Description

On 25 December 2003, a Boeing 727-200 being operated by UTA (Guinea) on a scheduled passenger flight from Cotonou to Beirut with a planned stopover at Kufra, Libya, failed to get properly airborne in day Visual Meteorological Conditions (VMC) from the 2400 m departure runway and hit a small building 2.45 m high situated on the extended centreline 118 metres beyond the end of the runway. The right main landing gear broke off and ripped off a part of the trailing edge flaps on the right wing. The airplane then banked slightly to the right and crashed onto the beach where it broke into several pieces and ended up in the sea where the depth of water varied between three and ten metres. Of the estimated 163 occupants, 141 were killed and the remainder seriously injured.

Investigation

A National Commission of Inquiry set up by the Benin Government to investigate the Accident delegated the Technical Investigation to the French Bureau d'Enquêtes et d'Analyses (BEA), who conducted their work in accordance with Annex 13 principles. The accident site is shown on the map below reproduced from the official report:

Using calculations based on Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) data, key points in the take off sequence were established as:

• A standing start with bleeds off was used
• At 80 knots, it was about 480 metres since brake release.
• At the V₁ / V_r call, it was about 1,620 metres since brake release and speed was about 137 knots; the co-pilot made an abnormally sharp pitch up to +10° in only two seconds but the aircraft angle of attack remained constant.
• Speed continued to increase and at 140 knots, the roll distance was about 1,780 m.
• At 145 knots elevator angle reached +16° but the angle of attack was only 0.5°.
• Lift off occurred approximately 100 metres before the end of the runway at a speed of 148 knots. As speed reached 155 knots, the first impact occurred.

The Investigation concluded that the aircraft operator was generally disorganised and lacked sufficient documentation, employees and procedures. In particular, operational records appeared to be largely absent and the operator was unable to provide the Investigation with copies of the load and trim sheets either into or out of Cotonou, or any of the other general documentations on aircraft weight. Passengers joining the flight, which had originated at Conakry, Guinea, at Cotonou had been permitted free seating. Problems with excessive cabin baggage were reported by the Senior Cabin Crew Member to the aircraft commander during boarding.

After detailed review, it was concluded that the aircraft had attempted take off at a higher weight than the crew believed was the case and that they had assumed a more aft centre of gravity for the elevator trim setting than was actually the case.

Causes of the Accident

The Investigation concluded that the accident was the result of:

• “the difficulty that the flight crew encountered in performing the rotation with an overloaded airplane whose forward center of gravity was unknown to them” (Direct Cause)
• “the operator’s serious lack of competence, organisation and regulatory documentation, which made it impossible for it both to organise the operation of the route correctly and to check the loading of the airplane” (Structural Cause)
• “the inadequacy of the supervision exercised by the Guinean civil aviation authorities and, previously, by the authorities in Swaziland, in the context of safety oversight. (Structural Cause)

Safety Recommendations

A series of Safety Recommendations were made as a result of the Investigation covering the Approval and Oversight of operators, the International Organisation of Air Transport and Autonomous systems for measuring aircraft weight and balance. They are reproduced below as published:

Guinea and all States that wish to issue Air Operator Certificates urgently draw up complete regulations in accordance with the recommended standards and practices relating to safety in aviation and ensure that they possess the structures and means necessary to enforce these regulations:

• this complete set of national regulations require the precise identification of the owner of aircraft operated and of the companies responsible for their maintenance as well as the effective setting up of a flight safety program;
• this complete set of national regulations include a minimum time period for the examination of the statutory documents and ensure that no provisional approval can be given, whether at the start of operations or when a new aircraft type enters service, if these documents are not complete and satisfactory from the point of view of operational safety;
• the national civil aviation authorities undertake a new and complete examination of the structures and capacities of a carrier each time that there is a significant change in its activity;
• the national civil aviation authorities undertake regular inspections of the various companies involved in the operation of an aircraft in commercial service;
• the national civil aviation authorities ensure that their aerodromes check the loading of aircraft and that a copy of the weight and balance sheet is filed with them;
• the national civil aviation authorities ensure that boarding cards are nominative and that they are checked on boarding.

The ICAO Council:

• vigorously follow up the actions to be taken as a result of the resolutions that the Assembly adopted in the area of safety by affirming its role as the lead actor and conductor where safety is concerned and by endeavouring to ensure, where necessary, that States be made aware of their responsibilities in this area;
• examine all of the provisions relating to safety oversight that are contained in the Chicago Convention and its various Annexes, so as to identify any updates required, in particular in relation to the role of the State of Operator and to the deletion of the distinctions made between scheduled flights and charter flights;
• endeavor to clarify the notion of operator, given the various forms of aircraft leasing and agreements between carriers, in order to avoid the dispersal of responsibilities;
• noting the inevitable complexity in regulations and documentation relating to safety oversight, study the development of a guide, intended for those responsible at a national level for safety matters, that informs them in a structured manner of their responsibilities relating to safety and of the provisions for which they are responsible for ensuring compliance;

States that have a tradition of technical assistance, given the means at their disposal and their long and confident relations with other States, in particular France, study the relevance of their current technical assistance programs in the realm of safety and, where appropriate, reorganise them to support and complete ICAO’s actions.

Civil aviation authorities, in particular the FAA and EASA

• modify the certification requirements so as to ensure the presence, on new generation airplanes to be used for commercial flights, of on-board systems to determine weight and balance, as well as recording of the parameters supplied by these systems

• put in place the necessary regulatory measures to require, where technically possible, retrofitting on airplanes used for commercial flights of such systems and the recording of the parameters supplied.

The Final Report of the Investigation may be seen in full at SKYbrary bookshelf: BEA Report 3x-o031225a (English)

Further Reading

• Aircraft Load and Trim
• Passenger Cabin Loading
• Loading of Aircraft Holds
• Loss of Control
• Takeoff Weight Entry Error and Fatigue (OGHFA SE)