The Subtlety of Instinct: The crash of Gulf Air flight 072
On the 23rd of August 2000, a Gulf Air Airbus A320 bound for Bahrain descended into the sea while attempting to execute a missed approach, killing all 143 people on board in a tragedy which shocked the tiny Persian Gulf nation. When the commission of inquiry retrieved the black boxes from the shallow sea bed off Bahrain, they revealed an approach which was hopelessly unstable from the very beginning, as the pilots pressed on toward the runway even though they were not properly lined up to land. In an attempt to correct the situation, the captain initiated a series of non-standard maneuvers in manual flight at very low altitude, only to find that he had made the situation worse. Disoriented and frustrated, he abandoned the approach — but within seconds he began to pitch down instead of up, propelling the plane into the sea even as the ground proximity warning system screamed at him to pull up. The sequence of events which led him to that point, and the psychological traps which sealed their fate, provide a stark warning of how mounting stress and lax adherence to rules can precipitate errors which a trained pilot would never normally make.
Registered in March 1950 by a British entrepreneur, Gulf Air is one of the longest continuously operating airlines in the Middle East, with services throughout the Persian Gulf region and beyond. Although the airline was originally a private company with a significant stake held by the British Overseas Airways Corporation, the independence of several Gulf states from Britain in the early 1970s led to a change of ownership. In 1973, the governments of Bahrain, Oman, Qatar, and Abu Dhabi (later the United Arab Emirates) bought out Gulf Air’s existing stakeholders and turned the airline into a joint flag carrier, which was legally based in Oman but rotated its chairmanship between representatives of the four countries every five years.
Today, Qatar, the UAE, and Oman have withdrawn from the consortium in order to focus on their own independent airlines, but Gulf Air remains the flag carrier of Bahrain, a tiny but wealthy petrostate located on a small island off the coast of Saudi Arabia. At the turn of the millennium, however, this breakup had not yet occurred, and this is where we pick up the story of the airline’s deadliest accident, on a dark and sweltering night on the Persian Gulf in the summer of 2000.
On the afternoon of the 23rd of August that year, a Gulf Air Airbus A320, registered as A4O-EK, began boarding at the gate in Cairo, Egypt for flight 072 to Bahrain. In command was 37-year-old Captain Ihsan Shakeeb, a Bahraini national with around 4,400 flying hours, of which just 85 were as pilot in command. As far as A320 captains are concerned, it would be hard to find many who were less experienced. And his Omani copilot, 25-year-old First Officer Khalaf Saeed Al Alawi, was even newer, with only 608 flight hours — so Captain Shakeeb knew he would need to be on top of his game.
Also on board flight 072 were 135 passengers and 6 flight attendants, bringing the total number of occupants to 143. Most of the passengers were from Egypt and Bahrain, but 17 nationalities were represented, including a diverse cabin crew featuring flight attendants not only from Bahrain and Oman, but also Morocco, India, the Philippines, and Poland — a microcosm of Gulf society itself, where (disenfranchised) expatriates far outnumber locals.
At 16:52 local time, flight 072 finally departed — 52 minutes behind schedule, thanks in part to a clerical error which sent the pilots to the wrong gate. The delay, which pushed their expected landing in Bahrain deeper into the hours of darkness, may have played an unexpected role in the tragedy which followed. Another coincidence, however, saved a life: an Egyptian man who was booked on flight 072 was turned away at security because his Bahrain work permit was not in order. Unfortunately, any survivor’s guilt he may have later felt was compounded, as his now-vacant seat was promptly sold to the woman in line behind him.
The flight east to Bahrain was uneventful, as the sun set behind them at 18:06 and night fell over Arabia. By 19:21, flight 072 was well into its descent and in contact with approach control in the city of Dammam, on the coast of Saudi Arabia across the strait from Bahrain. Descending out of 14,000 feet, the crew received permission from Dammam to begin their approach: “Gulf Air 072, self-navigation for runway one two is approved. Three point five as well approved, and Bahrain Approach one two seven eight five approved.”
Captain Shakeeb acknowledged the clearance, which allowed them to navigate to the start of the approach for runway 12 at Bahrain, descend to 3,500 feet, and contact Bahrain approach control. Signing off, Shakeeb said, “Have a good day,” then turned to his First Officer. “Call Bahrain and tell them we are going for runway one two,” he ordered.
“Bahrain Approach, salam alaikum, Gulf Air 072,” said First Officer Al Alawi. “We copied information tango and runway one two is approved.”
Flight 072 intended to perform a VOR/DME instrument approach to Bahrain’s runway 12 from the northwest. To fly this approach, the pilots needed to fly toward the VOR (VHF omnidirectional range), a radio beacon at Bahrain Airport, on a heading of 121 degrees, and then descend to certain altitudes at certain distances from the runway, according to their DME, or distance measuring equipment. While VOR/DME approaches in bad weather can be quite challenging, the weather over the Gulf that night was clear with hardly a cloud in the sky, so the difficulty normally associated with such an approach was rather diminished.
In response to First Officer Al Alawi’s transmission, the Bahrain controller said, “Gulf Air 072 Bahrain Approach, good evening to you, identified on handover. Runway one two, cleared self position, and uh, as you’re cleared by [Dammam]. Confirm three thousand five hundred feet?”
Normally, flights were cleared down to 3,500 feet by Dammam before the handoff to Bahrain, and the controller wanted to confirm that this was the case. But Captain Shakeeb had a different impression: “Tell them we are cleared to seven thousand,” he said, even though they had in fact been cleared to 3,500, as Dammam had said “three point five approved.”
Al Alawi dutifully complied. “We are cleared to seven thousand, Gulf Air 072,” he said.
In response, Bahrain cleared them to continue the descent to 3,500 feet. But Captain Shakeeb seemed to have planned the descent thus far in the belief that they would only be cleared to 7,000 feet, and now they needed to scramble to get down. Consequently, Shakeeb pitched down and descended rapidly, causing their speed to increase.
Meanwhile, as they neared the start of the approach, Shakeeb announced, “Approach checklist please.”
“Briefing?” Al Alawi asked.
“Confirmed,” said Shakeeb. It would later be noted that the briefing, which covered basic items such as target speeds and altitudes, navigational aids, and the standard missed approach procedure, was not heard on the 30-minute cockpit voice recorder tape. So did an approach briefing actually take place? We’ll probably never know.
As the pilots ran through more checks, the controller cleared them to descend to 1,500 feet and asked them to report established on the VOR/DME approach. First Officer Al Alawi acknowledged.
The pilots then reviewed their target speed indicators, or “bugs,” checked their seat belts, and confirmed their altimeters were correctly set. All appeared normal. Captain Shakeeb asked Al Alawi to set up the VOR so he could align with the runway, and he complied. “Okay, speed, ALT STAR, approach, nav…” Shakeeb said, reading off autopilot and authothrottle modes.
“Check,” said Al Alawi.
“Now you see you have to be ready for all this, okay?” Shakeeb said, pointing out how quickly he had set up the plane’s advanced automation.
“Okay,” said Al Alawi.
“Now I’ve just changed all the flight plan, RAD NAV, everything for you, before you even blink,” Shakeeb continued. “Yeah? Okay, got it?”
“Okay, got it,” Al Alawi replied, passively accepting his captain’s boastful lesson.
By 19:25, flight 072 had lined up with the runway from a distance of 9 nautical miles, but their airspeed was out of control, reaching a blistering 313 knots following their rapid descent. According to the proper VOR/DME approach procedure, they needed to be stabilized and fully configured for landing by the final approach fix, or FAF, which was located at 5 nautical miles from the runway. In this case, “fully stabilized and configured” meant on course, at an altitude of 1,500 feet and a speed of 136 knots with the flaps and landing gear fully extended. It should have been obvious that they would be unable to meet these targets — they had perhaps a minute in which to lose more than half their airspeed, which was completely impossible, especially given that they were also too high. Just four miles from the FAF, they were still at 1,800 feet, but the only way to get down to 1,500 was to descend faster, which would cause their speed to increase even more. And if they couldn’t get their speed below 177 knots, they would also be unable to fully extend the flaps, which provide extra lift for low-speed flight. Every flap setting — the A320 has five — comes with a speed limit, and it’s important that gross exceedances are avoided, or else the flaps could be damaged.
Despite the self-evident fact that they could not stabilize the approach, Captain Shakeeb pressed onward. At 7.7 nautical miles, he told First Officer Al Alawi to “Call established,” and Al Alawi radioed air traffic control to report that they were established on the VOR. Moments later, with the FAF at 5 miles fast approaching, Captain Shakeeb called for flaps 1 and landing gear down, completing both at the last possible second. Almost immediately thereafter, flight 072 reached the FAF, still nowhere near configured. Their speed was 223 knots instead of 136, they were 162 feet too high, and the flaps were still in position 1 (the available positions being 0, 1, 2, 3, and FULL). At this point, standard operating procedures called for the pilots to make a missed approach, circle back, and try again. But instead, Shakeeb announced “Visual with the airfield,” and switched from VOR/DME approach procedures to visual approach procedures.
Shakeeb may have been exploiting the fact that a visual approach, flown by eye, only requires that the flight path be stabilized and the plane fully configured by an altitude of 500 feet, which in this case would be 1.7 miles from the runway. By abandoning the stricter instrument-based VOR/DME approach and switching to visual flight rules, he seemingly bought himself more time to configure the airplane. Even so, it didn’t take a genius to realize that there was still no way they were going to make it.
As Shakeeb switched to the visual approach, he disconnected the autopilot, triggering a cavalry charge alarm. “Autopilot’s coming off,” he said.
“Check,” Al Alawi said, silencing the alarm.
“Flight directors off,” Shakeeb added.
“Off,” said Al Alawi.
The flight directors assist pilots in flying an instrument approach or other standardized procedure by generating “command bars” on the primary flight display, which tell the pilot to fly up, down, left, or right in order to achieve a certain pre-programmed course or aircraft attitude. But in a visual approach, there was no need for them, so he made Al Alawi turn them off.
“Have to be stabilized by 500 feet,” Shakeeb said.
“Yes,” said Al Alawi.
In the background, a flight attendant could be heard announcing, “Ladies and gentlemen, the no-smoking sign has now been illuminated. Please ensure that you carefully extinguish your cigarettes…”
Seconds later, however, Captain Shakeeb finally admitted the obvious. “(Damn),” he said, “we’re not gonna make it.”
“Yeah,” said Al Alawi.
“Flaps two,” Shakeeb ordered.
“Speed, check, flaps two,” said Al Alawi.
“We’re not gonna make it man,” Shakeeb repeated. “Fuck.”
“[That’s] a problem,” Al Alawi agreed. “Flaps at two.”
At this point, the proper course of action would be to level off, fly straight ahead, climb to 2,500 feet, and circle around for another attempt, which was the standard missed approach procedure for runway 12. But that would involve admitting defeat, and Captain Shakeeb wasn’t ready to do that — instead, he had a better idea. “Tell him [we] do a three six zero left,” he said.
Shakeeb’s plan was to salvage the approach by making a 360-degree left orbit, buying time to lose airspeed and altitude, before circling back to finish the approach. Earlier in the approach this would have been a prudent move, but by now, at an altitude of just 584 feet and barely one mile from the runway threshold, it was much too late. In fact, standard operating procedures prohibited this sort of maneuvering after passing the FAF — but that wasn’t going to stop him.
“Gulf Air 072, request three six zero to the left,” First Officer Al Alawi said to air traffic control.
“Approved, sir,” said the controller.
At that moment, Captain Shakeeb began turning the aircraft to the left, initiating the orbit at a distance of 0.9 nautical miles from the runway. As he did so, he called for flaps 3, then flaps full, bringing the airplane into the proper landing configuration. However, his manual flying skills appeared less than stellar. He was unable to maintain a consistent bank angle or pitch attitude, and at first the plane climbed to 965 feet before descending sharply. The bank angle reached 36 degrees, beyond the value normally used in flight, which would have been disconcerting to the passengers. And to make matters worse, once they had turned around, the lights of Bahrain disappeared behind them, and the pilots were faced with a black hole, as the empty waters of the Persian Gulf on a moonless night provided no visual references. Nevertheless, as Captain Shakeeb manhandled the plane through the orbit, the pilots hurried through the landing checklist, calling “Landing checklist complete” at 19:28 and 28 seconds.
However, trying to make a tight circle at low altitude with no outside reference and at full flaps, which decrease maneuverability, was far from easy, and it was clear that Shakeeb had bitten off more than he could chew. His control inputs were large and erratic, and in the end he leveled out too early, bringing the plane out of the orbit after turning only 270 degrees, rather than 360. Having descended to an altitude of 332 feet, the plane was now flying perpendicular to the runway course, with zero hope of landing.
“Runway in sight… 300,” said First Officer Al Alawi, spotting the runway in approximately their 10 o’clock position.
“Gulf Air 072, cleared to land runway one two,” the controller interjected.
“Cleared to land runway one two, Gulf Air 072,” Al Alawi read back.
Several seconds went by as Captain Shakeeb searched for the runway, before he eventually found it, far to their left. “Fuck, we overshot it,” he exclaimed. He turned sharply toward the runway, but it was immediately obvious that there was nothing he could do. Clicking his tongue in disappointment, he pushed the thrust levers to takeoff/go-around power and said, “Tell him going around.”
“Gulf Air 072, going around,” Al Alawi reported.
Having recognized the inconvenient truth of their situation, Shakeeb had finally decided to perform a go-around, climbing away to start their approach again. The time was 19:29 and 8 seconds.
“I can see that, 072,” the controller said. “Sir, uh, would you like radar vectors for final again?”
“Go-around flaps,” Shakeeb said, instructing Al Alawi to begin retracting the flaps. At that moment, the controller concluded his transmission, and Shakeeb immediately said, “Yes.”
“We’d like radar vectors, Gulf Air 072,” Al Alawi transmitted.
“Go-around flaps set,” Shakeeb said, confirming that the flaps had been retracted from “FULL” to position 3.
Within seconds, the engines spooled up to takeoff/go-around, or TOGA power, propelling the airplane up and away. But not all was done by the book: proper procedure called for the pilot to maintain 15 degrees pitch up during the go-around, but their actual pitch attitude never reached this value. Instead, the acceleration from the A320’s low-slung engines momentarily pushed the nose up to 13.7˚, before Captain Shakeeb eased it back down to just 5˚, well below the normal value. Now, with the plane in a very shallow climb with the engines set to nearly full power, their airspeed began to increase rapidly, much faster than the pilots were probably expecting.
As this was happening, the crew continued to work through the missed approach checklist, reconfiguring their airplane for the climb. “Speed check, positive climb, gear up,” First Officer Al Alawi called out, and a rumble in the background confirmed that the gear was retracting.
At that moment the controller interjected, “Roger, fly heading three hundred, climb two thousand five hundred feet.”
“Heading three hundred, climb two thousand five hundred feet, Gulf Air 072,” Al Alawi read back.
“Heading?” Shakeeb asked.
“Yes, three hundred,” Al Alawi confirmed.
“Right? Left?” Shakeeb asked. He wanted to know whether he should reach 300 degrees by turning right, or by continuing the left turn they were already in.
But at 19:29 and 41 seconds, before First Officer Al Alawi could answer the Captain’s question, a continuous, repetitive chime began to sound, warning that they were flying too fast with the flaps in position 3. Simultaneously, a caution message appeared on the screen of their Electronic Centralized Aircraft Monitoring system, or ECAM. The message read “OVERSPEED — VFE …. 185,” reminding them that the maximum speed with flaps 3 was 185 knots. In response, First Officer Al Alawi called out, “Speed, over speed limit!”
In the middle of a go-around, in an already high-workload situation, the flap overspeed warning was the last thing Captain Shakeeb needed. He let out an expletive, cutting into a transmission from air traffic control: “And contact approach, one two seven eight five, sir.”
“One two seven eight five,” Al Alawi read back.
During the crucial five-second period between 19:29:40 and 19:29:45, several things happened all at once. At 19:29 and 41 seconds, at exactly the same time as the flap overspeed alarm sounded, with the plane in a climbing left turn back away from the runway, the last visible lights disappeared from view, replaced by the pitch black expanse of the Persian Gulf. At that point, the only way for the pilots to determine their attitude was by referring to the attitude indicators on their primary flight displays, or PFDs. However, between their attempts to set the flaps and identify the reason for the flap overspeed problem, it is unlikely that they were looking at them.
Instead, the sudden loss of visual references caused Captain Shakeeb to experience what is known as a somatogravic illusion.
Besides the five primary senses, humans have several additional senses, including the ability to determine the orientation of one’s body in space. However, the somatosensory and vestibular systems, which regulate this sense of balance, cannot distinguish between acceleration and gravity. This means that an acceleration which pushes a person back into their seat is not inherently distinguishable from an increase in pitch attitude, where the sensation of being “pushed back” is caused by gravity. However, the human brain tends to interpret this sensation as being caused by gravity regardless of whether this is the case, giving rise to the somatogravic illusion — the belief that one is pitching up when one is actually accelerating. This sensation can be suppressed by orienting oneself in relation to visual references, but if no visual references exist — for example, on a moonless night over water — then the illusion is extremely powerful.
Because of this phenomenon, pilots are rigorously drilled to rely on their instruments and ignore physiological sensations when flying in clouds or darkness. Nevertheless, for whatever reason, Captain Shakeeb found himself caught out by the somatogravic illusion, as the plane accelerated rapidly into the go-around. And so, at 19:29 and 43 seconds, just two seconds after the last visible lights disappeared, he grabbed his sidestick and began semi-consciously pitching down in an attempt to counter a pitch-up which didn’t actually exist. He then held his stick in that position for 11 seconds, until the pitch angle reached 15 degrees nose down, at which point the Airbus’s flight envelope protection systems kicked in and stopped the nose from dropping farther.
Although the flight envelope protections averted an outright loss of control, their altitude peaked at about 1,050 feet, and the plane began to descend. First Officer Al Alawi had just called out “Speed checks, flaps three,” when suddenly the Ground Proximity Warning System, or GPWS, announced, “SINK RATE!”
“Flaps up,” Captain Shakeeb ordered, still focused on the flap overspeed problem.
“WHOOP WHOOP, PULL UP!” the GPWS blared. “WHOOP WHOOP, PULL UP! WHOOP WHOOP, PULL UP! WHOOP WHOOP, PULL UP!”
Captain Shakeeb uttered an expletive, and First Officer Al Alawi said, “Gear’s up, flaps…”
“WHOOP WHOOP, PULL UP!” the robotic voice repeated, over and over. “WHOOP WHOOP, PULL UP! WHOOP WHOOP, PULL UP!”
“Flaps all the way,” Shakeeb ordered. He began to pull the nose up, but only slightly, and the plane continued to descend.
“WHOOP WHOOP, PULL UP!” the GPWS repeated.
“Zero,” Al Alawi said, moving the flap lever to the fully retracted position.
One last time, the GPWS called out, “WHOOP WHOOP, PULL UP!”
And then, with a sickening crunch, Gulf Air flight 072 plowed directly into the Persian Gulf, pitched 6.5 degrees nose down and traveling at a speed of 280 knots. The high-speed impact ripped the plane apart in the blink of an eye, sending shattered debris tumbling and cartwheeling through the shallow water. By the time it came to a halt, all 143 passengers and crew were dead, consumed by the night-dark sea.
News of the crash spread quickly, as the accident’s repercussions shook the entire Gulf region and beyond. Bahrain declared three days of national mourning over what had proven to be among the tiny country’s worst peacetime disasters, and distraught crowds gathered at the airport in Cairo, desperate for news of their loved ones. At the accident site some 4 kilometers northeast of the airport, rescue teams and divers sifted through debris under about 3 meters of water, searching for the bodies of the victims. And amid all of this activity, Bahrain appointed a special commission of inquiry to carry out the most important task of all: finding the cause of the accident, so that it may never happen again.
When investigators reviewed the contents of the black boxes, they learned that after the go-around was initiated, the plane climbed slightly, then simply descended straight into the sea, while fully under control. In fact, the sole proximate reason for the descent was the captain’s 11-second nose-down input during the go-around, which caused the plane to pitch over from 5 degrees nose up to 15 degrees nose down, the maximum that a pilot could command on the A320.
Obviously, a pilot would not intentionally put the plane into such a steep descent during a go-around, when the objective is to climb. Instead, the captain’s pitch down had all the hallmarks of spatial disorientation, or more specifically, the somatogravic illusion, described earlier in this article. A study of the actual and perceived pitch sensations during the final minute of the flight was conducted by the United States Naval Aerospace Medical Research Laboratory, which confirmed that from the moment the go-around started at 19:29 and 8 seconds, the requisite conditions existed for a somatogravic illusion to occur, and in fact Captain Shakeeb’s inputs were consistent with its presence from the very beginning. Instead of achieving the required 15-degree nose-up attitude prescribed by the standard operating procedures, he made nose-down inputs which limited the pitch-up to only 5 degrees, which suggested some level of disorientation in pitch early in the go-around. Furthermore, the low climb angle caused the plane to accelerate faster than normal, which only compounded the strength of the illusion, until Shakeeb eventually reacted by putting the plane into a descent, of which he apparently remained unaware until the end.
In principle, Shakeeb should have been well aware of the fact that he could not rely on sensory cues while performing maneuvers in darkness, and he had probably even received training which discussed the somatogravic illusion specifically, since the danger it poses to aviators has been well known since the early years of powered flight. Therefore, the simple fact that a somatogravic illusion could have occurred did little to explain why Shakeeb fell victim to it.
Several factors can contribute to an otherwise trained pilot reacting, perhaps instinctively, to an illusory pitch-up sensation, of which the most important are probably lack of attitude awareness, workload, and stress. An examination of the final minutes of the flight revealed how these factors built upon one another until a critical situation developed.
From the very beginning, the approach was all but doomed to failure, mostly because of the flight’s grossly excessive airspeed. The high speed might have come about by some combination of poor descent planning and misheard clearances, and was then exacerbated by Captain Shakeeb’s failure to use the speed brakes to their fullest extent, allowing speed to build up as the plane descended to its initial approach altitude of 1,500 feet. Investigators noted that most airlines prohibit flight above 250 knots while below 10,000 feet, but that Gulf Air inexplicably did not, nor were there any speed restrictions imposed within the Dammam or Bahrain air traffic control sectors. The absence of such limitations may have contributed to the pilots’ lack of concern about their speed, which had ballooned to 313 knots by the time they were 9 miles from touchdown. Such a high airspeed so late in the approach was unacceptable and should have been cause for a go-around all by itself.
Instead, Captain Shakeeb decided to press on. When they reached the final approach fix for the VOR/DME approach, they were neither stabilized nor configured to land; again, they should have gone around, but they did not. Instead, Shakeeb switched to a visual approach, which allowed him to wait longer before reaching a stabilized condition, but this target could not be met either. And yet still, Shakeeb resisted going around, as he chose instead to violate standard operating procedures by making a 360-degree orbit at low altitude in a last-ditch attempt to get back on track. (Here investigators set aside some slight criticism for the air traffic controller. There was no procedure which explicitly told him what to do if a pilot requested a non-standard maneuver on final approach, but according to good practice, he should not have approved the pilots’ request to make the orbit without first confirming that they were visual with the runway and had climbed to the minimum safe altitude of 1,500 feet.)
In an attempt to explain why Shakeeb was so resistant to going around, investigators noted that the airline required pilots to file an occurrence report every time they conducted a go-around, explaining the circumstances of the decision. These reports were not anonymized, and some Gulf Air pilots believed that management would disapprove if they went around too often. The resulting pressure could have been significant, but even so, the decision to orbit at low altitude was inappropriate, and in fact set the stage for the disaster, as will soon be seen.
The orbit was made at altitudes as low as 332 feet above the sea, while in full manual flight without the guidance of a flight director, under conditions of total darkness, with the flaps fully extended, while the pilots were trying to complete the landing checklist and communicate with air traffic control. This put Captain Shakeeb, as the flying pilot, in a situation where the workload was extremely intense. It was also clear that he lacked manual flying experience, given his large and sometimes erratic inputs, which resulted in excessive bank angles and a presumably unwanted increase in altitude. It was at this point that Shakeeb first began to lose situational awareness. Having apparently lost track of his position, he rolled out of the orbit on a heading perpendicular to the runway course, and even after the First Officer called out “runway in sight,” it took him around 10 seconds to find it. By now he was becoming frustrated and anxious, as evidenced by his repeated swearing, and he was probably approaching the limit of his flying knowledge and ability.
Although the decision to go around at this point was unavoidable, the maneuver only added more things for him to think about. Having earlier turned off the flight directors in order to navigate visually to the runway, they remained off as he initiated the go-around, robbing him of a helpful flying aid. Had his flight director been turned on, the flight director pitch command bar on his PFD would have indicated a target pitch angle of 15 degrees, reminding him to achieve the standard go-around attitude. Perhaps if it had been there, he would have been able to reach the correct pitch with minimal mental effort. In the event, however, he seemed barely aware of their pitch, as he called for configuration changes, attempted to turn to their new heading, and frequently interrupted himself to tell First Officer Al Alawi how to respond to air traffic control. By this point the somatogravic illusion was probably starting to kick in, causing Shakeeb to instinctively push the nose forward, even as his mind remained elsewhere.
And then, into this high-strung situation came the flap overspeed warning, right as the last visual references disappeared. Already saturated with tasks, this event dealt a fatal blow to Shakeeb’s ability to keep control of the situation. As he focused on the ECAM display, the fault message, and the warning, he pushed the nose even further down, putting the plane into a descent. From that point on, however, his attention was consumed by the flaps. There was no standard procedure for dealing with a flap overspeed warning — the solution is obvious enough; one simply retracts the flaps. Nor is this a critical emergency which is likely to endanger the aircraft. But as they tried to figure out why the warning was sounding and what they were going to do about it, both pilots likely became fixated on the flap indications and the ECAM, which were located in the center of the instrument panel, drawing their attention away from their PFDs, which showed them pitched 15 degrees nose down and diving toward the sea.
It was then that a truly remarkable thing happened: the ground proximity warning system burst to life, calling out “SINK RATE,” followed by no less than nine calls of “WHOOP WHOOP, PULL UP,” and yet, somehow, neither pilot reacted. For 11 seconds, the warnings blared as the plane dropped toward the sea, and not only did the pilots express no sense of alarm, they simply kept discussing the flaps as though nothing else was wrong. Simulator tests would later show that if they had reacted to the warnings by pulling up in a timely manner, they would have saved the airplane. But they never did.
How is it that a pilot could simply ignore an alarm telling him that he’s about to crash? Such things occasionally happen when the pilot is, for whatever reason, expecting a false alarm, but this was clearly not the case on flight 072. Instead, investigators theorized that against all odds, Shakeeb and Al Alawi simply never heard the warnings. And pilots, before you laugh — it’s not as crazy as it sounds.
Recall that by this point in the sequence of events, the pilots were fully task saturated. In the 25 seconds leading up to the start of the GPWS warnings, they flew manually through a climbing turn with no flight director, made two configuration changes, discussed their assigned heading, responded to two calls from air traffic control, and exceeded the maximum speed with flaps 3, at which point a continuous repetitive chime started ringing in the cockpit. It was a lot to absorb in such a short period of time — perhaps too much. There is a limit to the number of stimuli which the human brain can track simultaneously, and under conditions of high stress and intense workload, the brain can reach a point at which it simply stops processing new inputs. Captain Shakeeb, and perhaps First Officer Al Alawi, probably reached this point when their already complex non-standard go-around was interrupted by the flap overspeed warning. Moments later, their attitude indicators began showing a pitch down, and the GPWS started to blare, but they did not perceive these stimuli, because their brains had already reached the maximum number of tasks that could be processed simultaneously.
In such situations, the brain will unconsciously prioritize certain stimuli over others, in the process “shedding” those deemed less critical, often without a clear reason. One of the purposes of rigorous training is to reorganize this subconscious hierarchy of tasks into something that makes sense in real life. That’s why it’s so important that pilots routinely practice responding to GPWS warnings, even though it might seem obvious that the correct response is to pull up. However, in the case of flight 072, investigators were surprised to discover that GPWS responses did not appear to be covered in Gulf Air’s recurrent training program. Both pilots had undergone a single GPWS response scenario as part of a module on controlled flight into terrain accidents during their initial training, but that was it.
A lack of experience responding to GPWS warnings turned out to be far from the only deficiency affecting this particular crew. First of all, neither was very experienced — Captain Shakeeb was new to the role of pilot in command, and First Officer Al Alawi was new to flying in general. This might have been fine most of the time, but it was perhaps more problematic given that neither of them were exemplary airmen. Captain Shakeeb almost failed his command examination when he scored a “D” in two categories involving engine failures on takeoff. Under Gulf Air’s rules, three D’s in one check ride would have resulted in an automatic fail.
But it was First Officer Al Alawi whose performance raised the most eyebrows. Al Alawi in fact failed his first A320 proficiency check in October 1999 after scoring a D in localizer/DME approaches, VOR/DME approaches, normal landings, crosswind landings, landings from non-precision approaches, automation and technology, and engine failure procedures — a staggering list of deficiencies. He was sent to retraining and passed a second check seven days later, but the scale of his initial failure suggested that he was, at best, a marginal pilot. This fact was confirmed in January 2000, while Al Alawi was still undergoing line training under an instructor’s supervision. On a flight out of Abu Dhabi, Al Alawi’s plane struck debris on takeoff, causing damage which prevented the airplane from pressurizing. An investigation by local authorities criticized the flight crew’s handling of the incident, citing “poor airmanship and awareness” during the emergency. As a result, Al Alawi was given remedial training before returning to regular flight duties.
According to interviews with other Gulf Air pilots, Al Alawi’s personality was also lacking. Captains who had flown with him said he was disciplined and polite, but by and large they described him using words such as “timid,” “meek,” “shy,” “mild,” and “reserved.” Some pilots felt that Al Alawi would be unlikely to challenge a captain who made a mistake. One instructor captain even decided to test this question by intentionally exceeding the taxiing speed limit during a training flight to see if Al Alawi would point it out. Needless to say, he did not.
These traits interacted unfavorably with some of Captain Shakeeb’s known tendencies, which included a tinge of overconfidence and perhaps stubbornness. This dynamic was evident throughout flight 072. During the initial part of the approach, Shakeeb boasted about his ability to set up the flight management system quickly, as though he were showing off his knowledge in order to compensate for his inexperience as a commander. This could conceivably have contributed to his insistence on avoiding a go-around, as though abandoning the approach would somehow undermine the image he was trying to project. However, such a conclusion risks descending into the weeds of unprovable speculation.
More importantly, the dynamic between the two crewmembers resulted in missed opportunities to avoid or correct some of Captain Shakeeb’s many errors. According to the principles of crew resource management, or CRM, the Captain should make use of the First Officer’s input in order to come to collective decisions about the flight, but that was not what happened on flight 072. Instead, Captain Shakeeb made all the decisions himself; Al Alawi offered no input, nor did Shakeeb ask for any. Instead, Al Alawi faithfully executed Shakeeb’s commands, like some kind of robot, even after Shakeeb began intentionally violating standard operating procedures. Al Alawi’s duty as First Officer was to call out any deviations, such as excessive speed, high bank angle, or insufficient pitch during a go-around, but he never did so. And he certainly never said, “We’re too close to the runway to do an orbit; we should follow the standard missed approach procedure and climb straight ahead to 2,500 feet.” If he had, the accident wouldn’t have happened.
The poor CRM skills displayed by the crew of flight 072 were symptomatic of a broader disregard for the latest safety practices at Gulf Air. In fact, Gulf Air previously had an informal CRM training program between 1992 and 1997, but when new management took over the airline, the program was dropped. The airline’s Manager for Human Factors tried to restart the program, but quit after his efforts went nowhere. In June 1999, Oman began requiring that airlines registered in the country have an approved CRM program, but Gulf Air was slow to set one up, and by the time of the accident in August 2000 it had barely made any progress.
A review of records kept by Oman’s Directorate General of Civil Aviation and Meteorology, or DGCAM, which was responsible for regulating the country’s airline industry, revealed that this was hardly the only area where Gulf Air was not doing its best to uphold safety standards. The DGCAM had in fact been finding violations at the airline for many years, which resulted in lots of strongly worded letters and broken promises by Gulf Air executives. At various points Gulf Air had been punished with sanctions such as the revocation of permission to fly ferry flights with inoperative engines or fly certain distances away from alternate airports. A number of crew licenses had been suspended for adverse findings. The former Principal Operations Inspector for Gulf Air stated the airline fell short of regulatory requirements in areas including quality management, safety awareness, and duty time limits. The airline had suffered non-fatal accidents in the past, but safety findings from the incidents weren’t distributed to pilots. The airline had previously attended International Air Transport Association safety meetings, but stopped going in the mid-1990s, around the time it came under new leadership. Gulf Air’s safety department consisted of a single employee who didn’t report to senior management. And in 1998, a review of Gulf Air by the International Civil Aviation Organization found that not only was the airline not meeting regulatory requirements, its executives were actively opposing Oman’s plan to overhaul its civil aviation regulations.
Based on this evidence, it was clear that Gulf Air had allowed a lax safety environment to develop, wherein adherence to standard procedures and quality of training were allowed to slip. The accident made these failings all too apparent, and in the aftermath, Gulf Air’s existing leadership was replaced in order to start from a clean slate. Numerous reforms followed. In September 2000, the airline suspended new instructor appointments in order to improve its instructor selection criteria, strengthened its command suitability exams for First Officers seeking to upgrade to Captain, and suspending its ab-initio training program. A new probationary period was added for newly promoted Captains, in which an instructor would observe them from the jump seat in order to judge how they interacted with real First Officers, and the DGCAM mandated that simulator training be performed with a trainee in one seat and an instructor in the other — Gulf Air had previously allowed two trainees in the simulator simultaneously. The airline also increased the frequency of training scenarios involving go-arounds and GPWS warnings, introduced a 250-knot speed limit below 10,000 feet, developed a confidential incident reporting system, and implemented an Airbus-supplied modification which would cause the flight directors to engage automatically when a go-around is initiated.
The story of Gulf Air flight 072 provides several useful lessons which have not diminished in significance even after more than 20 years of advancements in aviation safety. Most importantly, the events of flight 072 demonstrate in vivid detail how a progression of small errors of judgment and poor adherence to standard procedures can place pilots into a situation where they are capable of making gross errors that would never have otherwise occurred. No pilot thinks they could succumb to a somatogravic illusion or ignore ten consecutive GPWS warnings, and Captain Ihsan Shakeeb, were he alive to hear about it, would surely have been horrified to learn that he did so. But as he deviated farther and farther from standard practices and prescribed routines, conducting daring low-altitude maneuvers while flying manually and without visual reference, he steadily increased the risk of a catastrophic mistake. Even so, he was unlucky, but to kill 143 people, you only need to be unlucky once.
In the months before this article was written, there were some notable incidents around the world which bore a resemblance to Gulf Air flight 072. On January 10th 2023, a Qatar Airways Boeing 787 was departing Doha under nighttime conditions with the First Officer at the controls, when a loss of spatial awareness occurred. After climbing to 1,600 feet, the airplane began to descend, reaching a descent rate of 3,000 feet per minute and triggering a flap overspeed warning, before the Captain intervened and pulled the plane out at 800 feet above the water. There have also been reports of a similar incident involving a United Airlines Boeing 777 on takeoff from Kahului, Hawaii, in December 2022, although official information which could verify the nature of the event has not yet emerged. In any case, these incidents were averted by timely action in response to warnings — the last line of defense which failed in the case of Gulf Air flight 072. It would be better, however, if the need to execute a last-minute recovery could be avoided altogether, through conservative decision-making and careful consideration of risk. To that end, perhaps this tragic tale of a flight crew who steered a perfectly good airplane into the sea might provide something of value to those whose job is to make sure that never, ever happens.
Join the discussion of this article on Reddit
Support me on Patreon (Note: I do not earn money from views on Medium!)
(NEW!) Follow me on Twitter
Visit r/admiralcloudberg to read and discuss over 230 similar articles