Landing (descent or approach)

The pilot's failure to extend the landing gear, his improper aborted landing procedure, and inadvertent stall/mush. Factors in the accident were an improper adjustment of the landing gear warning horn system by company maintenance personnel, and the failure of the pilot to utilize the pre-landing checklist.

The instructor pilot's decision to initiate a go-around procedure after landing in the last third portion of the runway with the right engine inoperative, an insufficient runway length and an aircraft's weight that required to stay on the ground. The following contributing factors were identified:
- The decision of the crew to continue the flight after the failure of the right engine that required an immediate landing,
- The crew failed to follow the checklist,
- Failure of the instructor pilot to proceed to an adequate approach briefing,
- Wrong approach configuration,
- Lack of awareness about the runway's characteristics on part of the pilot-in-command,
- The total weight of the aircraft was above the permissible limit,
- Lack of crew coordination,
- The crew mistakenly feathered the left propeller.

Controlled flight into terrain while completing a turn on final approach, in night conditions, towards an airport of daytime operations only, as mentioned in the Aeronautical Information Publication (AIP).

Deterioration and failure of the oil filter converter plate gasket, which resulted in a loss of engine power and a subsequent in-flight fire.

The loss of left engine power as a result of the owner's failure to overhaul the engine before further flight after the lubrication system was found contaminated with metal. Contributing factors were the pilot's decision to fly the aircraft with a non-operating landing gear system, which resulted in a forced landing, and the lack of suitable terrain for the forced landing.

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.

The pilot's failure to preflight plan adequate fuel for the flight that resulted in fuel exhaustion and the subsequent loss of engine power.

Pilot's failure to follow instrument procedures and descended below approach minimums and collided with trees. A factor was low clouds.