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Can courtesy
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A320-212. There were two pilots, six cabin able, open to suggestions, happy, very helpful, and a speed of 207 knots, the captain said:
crew and 135 passengers on board. professional and sharp. They differed on “Have to be established by 500 feet.” Flaps
When GF-072 was about one nm from whether he was overconfident. two were selected.
touchdown and at an altitude of about 600 Gulf Air hired the first officer, aged 25, As the approach to Runway 12 continued,
ft, Bahrain air traffic control approved the as a cadet on July 4, 1999, after he attended the captain said at 1927:06, and again at
crew’s request for a 360-degree left-hand its ab-initio training program. He was 1927:13, “….we’re not going to make it”.
orbit. promoted to A320 first officer on April 20, At 1927:23, he instructed the first officer to
On completion of this manoeuvre, the 2000. “tell him to do a 360 (degree) left (orbit)”.
aircraft was about parallel to but beyond the He had accrued a total of 608 pilot hours, Bahrain tower approved the request. The left
extended centreline of the landing runway, made up of 200 hours in training, and 408 turn was initiated about 0.9 nm from the
and the crew initiated a missed approach. hoursrs as an A320 line pilot with Gulf Air. runway, at an altitude of 584 ft and an
With a radar vector offered by ATC, GF-072 Gulf Air pilots who had flown with the airspeed of 177 knots.
overflew the runway in a shallow climb to first officer described him as timid, meek, During the left turn, the flap configura-
about 1,000 ft. mild, polite, shy and reserved in social situ- tion went from flaps two to flaps three and
The aeroplane crashed into the sea about ations, and keen to learn. then to flaps full. At 1928:17, the captain
four kilometres north-east of the airport at While most felt his reserved nature would called for the landing checklist.
about 1930, Bahrain local time. The debris not stop his speaking up during flight oper- At 1928:28, with the Airbus about halfway
field was 700 m long and 800 m wide. Most ations, others felt he might have been too through the left turn, the first officer advised
of the aeroplane was recovered, along with reserved to challenge a captain. that the landing checklist was complete.
all significant structural components, flight The crash After an uneventful flight from After completing about three-quarters of
control surfaces and both engines. There was Cairo, the aircraft was prepared for a visual the 360-degree turn, the aircraft rolled wings
no evidence of pre-crash failure or fire approach and landing on Runway 12 at level.
damage. Bahrain. At the time, Runway 12 had no The Airbus’ altitude during the left turn
The crew GF-072’s last flight began with the instrument landing system. The weather was ranged from 965 ft to 332 ft, while its bank
arrival of its crew at the gate 25 minutes fine, and the night was clear and dark with angle reached a maximum of about 36
before the scheduled departure time of 1600. no moon. degrees.
The airliner was under the command of a The conversation and sounds in the At 1928:57, after being cleared again by
37-year-old captain who had joined Gulf Air cockpit for the 30 minutes before the acci- Bahrain tower to land on Runway 12, the
in 1979 as a cadet flight engineer. He had dent were recorded on the cockpit voice captain stated: “We overshot it.”
later retrained as a pilot, flying on the Boeing recorder (CVR). The aircraft began to turn left again,
767 and Airbus A320 as a first officer, and, At 1926:37, the captain stated: “OK, visual followed by changes consistent with an
since 1996, as a supervisory first officer. with airfield”. Seconds later, the flight data increase in engine thrust. At 1929:07, the
He was promoted to captain on the Airbus recorder (FDR) showed that the autopilot captain said: “Tell him going around.” The
A320 on June 17, 2000. He had logged total and flight director were disengaged. FDR indicated an increase to maximum
pilot time of 4416 pilot hours, 86 of which At 1926:49 and about 2.9 nm from the take-off/go around (TOGA) engine thrust.
were as pilot in command on the A320. runway, the aircraft descended through Bahrain tower provided radar vectors,
Gulf Air pilots who had flown with him 1,000ft. At 1926:51, with GF-072 about 2.8 with instructions to “fly heading three zero
described him as responsible, knowledge- nm from the runway, at an altitude of 976 ft zero (300 degrees), climb (to) 2,500”.
DIETMAR SCHREIBER
The A320 that crashed into the Arabian Gulf in 2000, pictured a year before the accident.
Other research after the accident included The team considered several scenarios: increase and to maintain +1.0G, the target
studies to determine the effects of certain • The pilots were instructed to recover with when the side stick is in the neutral position
variables on altitude loss during GPWS full aft stick movement at the onset of the in Normal Law. The pitch remained positive
recovery, simulations of the approach, orbit GPWS alert. The simulator recovered with and the aircraft climbed slowly.
and go-around of GF-072 at BAH, and a about 300 ft altitude loss. • The 360-degree turn was initiated to match
series of flight tests. • Half back stick was applied instead of the flight path and sequence and timing of
Variables examined in the GPWS recovery full back stick. The delay between the events recorded on the FDR. But instead of
study were the amount of the pilot’s pitch-up GPWS warning and the stick command rolling wings level upon reaching a heading
command, the time between the GPWS was approximately four seconds. The of about 211 degrees magnetic, as the
warning and the pilot’s reaction to it, and the simulator recovered with about 650 ft alti- captain of GF-072 had done, the 360-degree
duration of the pitch command input. tude loss. turn was continued at a moderate bank
An A320 fixed-base engineering simulator • The co-pilot performed a recovery after he angle at the pilot’s discretion to align with
at Airbus Industrie’s facilities at Toulouse, had verified that the captain had taken no Runway 12, and the approach and landing
France was used to simulate the approach, action to recover from the GPWS alert. The were continued. The pilots were able to
orbit and go-around of GF-072. co-pilot depressed the priority button on his successfully land on Runway 12 from the
The simulator also allowed investigators side stick, announced his control override, 360-degree turn.
to fly the approach to Runway 12 and to and applied full aft side stick input. The In this final scenario, the pilots noted that
observe cockpit warnings during flap over- simulator recovered with about 400ft of alti- the approach was not stabilised and little
speed and GPWS warnings. tude loss. time was available to successfully complete
During one of the simulator sessions, the • The 360-degree turn was performed but the final approach and landing.
360-degree turn and go-around manoeuvres the pilots were instructed to make no further On September 27, 2000 a flight demon-
were performed to approximate the flight path control inputs after selection of TOGA stration in an A320 test aircraft observed
and the sequence and timing of events recorded power. The simulator trimmed nose down various conditions similar to the flight
on the FDR recovered from the aircraft. to counter the noseup effect due to the thrust profile flown on August 23, 2000. It was
However, it also revealed that he played able, but untapped, resource available to the
little effective part in flight deck manage- captain, and crew resource management was
ment and decision making. He did not raise virtually non-existent in the cockpit of GF-072. “...airlines with positive
any issues with the captain or question his Although Gulf Air had been required by
decisions, even though the captain Sultanate of Oman regulations to provide a safety cultures, strongly
performed non-standard procedures and formal CRM training programme since June
manoeuvres. 1999, the original company CRM motivated towards
Crew resource management Evidence from programme, established in 1992 and active
the training records of the first officer indi- until early 1997, appeared to have been compliance with the
cated that he was seen as “shy” and discontinued with a change of management.
“unassertive”, and that his operational The acting manager of human factors at regulations, are in the
performance overall was marginal. the time of the accident said that his prede-
However, investigators also observed that cessor had resigned in frustration over his interests of the regulator.”
at no stage during the approach did the attempts to re-establish the program.
captain consult the first officer on any oper- Another factor contributing to the depar-
PHOTO: AAP
ational decisions. The first officer was a valu- ture from SOPs could be that a company might not emphasise strongly enough the
importance of, the reasons for and the need
to adhere to SOPs.
And although Gulf Air had a flight data
monitoring and analysis system in place, the
system was not functioning satisfactorily at
the time of the accident. Such systems can
help identify the level of compliance with
SOPs by detecting events including unsta-
bilised approaches or times when an aircraft
had exceeded specific pre-programmed
parameters, such as airspeed, in a particular
configuration.
CFIT training CFIT (controlled flight into
terrain) accidents account for the highest
proportion of fatalities in commercial aviation.
The CFIT training in the A320 fleet in Gulf
Air was severely limited at the time of the
accident. Airbus Industrie’s A320 normal
course syllabus includes a GPWS pull-up
demonstration. However, there was no
similar syllabus for Gulf Air and no require-
ment to execute such a demonstration for its
A320 fleet.
Nor did Gulf Air’s A320 training program
emphasise GPWS response training. The
Airbus training program requires an instant,
instinctive side stick response when a hard
GPWS warning occurs.
Organisational deficiencies: The investiga-
tors found that from 1998 to the time of the
accident, the manager of flight safety was the
only person in his department, and he did
not report directly to the highest executive
level within the company. They labelled this
a serious organisational deficiency.
They also noted that for many years Gulf
Air had not participated in the regular six-
monthly meetings of the International Air
Transport Association’s safety committee, at
which the latest safety information is shared
freely and confidentially between airlines,
manufacturers and safety specialists.
This had greatly restricted Gulf Air’s aware-
ness of developments in areas such as acci-
dent investigation case studies, safety and risk
Grim search Wreckage from Gulf Air Flight 072 is recovered from the Arabian Gulf. management, training and safety information.
The regulator: The investigators also exam- tions on the airline. Despite this, Gulf Air did Meanwhile, James Hogan, Gulf Air’s pres-
ined the relationship between Gulf Air and not implement many changes sought by ident and chief executive, says a lot has
its regulator, the Sultanate of Oman’s Direc- DGCAM. changed since the accident. The airline has
torate General of Civil Aviation and Meteo- A review of relevant information and enhanced regular fleet instructions and
rology (DGCAM). documentation covering the three years improved crew training, he says.
A review of correspondence between preceding the accident indicated that, despite The airline now electronically analyses
DGCAM and Gulf Air revealed letters citing intensive efforts, DGCAM could not get Gulf flight data to ensure adherence to standard
non-compliance with civil aviation regula- Air to comply with some critical regulatory operating procedures, while all Gulf Air crew
tions (CARs). In some areas, Gulf Air did not requirements. must be trained intensively in CRM, says
rectify problems identified by DGCAM. The investigators said regulatory authori- Hogan, who took up his position at the helm
The company lacked several programs ties and airlines had complementary roles in of the airline after the accident.
required by CARs. And it did not meet maintaining the safety of the aviation system. Gulf Air has incorporated into its flight
regulations in areas including crew Strong and effective regulators are in the crew training program modules driving
resource management, quality manage- interests of airlines because they provide an home the risks posed by spatial disorienta-
ment, safety awareness and other areas of independent means of quality control in tion, a problem also addressed in the first
crew training. airline operations. issue of the company’s upgraded safety
An evaluation of Gulf Air carried out by Conversely, airlines with positive safety magazine.
the International Civil Aviation Organisa- cultures, strongly motivated towards compli- And during the accident investigation,
tion for DGCAM in October 1998 turned up ance with the regulations, are in the interests Gulf Air reviewed its A320 flight training
evidence of delayed or non-compliance with of the regulator. program. This led to the reorganisation of
regulatory requirements. At the time of the accident, this was not the company’s operations division, a move
The ICAO review concluded that, except the case with the DGCAM and Gulf Air. The Hogan says ensures a high level of pilot
for isolated incidents, most of the infrac- regulator needs to check that airline training.
tions could be traced to inadequate super- resources, structures and processes necessary
visory oversight within Gulf Air, rather to ensure regulatory compliance are John Mulcair is a journalist based in Sydney.
than a deliberate disregard for the regula- adequate, the investigators said. It also needs Rob Lee is an international aviation safety
tions. the political support of the government to consultant and former director of the Australian
DGCAM was well aware of this situation, fulfill its safety role. This broader issue was Bureau of Air Safety Investigation. He was a
and had made many unsuccessful efforts to the subject of a specific recommendation in consultant to the Kingdom of Bahrain Gulf Air
correct it, including imposing various sanc- the GF-072 investigation report. Bahrain investigation team.
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