Gulf Air Flight 072 - Investigation

Investigation

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.

1. The individual factors particularly during the approach and final phases of the flight were:
   1. The captain did not adhere to a number of SOPs, such as:
      1. significantly higher than standard aircraft speeds during the descent and the first approach
      2. not stabilising the approach on the correct approach path; performing an orbit, a non-standard manoeuvre, close to the runway at low altitude
      3. not performing the correct go-around procedure
      4. other related items
   2. 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.
   3. 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’. He responded by making a ‘nose-down’ input, and as a result, the aircraft descended and flew into the shallow sea.
   4. 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.
2. The systemic factors, identified at the time of the above accident, which could have led to the above individual factors, were:
   1. Organisational factors (Gulf Air):
      1. A lack of training in CRM contributing to the flight crew not performing as an effective team in operating the aircraft.
      2. Inadequacy in the airline's A320 training programmes, such as: adherence to SOPs, CFIT, and GPWS responses.
      3. The airline’s flight data analysis system was not functioning satisfactorily, and the flight safety department had a number of deficiencies.
      4. 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.
   2. 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.

After the crash, the flight designator has been changed from GF072 to GF070.