Accident Airbus A320-212 A4O-EK,

ASN Wikibase Occurrence # 323444

Date:	Wednesday 23 August 2000
Time:	19:30
Type:	Airbus A320-212
Owner/operator:	Gulf Air
Registration:	A4O-EK
MSN:	481
Year of manufacture:	1994
Total airframe hrs:	17370 hours
Cycles:	13990 flights
Engine model:	CFMI CFM56-5A3
Fatalities:	Fatalities: 143 / Occupants: 143
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	2 km N off Bahrain International Airport (BAH) - Bahrain
Phase:	Approach
Nature:	Passenger - Scheduled
Departure airport:	Cairo International Airport (CAI/HECA)
Destination airport:	Bahrain International Airport (BAH/OBBI)
Investigating agency:	MoT Bahrain
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
The aircraft was conducting a normal approach to runway 12 at Bahrain International Airport with auto-pilot/flight director disconnected upon visual contact with the runway. Approximately 1nm from touchdown, at about 600 feet amsl and at an airspeed of 185 mph the crew requested a left-hand orbit (360 degree turn) because they were too high and fast on the approach. During the tight (36degree bank angle) left hand turn the flaps were fully extended and the landing checklist completed. When the aircraft crossed the extended runway centerline the crew reported they wanted to abort the landing. A controller gave the crew clearance to climb to 2,500 feet at a 300-degree heading to prepare for another approach. The plane's speed began increasing to 185 knots as it began to climb to 1000 feet in a 5-degree nose-up attitude. During the go-around at approximately 1,000 feet, the aircraft entered a rapid descent, 15-degrees nose down. As the GPWS sounded, the captain ordered the flaps to be raised and moved the sidestick aft. The Airbus impacted the sea at a 6.5-degreee nose down angle, north of the airport. The plane's last recorded airspeed was about 280 knots.
Two very remarkable accidents happened June 1950 within a period of just 3 days. On June 12 an Air France DC-4 descended into the sea while on a night-time approach to Bahrain. Two days later, another Air France DC-4 descended into the sea off Bahrain, also on a night-time approach.

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. All of these factors must be addressed to prevent such an accident happening again.
(1) The individual factors particularly during the approach and final phases of the flight were:
(a) The captain did not adhere to a number of 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 manoeuvre, close to the runway at low altitude; not performing the correct go-around procedure; etc.
(b) 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.
(c) 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.
(d) 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:
(a) Organisational factors (Gulf Air):
(i) A lack of training in CRM contributing to the flight crew not performing as an effective team in operating the aircraft.
(ii) Inadequacy in the airline's A320 training programmes, such as: adherence to SOPs, CFIT, and GPWS responses.
(iii) The airlines flight data analysis system was not functioning satisfactorily, and the flight safety department had a number of deficiencies.
(iv) 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.
(b) 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.

Accident investigation: