Bahrain

Cracks as result of fatigue caused the fracture of the hinge arm of the left main gear strut. The cracking most likely occurred as result of corrosion that remained undetected during the last maintenance inspection. The origin of pitting could not be identified, the investigation however identified deficiencies in the maintenance task conducted during last overhaul of the gear strut. Incomplete maintenance documentation and tools available during overhaul contributed to the accident.

The accident was caused by the decision to reject the takeoff 12 knots after passing V1 speed. The following factors contributed to the accident:
- Engine Nr 3 experienced a bird strike, causing it to stall. This phenomenon was accompanied by a loud bang, noticed by the crew.
- The aircraft line up at the B1 intersection although the take-off parameters were computed with the full length of the runway.
- The situational awareness of the crew,
- Less than maximum use of deceleration devices.
- Although the RESA conforms to the minimum ICAO requirement, it does not conform to the ICAO recommendation for length.

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.

Engine failure for undetermined reasons.

Failure of the reverse systems after touchdown for undetermined reason.

The aircraft, flying on instruments, drifted north of its normal track because of strong winds and crashed into the mountain. Contributing factors were:
- The winds were stronger than forecast,
- An accurate bearing could not be obtained at Muş, and Van had not been checked,
- Sub-normal temperatures would result in a high indicated altimeter reading,
- Calculations on the flight and contacts with beacons were not coordinated and controlled.