Safety Network. ..significantly higher than standard aircraft speeds during the descent and the first approach... ...performing an orbit, a non-standard manoeuvre, close to the runway at low altitude".. 
  20. ^ Civil Aviation Authority of Bahrain. "ACCIDENT INVESTIGATION REPORT Gulf Air Flight GF-072". Archived from the original on 12 February 2004. 
  21. ^ Civil Aviation Authority of Bahrain. "ACCIDENT INVESTIGATION REPORT Gulf Air Flight GF-072" (PDF). Archived from the original (PDF) on 12 June 2004. 4b. The analysis of FDR and 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... 
  22. ^ Bureau Enquetes-Accidents. "Airbus A320 A4O-EK accident record – Graphic – A40-EK Flight Path derived from Lat and Long FDR Parameters". Aviation Safety Network. 
  23. ^ "pe_03.html." CBS News. Retrieved 9 June 2009.
  24. ^ "Airbus A320 A4O-EK accident record". Aviation Safety Network. 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. 
  25. ^ "Bodies recovered from Gulf Air crash." BBC. 24 August 2000. Retrieved 2 February 2009.
  26. ^ "Appendix A." Final Accident Report.
  27. ^ https://reports.aviation-safety.net/2000/20000823-0_A320_A4O-EK.pdf

External links

  • Accident Investigation ReportCivil Aviation Affairs – Hosted by the Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile (BEA)
    • Alternate URL for whole report: Accident Investigation Board (AIB) Final Report – Gulf Air Flight GF-072 Airbus A320-212, REG. A40-EK on 23 August 2000 at Bahrain
  • GULF AIR STATEMENT ON THE PUBLICATION OF THE ACCIDENT INVESTIGATION BOARD'S (AIB) FINAL REPORT INTO GF072 - Gulf Air - 15 July 2002
  • Cockpit Voice Recorder transcript and accident summary
  • Gulf Air statement on the publication of the accident (Archive) 15 July 2002.
  • Crash in the Gulf, CBS News
  • Accident description at the Aviation Safety Network
  • Pre-crash photos of A40-EK
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