FLIGHT

SAFETY

F O U N D AT I O N

Accident Prevention
Vol. 59 No. 12

For Everyone Concerned With the Safety of Flight

December 2002

Nonadherence to Standard Procedures

Cited in Airbus A320 CFIT in Bahrain
The report said that spatial disorientation likely was involved in the flight crews
controlled flight into terrain (CFIT) during an attempted go-around.
The ground-proximity warning system generated nine warnings
before the aircraft struck the sea.
FSF Editorial Staff

About 1930 local time on Aug. 23, 2000, an Airbus

A320 operating as Gulf Air Flight GF-072 struck
water in the Arabian Gulf about three nautical miles
(six kilometers) northeast of Bahrain International
Airport in Muharraq, Bahrain, during an attempted
go-around in night visual meteorological conditions.
The two pilots, six cabin crewmembers and 135
passengers were killed. The aircraft was destroyed.
The Bahrain Accident Investigation Board (AIB)
said, in its final report, that the following individual
factors contributed to the accident:
Nonadherence to standard operating procedures (SOPs)
by the captain;
The first officer not drawing the attention of the captain
to the deviations of the aircraft from the standard flight
parameters and profile;
The spatial disorientation and information overload
experienced by the flight crew; and,
The non-effective response by the flight crew to the
ground-proximity warnings.
The report said, Systemic factors that could have led to these
individual factors were: a lack of a crew resource management

(CRM) training program; inadequacy in some of

the airlines A320 flight crew training programs;
problems in the airlines flight-data-analysis system
and flight safety department ; organizational and
management issues within the airline; and safetyoversight factors by the regulator.
Gulf Air is the national carrier of four countries: Abu
Dhabi, Bahrain, Oman and Qatar. At the time of the
accident, the airline operated 32 jet transport
airplanes and employed 485 pilots.
The captain, 37, held an airline transport pilot
certificate and had 4,416 flight hours, including 86 flight hours
as an A320 captain and 997 flight hours as an A320 first officer.
He had 2,402 flight hours as a Lockheed L-1011 flight
engineer.
The captain was employed by Gulf Air as an engineer cadet in
December 1979 and was promoted to flight engineer in 1989.
He served as an L-1011 flight engineer and as an L-1011,
Boeing 767 and A320 first officer until he was promoted on
June 17, 2000, to A320 captain.
Gulf Air pilots [who] had flown with the captain were
interviewed and used the following words to describe his
personality: responsible, knowledgeable, open to suggestions,
happy, very helpful, professional, and sharp, the report said.

Pilots interviewed varied in terms of their description of the

captains confidence in his abilities. One interviewee noted
that the captain was confident but not dominant or
overconfident. Another interviewee stated that the captain was
slightly overconfident but not overpowering or dominant, while
another interviewee indicated that the captain was a little loud

and confident to the extent that he may have bordered on

overconfidence and was somewhat boastful of his knowledge
of aircraft systems.
The first officer, 25, held a commercial pilot certificate and had
608 flight hours, including 408 flight hours as an A320 first
officer. He was employed by Gulf Air as a training cadet in July
1999 and was promoted to A320 first officer on April 20, 2000.
The first officer failed his initial proficiency check in the
A320 on October 29, 1999, the report said. He received
marks of D on the following: LOC/DME [localizer/distance
measuring equipment] approach, VOR [very-high-frequency
omnidirectional radio]/DME approach, normal landing,
crosswind landing, landing from nonprecision approach,
automation and technology, and engine-failure procedures.
(Gulf Air designated examiners grade pilots during proficiency
checks on a scale from A through E, with E as a failing
grade and three Ds constituting a failing grade.)
After receiving additional training, the first officer passed his
A320 proficiency check in November 1999 and began line
training.

Airbus A320
Development of the Airbus A320 twin-jet airliner began in
1984. Deliveries of the A320-100 and the A320-200 began
in 1988. The A320-200 (now called the A320) has wing-tip
fences, higher maximum takeoff weights and optional wingcenter-section fuel tanks.
The A320 is the first subsonic commercial aircraft with major
primary structures manufactured from composite materials,
a fly-by-wire control system and sidestick manual controls.
The airplane accommodates two flight crewmembers and
up to 180 passengers.
Airplanes built in 1988 have CFM International CFM56-5A1
turbofan engines, each producing 111.2 kilonewtons to
120.1 kilonewtons (25,000 pounds to 27,000 pounds static
thrust). A320s built from 1998 through 2002 have either
120.1-kilonewton CFM56-5B4/P engines or 117.9kilonewton (26,500-pounds-static-thrust) International Aero
Engines V2527E-A5 engines.
Standard fuel capacity is 23,859 liters (6,304 gallons). Two
wing-center-section fuel tanks can hold 2,900 liters (766
gallons) each. Maximum standard takeoff weight is 73,500
kilograms (162,038 pounds). Maximum standard landing
weight is 64,500 kilograms (142,197 pounds).
Maximum operating speed is 0.82 Mach. Optimum cruising
speed is 0.78 Mach. Service ceiling is 39,000 feet. Range
in standard configuration is 4,807 kilometers (2,596 nautical
miles).
Source: Janes All the Worlds Aircraft

Several Gulf Air captains [who] had flown with the first officer
were interviewed and used the following words to describe
the personality of the first officer: timid, meek, mild, polite,
disciplined, shy and reserved in social situations, and keen to
learn (i.e., inquisitive), the report said. While most of the
captains interviewed stated that they did not think that the first
officers reserved nature would hinder him from speaking up
during flight operations, others felt that he might have been
too reserved to speak up or challenge a captain.
One designated examiner/simulator training captain recalled
that during a training session, he intentionally exceeded the
30-knot taxi-speed limit specified in Gulf Air [SOPs] and the
first officer failed to challenge him regarding this.
The captain and the first officer had not flown together before
they began a four-day trip on Aug. 19, 2000. On Aug. 22, they
landed the accident aircraft in Cairo, Egypt, at 1350 local time
(Cairo and Bahrain are in the same time zone in summer).
They left their hotel at 1440 on Aug. 23 to continue the trip.
The flight to Bahrain was scheduled to depart from Cairo at 1600.
Actual departure time was 1652. The captain was the pilot flying.
Investigators did not determine whether the captain conducted
an approach briefing, as required by the airlines SOPs, before
beginning the descent from cruise altitude. An approach
briefing was not recorded by the cockpit voice recorder (CVR)
during the last 30 minutes of the flight.
At 1921, the aircraft was being flown through approximately
14,000 feet on descent about 30 nautical miles (56 kilometers)

FLIGHT SAFETY FOUNDATION ACCIDENT PREVENTION DECEMBER 2002

northwest of the Bahrain airport when a Dammam Approach

controller said, Gulf Air zero seven two, self navigation for
runway one two is approved. Three point five [3,500 feet] as
well approved, and Bahrain Approach one two seven eight
five approved.
The captain told the controller, Gulf Air zero seven two,
confirm we can go for runway one two.

The report said that the airlines SOPs specified that before
reaching the FAF, the aircraft must be established on the final
approach course (121 degrees) and at the published FAF
crossing altitude (1,500 feet), and be configured for the
approach with landing gear extended, flaps fully extended
and at the selected approach airspeed, which was 136 knots.
(The A320 FLAPS lever has five positions 0, 1, 2,
3 and FULL and controls the position of the wing
leading-edge slats as well as the trailing-edge flaps.)

The controller said affirmative.

The captain told the first officer to establish radio
communication with Bahrain Approach and to ask the
controller for confirmation that they could expect to land on
Runway 12. The first officer complied with the instruction,
and the Bahrain Approach controller told the crew that they
were cleared [for] self position and as youre cleared by
Dhahran and to confirm three thousand five hundred feet.
The report said that the captain believed that they had been
cleared by air traffic control to descend to 7,000 feet. He told
the first officer to tell the controller that they were cleared to
7,000 feet. The first officer complied, and the controller told
the crew to continue their descent to 3,500 feet.
The flight crew was conducting the Approach checklist at
1923 when the controller told them to continue their descent
to 1,500 feet and to report when they were established on
the final approach course for the VOR/DME approach to
Runway 12.
The airport is on the northern coast of Bahrain and has one
runway that is 3,956 meters (12,980 feet) long and 60 meters
(197 feet) wide with high-intensity approach lights and highintensity runway lights. Airport elevation is six feet.
At the time of the accident, the automatic terminal information
service (ATIS) reported weather conditions as CAVOK (i.e.,
ceiling and visibility OK, indicating that there were no clouds
below 5,000 feet above ground level [AGL] and that visibility
was at least 10 kilometers [six statute miles]). Surface winds
were from 090 degrees at seven knots. Temperature was 35
degrees Celsius (95 degrees Fahrenheit); dew point was 29
degrees Celsius (84 degrees Fahrenheit).

Although the aircraft was established on [the final approach

course] at the FAF, the other parameters were far from the
standard, the report said. The speed was 223 knots, instead
of 136 knots; the flaps position was 1, instead of FULL;
and the altitude was 1,662 feet, instead of 1,500 feet.
One of the reasons for not achieving the required
configurations was excessive speed, compared to the standard.
At this stage of flight, the SOPs define deviation from
standard to be when the speed varies by plus 10 [knots] or
minus zero knots and/or [when] altitude varies by 100 feet.
After the first officer told the controller that the aircraft was
established on the final approach course, the controller cleared
the crew to conduct the VOR/DME approach and told them to
call Bahrain Tower.
At 1926, the first officer told Bahrain Tower that the aircraft
was eight DME, established. The tower controller cleared
the crew to land and said that the surface wind was from 090
degrees at eight knots.
The aircraft was at 1,678 feet and 224 knots when the captain
told the first officer flaps one and gear down.
The captain then said OK, visual with airfield and disengaged
the autopilot and the flight director; the autothrottles remained
engaged (see Figure 1, page 4).
The aircraft was about 2.8 nautical miles (5.2 kilometers) from
the runway at 976 feet AGL and 207 knots when the captain
said, Have to be stabilized by five hundred feet. The airlines
SOPs required that a visual approach be stabilized before the
aircraft was flown to 500 feet AGL.

At 1925, the aircraft was about 7.7 nautical miles (14.3

kilometers) from Runway 12 about 2.7 nautical miles (5.0
kilometers) from the final approach fix (FAF) when the
captain told the first officer to call established.

The crew selected the flaps 2 position.

At the time, airspeed was 272 knots. The report said that
airspeed was excessive throughout the approach and that an
airspeed restriction below 10,000 feet was not specified by
the regulations governing the airspace in which the aircraft
was being flown or by the airlines SOPs. (After the accident,
Gulf Air specified an airspeed limit of 250 knots below 10,000
feet during normal operations.)

These remarks showed that the captain believed that from

that point in the approach, a successful landing could not be
achieved, the report said. The SOPs call for a go-around
action at this stage.

At 1927:06, the captain said, Were not going to make it. He

repeated the statement six seconds later.

The captain told the first officer to request clearance to conduct a

360-degree left turn. The controller approved the crews request.

FLIGHT SAFETY FOUNDATION ACCIDENT PREVENTION DECEMBER 2002

Flight Path of Gulf Air Airbus A320 and Selected Cockpit Voice Recorder Data and
Flight Data Recorder Data; Muharraq, Bahrain; Aug. 23, 2000
30

1
1926:36 "OK, visual with airfield"

3N
m

4N
m

1926:44 AP disconnect, 215 kt, 1,111 ft

2N
m

Accident Site

1930:00 Last FDR record 282 kt, 105 ft, pitch 6 down

1N
m

1927:13 196 kt, 672 ft

1929:58 "Gear's up, flaps " 269 kt, 288 ft

1929:57 Last recorded position

1927:25 "Gulf Air 0 7 2 request 3 60 to the left"

1929:51 GPWS Warning starts, 221 kt, 1,004 ft, pitch 12.7 down
1928:57 "We overshot it"
1929:42 "Speed, overspeed limit" 193 kt, 1,058 ft
1929:15 "Go around flaps" 140 kt, 597 ft, pitch 7.7 up
1929:30 "Heading 300, climb 2,500 ft"
BAH
1929:41 Master warning starts 191 kt, 1,054 ft

Note: All times are local.

Nm = Nautical miles kt = Knots ft = Feet AP = Autopilot GPWS = Ground-proximity warning system FDR = Flight data recorder
BAH = Bahrain VOR/DME (very-high-frequency omnidirectional radio/distance-measuring equipment)
Source: Bahrain Accident Investigation Board

Figure 1
The report said that the controller should have told the flight
crew to conduct the missed approach procedure because the
crew neither had told the controller that they had acquired
visual contact with the airport nor had canceled their instrument
flight rules (IFR) flight plan.
The report said that the captain apparently decided to conduct
the turn to reduce altitude and airspeed.
The captain performed this unsafe act without prior briefing
[of] his first officer and in the absence of any valid operational
necessity, such as an unexpected emergency, the report said.
The aircraft was about 0.9 nautical mile (1.7 kilometers) from
the runway and at 584 feet AGL when the captain began the
turn. Airspeed was 177 knots. Recorded flight data recorder
(FDR) data indicated that the flap configuration was changed
from flaps 2 to flaps 3 and then to flaps FULL during
the turn.
The report said that selection of the flaps FULL position
was not appropriate.
Flaps FULL is a flap setting intended only for the final
phases of flight: approach and landing, the report said. It

is generally selected when a landing can be accomplished.

Due to the associated drag, flaps FULL is not a setting for
maneuvering.
About 1928:17, the captain called for the Landing checklist.
Eleven seconds later, the first officer said that the Landing
checklist was complete.
FDR data showed that the airplanes altitude during the left
turn ranged from 965 feet [AGL] to 332 feet AGL and that the
airplanes bank angle reached a maximum of about 36 degrees,
the report said.
The report said that the captain apparently used external visual
cues, rather than the information displayed on the aircrafts
flight instruments, to control aircraft attitude and bank angle.
Standard rate of turn is three degrees per second; the accident
aircrafts average rate of turn was four degrees per second.
The SOPs require [the pilot not flying to] make call-outs in
respect of flight parameters, the report said. However, despite
a number of deviations from standard particularly in attitude,
bank angle and altitude the CVR showed no evidence of
such call-outs or any other relevant comments from the first
officer.

FLIGHT SAFETY FOUNDATION ACCIDENT PREVENTION DECEMBER 2002

The tower controller told investigators that the turn appeared

to be very tight.

11 seconds. The report said that deflection of the control reached

9.7 degrees; maximum forward (and aft) deflection is 16 degrees.

He stated that he had never seen that kind of approach before,

and he asked his tower colleague to look at this, the report
said.
An approach controller told investigators that the turn appeared
unusual and tight.

During this time, the airplanes pitch attitude decreased from

about five degrees nose-up to about 15.5 degrees nose-down,
the recorded vertical acceleration decreased from about +1.0
g [i.e., standard gravitational acceleration] to about +0.5 g,
and the airspeed increased from about 193 knots to about 234
knots, the report said.

He indicated that he has seen other 360-degree turns but that

they are usually not done so tight or so close to the runway
threshold, the report said.

The report said that when the captain applied forward sidestick,
he likely was experiencing a strong but false physical sensation
that the aircraft was pitching up.

At 1928:57, the captain rolled the aircraft wings-level on a

heading of about 211 degrees. At the time, the aircraft was
crossing the extended runway centerline. The captain said, We
overshot it. He then rolled the aircraft into a left turn, and
engine power was increased.

Even though the aircrafts instruments were displaying its

true pitch attitude, this information was not utilized by the
captain, the report said. It was effectively this nose-down
sidestick input that set in train the final sequence of events
leading to the accident.

About 1929:07, the captain told the first officer to tell the
controller that they were going around. The autothrottles
were disengaged, and takeoff/go-around (TOGA) power was
selected.

About 1929:51, the aircraft was descending through 1,004 feet

AGL at 221 knots, when the ground-proximity warning system
(GPWS) generated an aural sink rate warning.

SOPs for a go-around include increasing the aircraft pitch

attitude to 15 degrees nose-up. FDR data indicated that the
aircrafts pitch attitude initially reached nine degrees nose-up
but decreased to about five degrees nose-up over the next 25
seconds.
The controller asked the crew if they wanted radar vectors to
establish the aircraft on the final approach course. The first
officer said yes. The controller then told the crew to fly a
heading of 300 degrees and to climb to 2,500 feet.
During this time, the flaps were moved to position 3 and
the [landing] gear was selected up, the report said. FDR data
showed that the gear remained retracted until the end of the
recording.
The captain flew the aircraft in a shallow climb to 1,054 feet
AGL. The aircraft was crossing the runway wings-level and
on a heading of 040 degrees at 1929:41, when the aural flapoverspeed warning sounded. Airspeed was 191 knots; the limit
airspeed is 185 knots for flaps position 3.
The first officer said speed, overspeed limit.
At this time, the aircraft was being flown toward the gulf. There
was no moonlight, and no lights were visible on the horizon.
Thus, the visual horizon was unlikely to be distinguishable
over the sea, the report said.
FDR data indicated that, beginning at 1929:43, the captains
sidestick control was held forward of the neutral position for about

There should have been an instant response from the captain

pull up to full-back stick and maintain in accordance
with the SOP, the report said. The A320 FCOM [flight crew
operating manual] further states, During night or IMC
(instrument meteorological conditions), apply the procedure
immediately. Do not delay reaction for diagnosis.
At 1929:52, the GPWS generated an aural whoop whoop,
pull up warning. The warning was repeated once each second
for the next nine seconds.
Gulf Air procedures for response to a GPWS warning of
whoop whoop, pull up stipulate that full back stick is to be
employed and maintained, and that during night conditions,
the response should be immediate, the report said.
At 1929:52, the captain said flaps up. FDR data indicated
that the captains sidestick then was moved aft of the neutral
position to a maximum deflection of 11.7 degrees.
However, the FDR data showed that this nose-up command
was not maintained and that subsequent movements never
exceeded 50 percent of full-aft availability, the report said.
FDR data indicated no movement from the first officers
sidestick throughout the approach and accident sequence.
SOPs require that if a captain does not respond appropriately
to a GPWS warning, the first officer should assume that the
captain is incapacitated and take control of the aircraft.
In this case, it appears that the captain as well as the first
officer did not comprehend the criticality of the aircrafts attitude
and increasing proximity to the ground, the report said.

FLIGHT SAFETY FOUNDATION ACCIDENT PREVENTION DECEMBER 2002

The aircraft continued to descend.

to GPWS warnings and spatial disorientation, and that the airlines

flight-data-analysis program was not functioning satisfactorily.

At 1929:59, the captain said flaps all the way.

The first officer said zero. This was the last crew statement
recorded by the CVR.
The FDR data showed continuous movement of the flap
position toward the 0 position after the captains flaps up
command, the report said. The last flap position recorded on
the FDR was about two degrees of extension. The last recorded
pitch attitude was about six degrees nose-down, and the last
recorded airspeed was about 282 knots.
FDR data indicated that TOGA selection and corresponding
maximum engine thrust remained until the end of the
recording.
The aircraft broke into several pieces on impact. Autopsies
and toxicological tests indicated that all the occupants died of
blunt-force trauma.
There was no evidence of any thermal injuries or carbonmonoxide inhalation, the report said.
Most of the wreckage was recovered from about three meters
(10 feet) of water, and there was no indication of structural
failure, flight-control failure or fire before impact. Both engines
were producing power on impact.
The FDR and CVR were recovered the day after the accident;
the underwater-locator beacons had separated from both
recorders during impact.
The digital aircraft integrated data system recorder (DAR) also
was recovered but contained no flight data.
The DAR provides easy access for downloading data for
condition monitoring and trend analysis, the report said.
Although the DAR is not crash-protected like FDRs and
CVRs, the unit from GF-072 was recovered in relatively good
condition with only impact marks to the case.
However, subsequent examination revealed that no data had
been recorded on the [DAR] tape, and the tape was found at
the beginning of the track.
The report said that Flight Safety Foundation research on CFIT
accidents identified several common factors, including night
conditions, limited-visibility conditions, unstabilized approaches,
loss of situational awareness and uncertainty about altitude.
Nearly all these factors were present in the accident to
GF-072, the report said.
The report said that the airlines pilot-training programs at the
time of the accident were deficient in CFIT prevention, response

The report said that although Airbus A320 pilot-training

materials include a GPWS pull-up demonstration, the airline
did not require a GPWS pull-up demonstration during pilot
training at the time of the accident.
During post-accident tests that replicated the accident flight in
an A320 flight simulator, pilots moved the sidestick either fully
aft or halfway aft when the GPWS warning sounded and
maintained the sidestick deflection to recover from the dive. The
report said that with the sidestick moved fully aft, about 300
feet of altitude was lost during recovery; with the sidestick moved
halfway aft, about 650 feet of altitude was lost during recovery.
In another scenario, a recovery was performed by the copilot
after he verified that the captain took no action to recover from
the GPWS whoop whoop, pull up alert, the report said. The
copilot depressed the priority button on his sidestick,
announced his control override and applied full-aft sidestick
input. In this scenario, the simulator recovered with about 400
feet of altitude loss.
In another test, instead of rolling the aircraft out of the turn on
a heading of 211 degrees, the pilots continued the turn at a
moderate bank angle to align the aircraft with Runway 12
and continue the approach and landing.
In these demonstrations, the pilots were able to successfully
land on Runway 12 from the 360-degree turn, the report said.
However, the pilots noted that the approach was not stabilized
and a short amount of time was available to successfully
complete the final approach and landing.
The report said that the captain apparently experienced high
workload, a high level of stress and information overload while
conducting an unplanned and unpracticed maneuver at low
altitude with negligible external visual references and in a highdrag aircraft configuration. The captains workload further
was increased by the necessity to respond to the flap-overspeed
warning.
Under this very high workload and stressful situation, and with
his conscious attention focused on the flap overspeed in the last
moments before impact, the captain did not possess sufficient
spare information-processing capacity to perceive and respond
to the information from the aircrafts instruments, the report
said. Information from the instruments was filtered out. The
overall lack of situational awareness demonstrated by the captain
was evidence of information overload on the part of the captain.
A study conducted by the U.S. Naval Aerospace Medical
Research Laboratory indicated that the captain experienced a
somatogravic illusion while he focused his attention on
responding to the flap-overspeed warning during the goaround. Although the aircrafts pitch attitude was five degrees,

FLIGHT SAFETY FOUNDATION ACCIDENT PREVENTION DECEMBER 2002

the captain perceived that the pitch attitude was approximately

12 degrees.

Gulf Airs flight safety department was staffed by one person

from 1998 to the time of the accident.

In this illusion, the absence of visual cues combined with

rapid forward acceleration creates a powerful pitch-up
sensation, the report said. The somatogravic illusion has been
identified as a significant factor in numerous dark-night takeoff/
go-around accidents. In these accidents, the aircraft involved
were typically accelerating into an area of total blackness.

He did not report directly to the highest executive level within

the company, the report said. This lack of resources within
the flight safety department and its inappropriate corporate
status within the company [were] serious organizational
[deficiencies].

Under such conditions, the somatogravic illusion induced by

the aircrafts acceleration under TOGA power causes the pilot
to perceive that the aircraft is pitching up, and he responds by
making a nose-down input on the controls. As a result, the
aircraft descends and thereafter flies into the ground or water.
At the time of the accident, the airline required an air safety
report to be submitted after a go-around (missed approach)
was conducted.

The report said that the airlines participation in regular

meetings conducted by the International Air Transport
Association (IATA) Safety Committee (SAC) was interrupted
during an unspecified number of years preceding the accident.
This greatly restricted the airlines awareness of new information
and developments in areas such as accident investigation case
studies, safety and risk-management programs, CRM and LOSA
[line operations safety audit] training, safety information systems
and safety management programs, the report said.

Although Gulf Air stated that its policy was not to take action
against any pilot who had conducted a missed approach, it
was apparent that, at the time of the accident, a perception
existed on the part of some company pilots that a missed
approach would be regarded unfavorably by company
operational management, the report said.

The report said that after the accident, the airline resumed
participation in IATA SAC meetings.

After the accident, the airline issued a fleet instruction that

said, No disciplinary action whatsoever will be taken against
any crew that elects to carry out a go-around for safety-related
reasons, including inability, for whatever reason, to stabilize
an approach by the applicable minimum height. Gulf Air also
prohibited 360-degree turns and other maneuvers for descentprofile adjustments on final approach.

A review of correspondence between DGCAM and Gulf Air

revealed numerous letters citing a lack of compliance with
[civil aviation regulations], the report said. The evidence
indicated that in some safety areas, Gulf Air did not effect
timely changes when problems were identified by DGCAM.

The report said that the CVR transcript indicated an absence

of CRM by the accident pilots; the captain conducted the final
portion of the flight as if it were a single-pilot operation, and
the first officer was not assertive.
The captain did not utilize effectively the first officer, a
valuable resource, the report said. The first officer performed
routine procedural functions and made little significant
contribution to the conduct of the last critical phases of the
flight. He deferred to all of the captains decisions and
actions, even though they involved the violation of SOPs.
At the time of the accident, Gulf Air was developing CRM
training programs. The report said that, as of May 2001, the
airline had implemented a generic CRM ground school
program for flight crew and cabin crew but had not
implemented type-specific CRM flight simulator training and
line-oriented flight training (LOFT) for A320 flight crew.
Gulf Air [said] that these [training programs] are expected to
be introduced along with the annual recurrent CRM training
program during the year 2002, the report said.

The Oman Directorate General of Civil Aviation and

Meteorology (DGCAM) was responsible for regulatory
oversight of the airline.

Based on these findings, the AIB made the following

recommendations to the DGCAM:
Review whether safety oversight surveillance is
adequate to ensure airlines timely compliance with all
critical regulatory requirements;
Ensure that Gulf Air updates the [CRM] program by
integrating it in [LOFT] in accordance with DGCAM
regulatory requirements, and consider implementing a
[LOSA] program;
Ensure that Gulf Air reviews and enhances, in
accordance with DGCAM regulatory requirements, the
A320 flight crew training programs to ensure full
compliance with the [SOPs] and increase the
effectiveness of the first officer. The training in CFIT
avoidance and GPWS responses should be augmented
by including it in the recurrent training program, with a
detailed syllabus in accordance with DGCAM
requirements. The Approach-and-landing Accident
Reduction (ALAR) Tool Kit, produced by Flight Safety
Foundation with extensive airline-industry input, could
be a key element in the updated training program;

FLIGHT SAFETY FOUNDATION ACCIDENT PREVENTION DECEMBER 2002

 Ensure that Gulf Air companys training and evaluation

of flight crew performance consistently meets the
required DGCAM standards;

Ensure that the management of Gulf Air complies with

civil aviation regulatory requirements effectively and
expeditiously.

Consider requiring Gulf Air to include in its flight

crew training programs (initial as well as recurrent)
comprehensive information on spatial disorientation;

The AIB recommended that Bahrain Civil Aviation Affairs

enhance guidance to air traffic controllers for addressing
requests from pilots to execute non-standard maneuvers (such
as an orbit [i.e., 360-degree turn]) during the final approach.
When on final approach, requests from pilots to conduct nonstandard maneuvers should only be approved by controllers
after they have ascertained the required safety parameters.

Ensure that Gulf Air reviews and improves the

functioning and utilization of the A320 flight data
analysis system, in accordance with DGCAM regulatory
requirements; [and,]
Consider requiring Gulf Air to augment [its] accidentprevention strategies and adopt programs, such as the
Procedural Event Analysis Tool (PEAT [a software-based
analytic tool developed by Boeing Commercial Airplanes
to help identify factors contributing to flight crew
nonadherence to SOPs]), and implement a comprehensive
integrated safety and risk management program.
The AIB made the following recommendations to Abu Dhabi,
Bahrain, Oman and Qatar:
Ensure that the civil aviation regulatory authority for
Gulf Air (DGCAM) [has your] full and continuing
support in implementing regulatory compliance by
the airline; and,

The AIB made the following recommendations to the

International Civil Aviation Organization (ICAO):
Consider making the following a standard applicable
in all classes of airspace: a speed limit of 250 knots
below 10,000 feet AMSL [above mean sea level]; [and,]
Consider prohibiting non-standard maneuvers (such as
orbit) when an aircraft is on the final approach, unless
safety considerations demand otherwise.
[FSF editorial note: This article, except where specifically
noted, is based on the Bahrain Accident Investigation Board
(AIB) Accident Investigation Report: Gulf Air Flight GF-072,
Airbus A320-212, Reg. A40-EK, on 23 August 2000 at Bahrain.
The 126-page report contains illustrations and appendixes.]

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Accident Prevention
Copyright 2002 by Flight Safety Foundation Inc. All rights reserved. ISSN 1057-5561
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FLIGHT SAFETY FOUNDATION ACCIDENT PREVENTION DECEMBER 2002