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Crash of an Airbus A320-212 off Bahrain: 143 killed

Date & Time: Aug 23, 2000 at 1930 LT
Type of aircraft:
Operator:
Registration:
A4O-EK
Survivors:
No
Schedule:
Cairo - Bahrain - Muscat
MSN:
481
YOM:
1994
Flight number:
GF072
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
135
Pax fatalities:
Other fatalities:
Total fatalities:
143
Captain / Total flying hours:
4416
Captain / Total hours on type:
1083.00
Copilot / Total flying hours:
608
Copilot / Total hours on type:
408
Aircraft flight hours:
17370
Aircraft flight cycles:
13990
Circumstances:
On 23 August 2000, at about 1930 local time, Gulf Air flight GF072, an Airbus A320-212, a Sultanate of Oman registered aircraft A4O-EK, crashed at sea at about 3 miles north-east of Bahrain International Airport. GF072 departed from Cairo International Airport, Egypt, with two pilots, six cabin crew and 135 passengers on board for Bahrain International Airport, Muharraq, Kingdom of Bahrain. GF072 was operating a regularly scheduled international passenger service flight under the Convention on International Civil Aviation and the provisions of the Sultanate of Oman Civil Aviation Regulations Part 121 and was on an instrument flight rules (IFR) flight plan. GF072 was cleared for a VOR/DME approach for Runway 12 at Bahrain. At about one nautical mile from the touch down and at an altitude of about 600 feet, the flight crew requested for a left hand orbit, which was approved by the air traffic control (ATC). Having flown the orbit beyond the extended centreline on a south-westerly heading, the captain decided to go-around. Observing the manoeuvre, the ATC offered the radar vectors, which the flight crew accepted. GF072 initiated a go-around, applied take-off/go-around thrust, and crossed the runway on a north-easterly heading with a shallow climb to about 1000 feet. As the aircraft rapidly accelerated, the master warning sounded for flap over-speed. A perceptual study, carried out as part of the investigation, indicated that during the go-around the flight crew probably experienced a form of spatial disorientation, which could have caused the captain to falsely perceive that the aircraft was ‘pitching up’. He responded by making a ‘nose-down’ input, and, as a result, the aircraft commenced to descend. The ground proximity warning system (GPWS) voice alarm sounded: “whoop, whoop pull-up …”. The GPWS warning was repeated every second for nine seconds, until the aircraft impacted the shallow sea. The aircraft was destroyed by impact forces, and all 143 persons on board were killed.
Probable cause:
The factors contributing to the above accident were identified as a combination of the individual and systemic issues. Any one of these factors, by itself, was insufficient to cause a breakdown of the safety system. Such factors may often remain undetected within a system for a considerable period of time. When these latent conditions combine with local events and environmental circumstances, such as individual factors contributed by “frontline” operators (e.g.: pilots or air traffic controllers) or environmental factors (e.g.: extreme weather conditions), a system failure, such as an accident, may occur.
The investigation showed that no single factor was responsible for the accident to GF072. 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 SOP’s.
(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 airline’s 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.
Final Report:

Crash of a Boeing 707-123B in Bahrain

Date & Time: Aug 19, 1979
Type of aircraft:
Operator:
Registration:
5B-DAM
Survivors:
Yes
Schedule:
Larnaca - Bahrain
MSN:
17628/7
YOM:
1958
Flight number:
CY402
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
73
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
93.00
Circumstances:
The four engine airplane landed hard on runway 30 at Bahrain-Muharraq Airport. It bounced then landed on its nose gear first. Upon touchdown, the nose gear collapsed and the airplane slid on its nose for few hundred meters then veered to the right and came to rest. All 81 occupants escaped uninjured while the aircraft was damaged beyond repair. It appears the aircraft was unstable during the last segment.

Crash of a Pilatus PC-6/B1-H2 Turbo Porter in Bahrain

Date & Time: Dec 15, 1969
Operator:
Registration:
HB-FCY
Flight Type:
Survivors:
Yes
MSN:
650
YOM:
1967
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances in Bahrain while on a delivery flight to the operator Borneo Skyways based in Indonesia. The aircraft was written off.

Crash of a Vickers 607 Valetta C.1 in Bahrain

Date & Time: Aug 4, 1954
Type of aircraft:
Operator:
Registration:
VX557
Flight Type:
Survivors:
Yes
YOM:
1950
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Bahrain Airport, the crew encountered technical problems with the undercarriage that remained down. The pilot obtained the permission to return for an emergency landing when all undercarriage collapsed upon touchdown. The aircraft slid for several yards and came to rest, damaged beyond repair. There were no injuries.

Crash of a Douglas DC-4-1009 off Bahrain: 40 killed

Date & Time: Jun 15, 1950 at 0153 LT
Type of aircraft:
Operator:
Registration:
F-BBDM
Survivors:
Yes
Schedule:
Saigon – Karachi – Bahrain – Paris
MSN:
42990
YOM:
1946
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
45
Pax fatalities:
Other fatalities:
Total fatalities:
40
Captain / Total flying hours:
10550
Copilot / Total flying hours:
2100
Aircraft flight hours:
8705
Circumstances:
The approach to Bahrain was completed by night. On final approach, the aircraft christened 'Ciel de Gascogne' hit the water surface and crashed into the Persian Gulf, few hundred yards from the runway 29 threshold. First rescuers arrived on site about four hours later. Three crew members and ten passengers were rescued while 40 other occupants were killed.
Crew:
Robert Plamont, pilot, †
Mr. Cartier, copilot,
Mr. Thibaud, radio officer,
Lucien Duval, radio officer, †
Mr Franco, mechanic,
Mr. Gourhaut, steward,
Roland Rimbol, steward, †
Mrs. Hervé, stewardess.
Probable cause:
Failure of the pilot in command to adopt the timed approach procedure to the prevailing conditions. Having descended to 300 feet, the pilot in command did not take the appropriate measures to maintain this altitude until such time as the runway lights became visible. At the time of the accident, the airport of Bahrain was not equipped radio landing aids and suitable runway approach lights, which was considered as a contributory factors.
Final Report:

Crash of a Douglas DC-4-1009 off Bahrain: 46 killed

Date & Time: Jun 13, 1950 at 0116 LT
Type of aircraft:
Operator:
Registration:
F-BBDE
Survivors:
Yes
Schedule:
Saigon – Karachi – Bahrain – Paris
MSN:
42937
YOM:
1946
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
44
Pax fatalities:
Other fatalities:
Total fatalities:
46
Captain / Total flying hours:
19500
Copilot / Total flying hours:
2750
Aircraft flight hours:
8128
Circumstances:
The approach to Bahrain was completed by night and limited visibility (1,370 meters). About 5,200 meters short of runway 29 threshold, the aircraft christened 'Ciel de Picardie' hit the water surface and sank by 12 feet in the Persian Gulf. First rescuers arrived on site about eight hours later. Two crew members, the captain and the radio officer, and four passengers, were rescued while 46 other occupants were killed.
Crew:
J. Sladek, pilot,
Raoul Saury, copilot, †
Yvan Moulis, radio navigator, †
M. Collard, radio officer,
Jacques Michel, mechanic, †
Nicole Combaret, stewardess, †
Roger Bertru, steward, †
Roland Bequet, steward. †
Probable cause:
The pilot in command did not keep an accurate check of his altitude and rate of descent during the timed approach procedure, thus allowing his aircraft to fly into the surface of the sea. The possibility that the pilot-in-command was feeling the effects of fatigue cannot be ruled out. At the time of the accident, the airport of Bahrain was not equipped radio landing aids and suitable runway approach lights, which was considered as a contributory factors.
Final Report:

Crash of a Short S.25 Sandringham V off Bahrain: 10 killed

Date & Time: Aug 22, 1947 at 0400 LT
Type of aircraft:
Operator:
Registration:
G-AHZB
Survivors:
Yes
Schedule:
Hong Kong – Karachi – Bahrain – London
MSN:
SH-38C
YOM:
1946
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
The approach to Bahrain was completed by night and the crew landed in the Marine Base at an indicated speed of 85 to 90 knots. Upon landing, the seaplane had a tendency to nose down so the captain counteracted with the control column and increased power simultaneously. The aircraft bounced, left water for about one to two seconds and then veered sharply to the left. Out of control, it plunged into water and came to rest. Three crew members and seven passengers were killed.
Probable cause:
Wrong approach configuration and poor landing technique on part of the crew, causing the aircraft to land hard.

Crash of a Curtiss C-46A-40-CU Commando off Bahrain: 34 killed

Date & Time: Sep 22, 1944 at 1850 LT
Type of aircraft:
Operator:
Registration:
42-107360
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Habbaniyya – Bahrain – Karachi
MSN:
27047
YOM:
1944
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
30
Pax fatalities:
Other fatalities:
Total fatalities:
34
Circumstances:
The crew was performing a fuel stop in Bahrain on a flight from Habbaniyya to Karachi. After take off, while climbing to a height of some 800 feet, the aircraft banked left and dove into the sea. All 34 occupants were killed.