Gulf Air Flight 072

Gulf Air Flight 072
	A4O-EK, the aircraft involved, 1999
Accident
Date	23 August 2000
Summary	Somatogravic illusion leading to pilot error and loss of situational awareness; Controlled flight into terrain
Site	Persian Gulf, 2 km (1.2 mi) north off Bahrain International Airport, Muharraq, Bahrain ; 26°17′51″N 50°38′49″E / 26.297500°N 50.646944°E
Aircraft
Aircraft type	Airbus A320-212
Operator	Gulf Air
IATA flight No.	GF072
ICAO flight No.	GFA072
Call sign	GULF AIR 072
Registration	A4O-EK
Flight origin	Cairo International Airport, Cairo, Egypt
Destination	Bahrain International Airport, Muharraq, Bahrain
Occupants	143
Passengers	135
Crew	8
Fatalities	143
Survivors	0

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 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 2 km (1 nmi) from the airport.^[4] All 143 people on board the aircraft were killed.

The crash of Flight 072 remains the deadliest aviation accident in Bahraini territory,^[1] 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 Standard Operating Procedures (SOP) 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 (CRM) training by Gulf Air and safety oversights by the Directorate General Of Civil Aviation and Meteorology of Oman.^[2]

Aircraft

Flight 072 was operated with an Airbus A320-212, registered as A4O-EK with serial number 481. It first flew on 16 May 1994, and was delivered new to Gulf Air in September 1994.^[7] It was powered by two CFM International CFM56-5A3 engines^[8] and had accumulated 17,370 hours in 13,990 takeoff and landing cycles before the accident.^[1]^[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.^[2]^: 15–16

Passengers and crew

People on board by citizenship^[10]^[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^[b]	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 135 passengers, 2 pilots, and 6 cabin crew members from 17 countries, mostly from Egypt and Bahrain.^[4] One Egyptian who was supposed to board the flight was turned away by immigration officials in Cairo who found his passport was not stamped with the necessary Egyptian interior ministry permit for working abroad.^[14]

Crew

There were two pilots in the aircrew:^[2]^: 9–12

The pilot-in-command was 37-year-old Bahraini Captain Ihsan Shakeeb.^[15]^[16] He joined Gulf Air as a cadet pilot in 1989 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 (including 1,083 hours on the Airbus A320),^[9] of which 86 were as captain.^[c]
The First Officer was 25-year-old Omani Khalaf al-Alawi.^[15] He joined Gulf Air as a cadet pilot in 1999 and promoted to first officer of the Airbus A320 in 2000. Al-Alawi had logged 608 hours of flying experience, 408 of them on the Airbus A320.^[2]^: 12^[9]

Passengers

Among the 135 passengers were 61 men, 37 women and 37 children (including 8 infants).^[2]^: 26

A 144th set of remains was found, and was identified as a fetus that had been delivered during the crash, but this was not counted as a fatality in the final report.^[2]^: 35

Accident

Flight 072 departed from Cairo at 16:52 local time with 143 passengers and crew on board. The aircraft approached the landing at higher speeds than normal, initially at 313 knots (580 km/h; 360 mph) and then decreasing to 272 knots (504 km/h; 313 mph). At 19:22 Dammam approach gave the flight approval for self navigation to land on runway 02. First Officer al-Alawi then contacted Bahrain approach, informing that they would be landing on runway 02. The approach was too high and the flight crew carried out an unusual low altitude orbit in an attempt to correct the approach.^[2]^{: 15–16, 87}^[17] 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 ground proximity warning system (GPWS) activated, first sounding a "sink rate" alarm and then nine "whoop whoop pull up" alarms, which continued to sound until impact. The aircrew did not respond to repeated GPWS warnings^[2]^: 88 and approximately one minute after starting the go-around the aircraft disappeared from radar screens.^[18] At 19:30:02, the aircraft crashed into the sea. There were no survivors.^[19]

Investigation

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.^[2]

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.
The individual factors particularly during the approach and final phases of the flight were:
The captain did not adhere to a number of Standard Operating Procedures (SOPs), such as:
significantly higher than standard aircraft speeds during the descent and the first approach

not stabilising the approach on the correct approach path; performing an orbit, a non-standard maneuver, close to the runway at low altitude

not performing the correct go-around procedure

other related items

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.

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' (Somatogravic illusion). He responded by making a 'nose-down' input, and as a result, the aircraft descended and flew into the shallow sea.

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.

The systemic factors, identified at the time of the above accident, which could have led to the above individual factors, were:
Organisational factors (Gulf Air):
A lack of training in CRM contributing to the flight crew not performing as an effective team in operating the aircraft.

Inadequacy in the airline's A320 training programmes, such as: adherence to SOPs, CFIT, and GPWS responses.

The airline's flight data analysis system was not functioning satisfactorily, and the flight safety department had a number of deficiencies.

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.

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.^[2]^: A1–A2^[20] 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.^[2]

Aftermath

After the accident, Hamad bin Isa al-Khalifa, the Emir of Bahrain, declared three days of national mourning.^[4]

Notes

^ GF is the IATA designator and GFA is the ICAO airline designator.^[3]
^ The first officer.
^ The remaining 997 of his flight hours on the A320 were as first officer.^[2]^: 10

References

^ ^a ^b ^c Ranter, Harro. "ASN Aircraft accident Airbus A320-212 A4O-EK Bahrain International Airport (BAH)". aviation-safety.net. Aviation Safety Network. Retrieved 5 July 2016.
^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m "ACCIDENT INVESTIGATION REPORT Gulf Air Flight GF-072" (PDF). Civil Aviation Authority of Bahrain. 15 August 2002. Retrieved 13 May 2019 – via SKYbrary.
^ "Gulf Air. Airline code, web site, phone, reviews and opinions". Airlines Inform. Retrieved 5 June 2016.
^ ^a ^b ^c "Bodies recovered from Gulf Air crash". BBC News. BBC. 24 August 2000. Retrieved 2 February 2009.
^ "23 August 2000 - Gulf Air 072". tailstrike. Retrieved 5 July 2016.
^ "Pilot's family fight to clear his name". Gulf Daily News. 7 April 2015. Archived from the original on 15 January 2023. Retrieved 5 July 2016.
^ "Clue to Gulf Air crash". BBC News. BBC. 25 August 2000. Retrieved 25 May 2016.
^ "Airbus's reliability record". BBC News. BBC. 24 August 2000. Retrieved 7 July 2016.
^ ^a ^b ^c "Crash of an Airbus A320 in Bahrain: 143 killed". Bureau of Aircraft Accidents Archives. Retrieved 5 July 2016.
^ Starr, Barbara; Masterman, Sue; Chang, Andrew (23 August 2000). "143 Bodies Recovered From Persian Gulf". ABC News. American Broadcasting Company. Retrieved 5 July 2016.
^ "143 Passengers Killed in Gulf Air Plane Crash off Bahrain". Al Bawaba. 24 August 2000. Retrieved 5 July 2016.
^ Menon, Kesava (24 August 2000). "Indian crew member among victims in Gulf Air crash". The Hindu. Retrieved 5 July 2016.^{[dead link]}
^ "Classified Material Recovered From Crash Site". ABC News. American Broadcasting Company. 26 August 2000. Retrieved 5 July 2016.
^ "Relief amid Gulf crash tragedy". BBC News. BBC. 25 August 2000. Retrieved 5 July 2016.
^ ^a ^b "One of Bahrain's biggest tragedies" (PDF). Gulf Daily News. 23 August 2010. Archived from the original (PDF) on 4 October 2016. Retrieved 5 July 2016.
^ "'No pilot error' in Gulf crash". BBC News. BBC. 25 January 2000. Retrieved 15 January 2020.
^ "ACCIDENT INVESTIGATION REPORT Gulf Air Flight GF-072". Civil Aviation Authority of Bahrain. Archived from the original on 12 February 2004.
^ "Airbus A320 A4O-EK accident record – Graphic – A40-EK Flight Path derived from Lat and Long FDR Parameters". Bureau of Enquiry and Analysis for Civil Aviation Safety – via Aviation Safety Network.
^ "pe_03.html". CBS News. Retrieved 9 June 2009.
^ "Appendix A." Final Accident Report.

External links

Accident Investigation Report (Archive) – Civil Aviation Affairs – Hosted by the Bureau of Enquiry and Analysis for Civil Aviation Safety (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 (Archive) - 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 (Archive), CBS News
Accident description at the Aviation Safety Network
Pre-crash photos of A40-EK
Salvage operation on the crash site from Associated Press Archive

[4] GF is the IATA designator and GFA is the ICAO airline designator.^[3]

[15] The first officer.

[19] The remaining 997 of his flight hours on the A320 were as first officer.^[2]^: 10

[ASN-1] Ranter, Harro. "ASN Aircraft accident Airbus A320-212 A4O-EK Bahrain International Airport (BAH)". aviation-safety.net. Aviation Safety Network. Retrieved 5 July 2016.

[CAA-2] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m "ACCIDENT INVESTIGATION REPORT Gulf Air Flight GF-072" (PDF). Civil Aviation Authority of Bahrain. 15 August 2002. Retrieved 13 May 2019 – via SKYbrary.

[3] "Gulf Air. Airline code, web site, phone, reviews and opinions". Airlines Inform. Retrieved 5 June 2016.

[Bodies-5] "Bodies recovered from Gulf Air crash". BBC News. BBC. 24 August 2000. Retrieved 2 February 2009.

[6] "23 August 2000 - Gulf Air 072". tailstrike. Retrieved 5 July 2016.

[7] "Pilot's family fight to clear his name". Gulf Daily News. 7 April 2015. Archived from the original on 15 January 2023. Retrieved 5 July 2016.

[8] "Clue to Gulf Air crash". BBC News. BBC. 25 August 2000. Retrieved 25 May 2016.

[9] "Airbus's reliability record". BBC News. BBC. 24 August 2000. Retrieved 7 July 2016.

[B3A-10] "Crash of an Airbus A320 in Bahrain: 143 killed". Bureau of Aircraft Accidents Archives. Retrieved 5 July 2016.

[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.^{[dead link]}

[14] "Classified Material Recovered From Crash Site". ABC News. American Broadcasting Company. 26 August 2000. Retrieved 5 July 2016.

[16] "Relief amid Gulf crash tragedy". BBC News. BBC. 25 August 2000. Retrieved 5 July 2016.

[gdnonline-17] "One of Bahrain's biggest tragedies" (PDF). Gulf Daily News. 23 August 2010. Archived from the original (PDF) on 4 October 2016. Retrieved 5 July 2016.

[18] "'No pilot error' in Gulf crash". BBC News. BBC. 25 January 2000. Retrieved 15 January 2020.

[20] "ACCIDENT INVESTIGATION REPORT Gulf Air Flight GF-072". Civil Aviation Authority of Bahrain. Archived from the original on 12 February 2004.

[21] "Airbus A320 A4O-EK accident record – Graphic – A40-EK Flight Path derived from Lat and Long FDR Parameters". Bureau of Enquiry and Analysis for Civil Aviation Safety – via Aviation Safety Network.

[22] "pe_03.html". CBS News. Retrieved 9 June 2009.

[23] "Appendix A." Final Accident Report.

[1]

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[a]

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[8]

[9]

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[12]

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[b]

[14]

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[3]

Gulf Air Flight 072

Aircraft

Passengers and crew

Crew

Passengers

Accident

Investigation

Aftermath

See also

Notes

References

External links

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