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ACCIDENT INVESTIGATION REPORT
Gulf Air Flight GF-072
Airbus A320-212, REG. A40-EK
on 23 August 2000 at Bahrain


1. Factual Information
1.1 History of Flight 1
1.2 Injuries to Persons 9
1.3 Damage to Airplane 9
1.4 Other Damage 9
1.5 Personnel Information 9
  1.5.1 The Captain 9
  1.5.2 The First Officer  12
  1.5.3 Flightcrew 72-Hour History  14
  1.5.4 The Air Traffic Controllers  14
       1.5.4.1   Bahrain Approach Control  14
       1.5.4.2   Air Traffic Control Tower  15
1.6  Airplane Information  15
  1.6.1 A320 Flight Control Design 16
  1.6.2 Auto Thrust 19
  1.6.3 A320 Cockpit Instrumentation  19
  1.6.4 A320 Flight Envelope Protections  24
  1.6.5 A320 Flap Control System  24
  1.6.6 Flap Overspeed Condition 25
  1.6.7 Ground Proximity Warning System  26
  1.6.8 Weight and Balance 26
1.7 Meteorological Information 27
  1.7.1 Weather Conditions at Bahrain International Airport 27
1.8 Aids to Navigation 28
  1.8.1 Precision Approach Path Indicator (PAPI) 28
  1.8.2 Radio Navigation and Landing Aids 28 28
1.9 Communications 29
1.10 Airport Information 29
  1.10.1 Bahrain International Airport  29
  1.10.2 VOR/DME Runway 12 Approach Procedure at Bahrain
International Airport
32
1.11 Flight Recorders 33
  1.11.1 Flight Data Recorder 33 33
  1.11.2 Cockpit Voice Recorder 33 33
  1.11.3 Digital Aids Recorder 33 33
1.12 Wreckage and Impact Information 34
1.13 Medical and Pathological Information 35
1.14 Fire 36
1.15 Survival Aspects 36
1.16 Tests and Research 36
  1.16.1 Recovery Study 36
  1.16.2 GF-072 Simulation 37
  1.16.3 Flight Tests 38
  1.16.4 Over water Light Visibility Study 39
  1.16.5 Flap Lever Examination 39
  1.16.6 Final Flight Path Study  39
1.17 Gulf Air Organisational and Management Information 41
  1.17.1 Gulf Air  41
    1.17.1.1 Gulf Air Flight Safety 42
  1.17.2 Gulf Air A320 Flight Crew Training  42
    1.17.2.1 Recurrent Training and Proficiency Checks  43
    1.17.2.2 Controlled Flight Into Terrain (CFIT) Training Programme  43
    1.17.2.3 Flap Overspeed Situations  44
    1.17.2.4 Go-Arounds  45
    1.17.2.5 Safety Equipment Procedures Training  45
  1.17.3 Gulf Air A320 Procedures 45
    1.17.3.1 Speed Restrictions during Descent  45
    1.17.3.2 Stabilised Approach  45
    1.17.3.3 Circling  46
    1.17.3.4 Go-Around  46
    1.17.3.5 Flap Retraction Schedule  47
    1.17.3.6 Overspeed Situations  48
    1.17.3.7 GPWS Alert 48
  1.17.4 Flight Crew Decision-making and Task Sharing  48
    1.17.4.1 Standard Calls  49
    1.17.4.2 Crew Resource Management Programme  49
  1.17.5 Crew Pairing  50
  1.17.6 Gulf Air Accident and Incident History 50
    1.17.7 Gulf Air Violations/Sanctions/Misc 51
     1.17.8 Oversight of Gulf Air  52
    1.17.8.1 DGCAM Oman Safety Oversight  52
  1.17.9 ICAO Special Evaluation  53
  1.17.10 Lufthansa Consulting Group’s Assistance  54
  1.17.11 Gulf Air Postaccident Safety Initiatives  54
    1.17.11.1 Go-Around Procedures  54
    1.17.11.2 Ab-Initio Training  54
    1.17.11.3 Cockpit Crew Resource Management (CRM)Training  55
    1.17.11.4 Command Upgrade Training  55
    1.17.11.5 Gulf Air A320 Fleet Instructions  55
    1.17.11.6 Recurrent Training and Checking  55
    1.17.11.7 Instructor Selection and Training  56
    1.17.11.8 Pilot Selection 56
    1.17.11.9 Modification to A320 Automatic Flight System (AFS)  56
1.18 Additional Information 56
  1.18.1 Spatial Disorientation Studies 56
  1.18.2 Flight Safety Foundation Study of CFIT Accidents  57
 
2. Analysis
2.1 General 58
2.2 Meteorological Factors on the Approach 58
2.3 Analytical Methodology 59
  2.3.1 Individual Human Factors 59 59
  2.3.2 Organisational and Management Aspects  59
  2.3.3 Reason Model of Systems Safety 60
2.4 Accident Sequence: Description of Approach and Flight Crew Actions 60
  2.4.1 The First Approach 60 60
    2.4.1.1 The Approach Configurations  
    2.4.1.2 Speeds during the Descent and Approach  
    2.4.1.3 Stabilising the Approach  
  2.4.2 The 360-degree Orbit and the Second Approach  63
  2.4.3 Go-around  66
    2.4.3.1 Radar Vectors  
    2.4.3.2 Flap Over-speed  
    2.4.3.3 Ground Proximity Warning   
  2.4.4 Spatial Disorientation  68
  2.4.5 The Perceptual Study by the NAMRL  68
  2.4.6 Information Overload  69
  2.4.7 Controlled Flight into Terrain (CFIT)  70
2.5 Non-adherence to Standard Operating Procedures (SOP)  72
  2.5.1 Accident Prevention Strategies  72
  2.5.2 Reasons for Non-adherence to the SOP’s 73
  2.5.3 Errors and Violations 74
2.6 Flight Crew Performance 75
  2.6.1 The Captain’s Performance  75
  2.6.2 The First Officer’s Performance  77
  2.6.3 Flight Crew Performance As a Team 77
  2.6.4 Flight Crew Fatigue Factors  78
2.7 Crew Resource Management (CRM) 79
2.8 A320 Flight Crew Training in Gulf Air 80 80
  2.8.1 CRM Training  80
  2.8.2 A320 Training on CFIT  81
  2.8.3 GPWS Pull-up Demonstration and Response Procedures  81
  2.8.4 Objectives of Flight Crew Training  82
2.9 Gulf Air Organisational Factors 82
  2.9.1 Flight Data Analysis  82
  2.9.2 The Flight Safety Department  83
  2.9.3 Safety and Risk Management Programmes  84
2.10 Safety Oversight Factors 84
  2.10.1 Role of the Regulatory Authority  84
  2.10.2 DGCAM, Sultanate of Oman  85
  2.10.3 Complementary Roles in Maintaining Safety  85
  2.10.4 Systemic, Structural and Organisational Issues  86
   
3. Conclusions
3.1 Findings  87
3.2 Contributory Factors 89
 
4. Safety Recommendations 91
Appendix A Investigation
Appendix B Cockpit Voice Recorder Transcript
Appendix C Flight Data Recorder Read-out 
Appendix D Gulf Air A320 Fleet Instructions 
Appendix E The Perceptual Study by the NAMRL
 
Figures
 

Figure 1:

Instrument Approach Chart of Bahrain Runway 12
VOR/DME Procedure
6
  Figure 2 Overhead View of GF-072 Trajectory with selected 
FDR, CVR and ATC communication excerpts
7
  Figure 3: Side View (Vertical Profile) of GF-072 Trajectory 8
  Figure 4 Sidestick Spring Forces vs. Deflection 18
  Figure 5/5a: A320 Cockpit Instrumentation 20/21
  Figure 6: Primary Flight Display 22
  Figure 7: Slats/Flaps Configuration 23
  Figure 8: Aerodrome Ground Movement Chart AD 2-11 30
  Figure 9: Aerodrome Lighting Chart 2-13 31
  Figure 10: Varieties of Unsafe Acts 74
 
Tables
  Table 1: Injury Chart 9
  Table 2: Flying and Duty Time – Captain 10
  Table 3: Flying and Duty Time – First Officer 12
  Table 4: Flap Retraction Time 25
  Table 5: Weight and Balance  26
  Table 6: Radio Navigation and Landing Aids  28
  Table 7: Responses vs Altitude Loss 36
  Table 8: Some of the significant events on the first approach 61

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