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of Bahrain International Airport.
GF-072 had departed from Cairo International
Airport, Egypt, with two pilots, six cabin crew
and 135 passengers on board, on a scheduled
flight to Bahrain.
GF-072 was on an instrument flight rules
(IFR) flight plan.
The aircraft was cleared for a VOR/DME
approach for Runway 12 at Bahrain.
About 1 nm from the touchdown and at an
altitude about 600 feet, the crew requested a
left hand orbit, which ATC approved.
Accident Synopsis
(Cont)
Having flown the orbit beyond the extended
centre-line on a south-westerly heading, the
crew initiated a missed approach.
Observing the manoeuvre, the ATC offered
a radar vector, which the crew accepted.
GF-072 crossed the runway on a northeasterly
heading with a shallow climb to
about 1000 feet.
Accident Synopsis
(Cont)
The master warning (for flaps-overspeed)
sounded.
GF-072 entered into a descent. Within a few
seconds a ground proximity (GPWS) warning
sounded
The GPWS warning lasted for about nine seconds
until impact
The aircraft was destroyed by impact forces, and
all 143 persons on board were killed
Accident Synopsis
(Cont)
The accident happened in our own
back yard (Bahrain)!

GF 072 Accident Report
Findings
“The investigation showed that all the latent
organisational and management conditions
that had precipitated the accident to GF 072
were present long before the accident.”
Regulatory Oversight Recommendation B-01-8 in report !
President and Chief Executive
James Hogan –May 2002
The Change Begins !
Analysis and Consultation with Prof. Rob Lee
GF 072 Accident Investigator
Event Analysis template
GF 072 Corrective Action Plan
(Accident Report Released May/June 2002)
http://www.bahrainairport.com/caa/civil_gf072.htm
GF 072 Follow-up table V-6 14/09/2003
The table outlines the status review and action plan to address the Safety Recommendations made in the Accident
Report.
SAFETY
RECOMMENDATION
CORRECTIVE ACTION PLAN TARGET
DATE
TANGIBLE
EVIDENCE
FOLLOW-UP
BY
STATUS
(B-01-2)
To ensure that Gulf Air
updates the CRM programme,
by integrating it in LOFT in
accordance with DGCAM
regulatory requirements …
CRM Programme introduced 01
Nov 00
LOFT introduction for ab-initio
training in lieu of route
exercises
LOFT introduction in progress
in lieu of event training:
--
01/03
Flt Ops
newsletter
12/00 Edition
09/01
OM D and in
lesson plans:
B767 -09/10/02
Airbus30/11/02
OM D and in
Lesson plans:
VPO Office
HOFST
HOFST
Closed
Closed
- B767 fleet 09/10/02 B767 -09/10/02 Closed
- All Airbus fleets 30/11/02 Airbus30/11/02 Closed
All flight instructors undergone
NOTECH courses as per OM D
GF is embarking on 3 year
programme of introduction of
AQP in conjunction with new
Ongoing
Start
April
2003
OM D
Correspondence
& program
HOFST
HOFST
Closed
Open
(on-going)
DGCAM team (POI & POM)
Find out what went wrong ? –
Reason’s Model – Accident Causation
OPERATIONS
LATENT DEFICIENCIES IN DEFENCES
(HOLES IN THE DEFENCES - SWISS CHEESE MODEL)
DEFENCES
BARRIERS
The Reason Model: the Organisational
Accident
ACCIDENTS
&
SERIOUS
INCIDENTS
WORKPLACE
local conditions
ERRORPRODUCING
CONDITIONS
VIOLATIONPRODUCING
CONDITIONS
ORGANISATION
organisational
Deficiencies:
latent conditions
MANAGEMENT
DECISIONS
AND
ORGANISATIONAL
PROCESSES
TASKING
PERSON
group/team
VIOLATIONS
ERRORS
Limited coping resources can get nibbled away
Accumulat ion of minor
event s. N ot so much
holes as st eady
at t r it ion
(Re ason , 2 000 )
Defences
IInnddivivididuuaal/l/TTeeaammaaccttioionnss
TTaasskk//EEnnvviriroonnmmeennttaallccoonnddititioionnss
OOrrggaannisisaattioionnaallffaaccttoorrss
LLoosssseess
DANGER
Hazards
Causes
Investigation
Latent
condition
pathways
Stages in the development and investigation of an organisational
accident
(Adapted from
Reason, 1997)
Flight Safety References
(You don’t have to re-invent the wheel)
”Managing the risks of Organisational Accidents”,
　
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