reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2000 A320 LOC following orbit after unstable app Bahrein

Brief account : 

The A320 was fast on the night VMC VOR/DME approch. The Captain declared "visual" and disconnected the autopilot, realised that the aircraft was not in a position to land  and called for an "orbit" on short final. After this the aircraft was still not in a position to land and a go-around was called for. The Captain appeared to become disoriented during the GA and lost control  resulting in a crash into into the sea.   

Crew-related factors : 

The Captain (PF) was relatively experienced, but the F/O had only been on line for 4 months after an initial training failure. He had 600 hours total and was probaly underconfident and non-assertive.  The VOR/DME approach conducted by the Captain was satisfactory in the initial vertical profile, but the speed was seriously excessive.   

After the first approach the "orbit" was flown in an inappropriate configuration, primarily by limited visual cues which resulted in significant height oscillations, and did not place the aircraft properly for a second approach. This resulted in the second missed approach, a manually flown go-around, during which multiple GPWS warnings occurred but were ignored.

The report noted that there was no record of a briefing being carried out, and that after disconnecting the autopilot the Captain had effectively operated the aircraft on his own, with no involvement of the F/O. Neither pilot had received CRM training.

If PicMA had been the SOP, then it is likely that

1) a positive briefing would have taken place, and the F/O would have executed the VOR/DME approach with a more conservative attitude to speed control, resulting in a more stable approach 

2) if the approach had still been unstable (fast) , the Captain might have called for a go-around or a 360 earlier and the F/O would probably have flown it according to the SOP.

3) in the same situation, if the Captain had assumed control the F/O might have been more instrument-oriented; both pilots were evidently "head-up" during the orbit with limited ground cues. They may have been suffering disorientation due to somatogravic effects and the absence of cues over the sea at night. 

Type: 
A320-200
Where: 
Bahrein AP Bahrein
Expected weather: 
Visual
Pilot in charge: 
Capt
Early transition: 
Yes
Go-around : 
At or above DH/A
Damage: 
Serious
PicMA potential: 
Major
Year: 
2000
Time: 
Night
Deterioration: 
No
Vert Guidance: 
None
Both Head Up: 
Yes
LoC: 
Yes
Operator: 
GulfAir
Fully prepared: 
No
Actual Weather: 
None relevant
Autopilot : 
Y
CCAG: 
High