(cache)GF072 Final Report

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

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