FLIGHT SAFETY AUSTRALIA

NOVEMBER–DECEMBER 2003

COVER STORY

Can courtesy

kill?

FLIGHT SAFETY AUSTRALIA

NOVEMBER–DECEMBER 2003 27

CAPTAIN’S FEARSthat hiscompany would frown on himifhe conducted a missedapproach is one possible factorin the fatal crash ofa GulfAirA320 into the shallow waters oftheArabian Gulf.The failure ofthe first officer,a shy,polite type,to take issue with the captain’sdecision to execute a 360-degree orbitinstead ofa missed approach and goaround,is another possible factor in theaccident,near Bahrain InternationalAirport on August 23,2000.However,as with many aviation disas-ters,the crash ofGF-072 represents afailure ofthe aviation system.The inves-tigation revealed a complex series of human,organisational and managementinfluences that combined to set the scenefor the accident,which culminated in thecrew’s failure to respond to insistentwarnings to “pull up”from the aircraft’sground proximity warning system(GPWS).A multinational team ofaccident inves-tigators set up by the Kingdom ofBahrainin accordance with international civilaviation agreements

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found no technicaldeficiencies in the aircraft or its systems.The investigators attributed the tragedymainly to human factors at the individualand organisational level.They turned upevidence oferrors and procedural viola-tions committed by the flight crew,and of long-standing organisational and manage-mentproblems that had been identifiedbut not rectified.GulfAir has since acted on many oftherecommendations made in the AccidentInvestigation Board’s report on the crashand plans to implement the rest.It is establishing a new integrated safetymanagement system,and has beefed upits safety department,while stepping upinternal safety promotion.GulfAir flight GF-072 was a scheduledservice from Cairo International Airportto Bahrain International Airport (BAH).It was operated by an Airbus Industrie

Embarrassment about making a mistake, reluctance tochallenge a captain’s decision and spatial disorientationare possible factors in an accident that killed 143 people.But, as John Mulcair and Rob Lee report, there is muchmore to the story.

P H OT O

AAP

FLIGHT SAFETY AUSTRALIA

NOVEMBER–DECEMBER 2003

D I E T M A R S C H R E I B E R

A320-212.There were two pilots,six cabincrew and 135 passengers on board.When GF-072 was about one nm fromtouchdown and at an altitude ofabout 600ft,Bahrain air traffic control approved thecrew’s request for a 360-degree left-handorbit.On completion ofthis manoeuvre,theaircraft was about parallel to but beyond theextended centreline ofthe landing runway,and the crew initiated a missed approach.With a radar vector offered by ATC,GF-072overflew the runway in a shallow climb toabout 1,000 ft.The aeroplane crashed into the sea aboutfour kilometres north-east ofthe airport atabout 1930,Bahrain local time.The debrisfield was 700 m long and 800 m wide.Mostofthe aeroplane was recovered,along withall significant structural components,flightcontrol surfaces and both engines.There wasno evidence ofpre-crash failure or firedamage.

The crew

GF-072’s last flight began with thearrival ofits crew at the gate 25 minutesbefore the scheduled departure time of1600.The airliner was under the command ofa37-year-old captain who had joined GulfAirin 1979 as a cadet flight engineer.He hadlater retrained as a pilot,flying on the Boeing767 and Airbus A320 as a first officer,and,since 1996,as a supervisory first officer.He was promoted to captain on the AirbusA320 on June 17,2000.He had logged totalpilot time of4416 pilot hours,86 ofwhichwere as pilot in command on the A320.GulfAir pilots who had flown with himdescribed him as responsible,knowledge-able,open to suggestions,happy,very helpful,professional and sharp.They differed onwhether he was overconfident.GulfAir hired the first officer,aged 25,as a cadet on July 4,1999,after he attendedits ab-initio training program.He waspromoted to A320 first officer on April 20,2000.He had accrued a total of608 pilot hours,made up of200 hours in training,and 408hoursrs as an A320 line pilot with GulfAir.GulfAir pilots who had flown with thefirst officer described him as timid,meek,mild,polite,shy and reserved in social situ-ations,and keen to learn.While most felt his reserved nature wouldnot stop his speaking up during flight oper-ations,others felt he might have been tooreserved to challenge a captain.

The crash

After an uneventful flight fromCairo,the aircraft was prepared for a visualapproach and landing on Runway 12 atBahrain.At the time,Runway 12 had noinstrument landing system.The weather wasfine,and the night was clear and dark withno moon.The conversation and sounds in thecockpit for the 30 minutes before the acci-dent were recorded on the cockpit voicerecorder (CVR).At 1926:37,the captain stated:“OK,visualwith airfield”.Seconds later,the flight datarecorder (FDR) showed that the autopilotand flight director were disengaged.At 1926:49 and about 2.9 nm from therunway,the aircraft descended through1,000ft.At 1926:51,with GF-072 about 2.8nm from the runway,at an altitude of976 ftand a speed of207 knots,the captain said:“Have to be established by 500 feet.”Flapstwo were selected.As the approach to Runway 12 continued,the captain said at 1927:06,and again at1927:13,“….we’re not going to make it”.At 1927:23,he instructed the first officer to“tell him to do a 360 (degree) left (orbit)”.Bahrain tower approved the request.The leftturn was initiated about 0.9 nm from therunway,at an altitude of584 ft and anairspeed of177 knots.During the left turn,the flap configura-tion went from flaps two to flaps three andthen to flaps full.At 1928:17,the captaincalled for the landing checklist.At 1928:28,with the Airbus about halfwaythrough the left turn,the first officer advisedthat the landing checklist was complete.After completing about three-quarters of the 360-degree turn,the aircraft rolled wingslevel.The Airbus’altitude during the left turnranged from 965 ft to 332 ft,while its bank angle reached a maximum ofabout 36degrees.At 1928:57,after being cleared again byBahrain tower to land on Runway 12,thecaptain stated:“We overshot it.”The aircraft began to turn left again,followed by changes consistent with anincrease in engine thrust.At 1929:07,thecaptain said:“Tell him going around.”TheFDR indicated an increase to maximumtake-off/go around (TOGA) engine thrust.Bahrain tower provided radar vectors,with instructions to “fly heading three zerozero (300 degrees),climb (to) 2,500”.

COVER STORY

The A320 that crashed into the Arabian Gulf in 2000, pictured a year before the accident.