Gulf Air Flight 072

Investigation

The investigation initially would be spearheaded by Bahrain; however, government officials quickly asked for assistance from the U.S. National Transportation Safety Board (NTSB) for the investigation of the crash. NTSB would later be declared as the agency in charge of the investigation. They would be joined by representatives from France, Egypt, and Oman. A total of 20 investigators would be involved in the probe.

Bahraini state TV initially claimed that the aircraft's engines were on fire before the aircraft plunged into the sea. A Bahraini ATC worker confirmed that no distress call had been made by the crew prior to the crash. The claim was corroborated by the recording, which showed that the crew didn't make any mayday calls to the ATC. The Bahraini Ministry of Transportation later stated that reports of engine fires were "pure speculation."

Several eyewitnesses claimed that the aircraft was seen circling over the sky of Manama twice before it fell. At some point the aircraft could be seen trying to swerve from the buildings in the capital. An official from the Ministry of Transportation eventually confirmed that the aircraft had tried to circle the airport twice, and somehow it veered onto the sea. Gulf Air's Chief Pilot Hameed Ali clarified that the crew had only commenced the approach once and was quick to refute claims that the crash had been caused by pilot error. He admitted that investigators would look into the conduct of the approach of Flight 072 following the reports. Ali further stated that there was "not an error spotted" in Captain Shakeeb's flying.

The flight recorders were found within days after the crash and were taken to Washington, D.C. on August 27 for readout. Preliminary analysis on the recorders revealed that there were indications that the crews had been facing difficulty in controlling the aircraft. Head of NTSB investigators in Bahrain, Frank Hilldrup, stated that the aircraft had been flown at an excess speed and the pilot at the helm had been warned by the co-pilot, but the warning was not heeded. The aircraft was put into a steep descent and didn't slow down until it crashed into the sea. Bahrain's Undersecretary for Civil Aviation, Ibrahim al-Hamer, stated that it was "premature" to express their opinion on the crash, though he added that it was the responsibility of the pilot to land their aircraft safely.

Conclusion

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.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

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.

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.