Gulf Air Flight 42

Synopsis

On August 23, 2000, an Airbus A320-200 passenger aircraft with the Sultanate of Oman aircraft registration of A40-EK crashed into the sea of Arabian Gulf near Muharraq, Bahrain. At 1930hours Bahrain Local time (1630 UTC), Flight GF72 operated by Gulf Air, crashed minutes after executing a go-around upon attempting landing on Runway 12 at Bahrain International Airport for the second time. Of the two flight crew members, six cabin crew members and 135 passengers aboard the flight, no one survived the accident.

Latent Errors

1) Inadequate Training of the Flight Crew

The unprofessionalism displayed by the flight crew in executing inappropriate decisions and actions during the flight highlighted the inadequacy of Gulf Air flight crew training. The flight crew members have exhibited many areas of incapability to fulfill criteria of the aircraft Standard Operating Procedures (SOP), respond to the alarms of the Ground Proximity Warning System (GPWS) of a possibility of Controlled Flight Into Terrain (CFIT).

2) Absence of Crew Resource Management (CRM) Training

Inadequate CRM training for Gulf Air pilots proposed the possibility of the flight crew members not performing cooperatively as an effective work team for aircraft operations.

3) Safety Oversight

For three years prior to the occurrence of the accident, the civil aviation regulatory authority of Bahrain (DGCAM) had expressed difficulties in coordinating cooperative actions from Gulf Air towards executing corrective actions in the rectification of non-compliance with the Standard Operating Procedures (SOPs). Despite being the official civil aviation regulatory authority of Bahrain, the DGCAM had failed in commanding its country’s flight operators to comply with important regulatory requirements.

4) Organisational & Managerial Problems

Besides training inadequacy, Gulf Air’s flight data analysis system failed to work in a satisfactory manner according to DGCAM. The airline department in charge of flight safety was found to have breached safety policies. The airline was also not cooperative in correcting deficient safety defences.

Active Errors:

1) Flight Crew Failure to Adhere to Aircraft SOP & Respond to GPWS Alarms

Due to improper flight crew training provision, the flight crew of GF42 did not display sufficient capability to adhere to the aircraft SOP for a safe flight operation. The airspeed during the descent and approach phases was greater (more than 250 knots) than the standard airspeeds. The flight crew failed to stabilize their landing approach. They also performed an orbit, an unapproved maneuver when they were too close to the runway. The standard go around procedures were not executed either. The flight crew did not consider the GPWS alarms at all.

2) Absence of Effective Communication Among the Flight Crew

Due to the absence of the CRM training in Gulf Air, the First Officer failed to display sufficient capability to engage the attention of the Captain (Pilot In Command (PIC)) by not conveying information of the aircraft deviations from the approved flight parameters and profile standards.

3) Spatial Disorientation & Excessive Focus on Non-Critical Issue

After performing the orbit during the go around, the Captain might have experienced spatial disorientation, which gave him the false perception that the aircraft nose is pitching upwards. He henceforth naturally inputted a responsive action by pushing the nose downwards too much. The aircraft lost altitude rapidly and crashed into the sea. Due to excessive focus on the non-critical issue of flap over-speed, the Captain failed to focus on making use of useful flight deck instrument data.

Lessons Learnt:

1) Regulatory Authority must assure the adequacy of flight operational safety oversight monitoring in ensuring that flight operators comply with the critical regulatory demands.

2) Airlines must include CRM training is their Line Oriented Flight Training (LOFT) and the Line Operations Safety Audit (LOSA) system.

3) Airlines must comply with regulatory demands of the local aviation regulatory authority cooperatively, fulfill aircraft SOP as well as increase awareness on flight crew workload coordination, responses to warning systems alarms.

4) Airlines must ensure that their flight training are of international approved standards as well as include clear in-depth information on key aeronautical issues such as spatial disorientation.

5) Airlines must review and enhance the usage of their fleet flight data analysis system.

6) Airlines must explore strategies to prevent accident as well as to safety risk evaluation and management systems.

7) Air Traffic Controllers should approve flight crew to perform non-standard flight maneuvers such as an orbit on their final landing approach only when they are within the safety parameters.

8) ICAO should implement a standard stating that all flights should remain below an airspeed limit of 250 knots below 10,000 feet Above Mean Sea Level (AMSL) in all classes of airspaces.

References

Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile. (2003). Accident investigation report: Gulf air flight gf-072 airbus A320-212, reg. a40-ek on 23 August 2000 at Bahrain. Retrieved 25 August 2010, from http://www.bea.aero/docspa/2000/a40-ek000823a/htm/a40-ek000823a.html.

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