B732, vicinity Tamanrassat Algeria, 2003

Summary: 

On 6 March 2003, a Boeing 737-200 being operated by Air Algerie had just become airborne during a daylight departure when the left hand engine suddenly failed just after the PF had called for gear up . Shortly afterwards, the aircraft commander, who had been PNF for the departure, took control but the normal pitch attitude was not reduced to ensure that a minimum airspeed of V2 was maintained and landing gear was not retracted. The aircraft lost airspeed, stalled and impacted the ground approximately 1nm from the point at which it had become airborne. A severe post crash fire occurred and the aircraft was destroyed and all on board except one passenger, were killed.

Event Details
When: 
06/03/2003
Event Type: 
Day/Night: 
Day
Flight Conditions: 
On Ground - Normal Visibility

18938

Flight Details
Aircraft: 
Operator: 
Type of Flight: 
Public Transport (Passenger)
Flight Origin: 
Intended Destination: 
Take-off Commenced: 
Yes
Flight Airborne: 
Yes
Flight Completed: 
No
Phase of Flight: 
Take Off
Location
Location - Airport
Airport: 
General
Tag(s): 
Inadequate Aircraft Operator Procedures
FIRE
Tag(s): 
Post Crash Fire
HF
Tag(s): 
Inappropriate crew response - skills deficiency, Inappropriate crew response (technical fault), Ineffective Monitoring, Procedural non compliance
LOC
Tag(s): 
Loss of Engine Power, Flight Management Error, Aircraft Flight Path Control Error
AW
System(s): 
Electrical Power, Engine - General
Contributor(s): 
Component Fault in service
Outcome
Damage or injury: 
Yes
Aircraft damage: 
Hull loss
Non-aircraft damage: 
Yes
Non-occupant Casualties: 
No
Occupant Injuries: 
Few occupants
Occupant Fatalities: 
Most or all occupants
Off Airport Landing: 
Yes
Ditching: 
Yes
Causal Factor Group(s)
Group(s): 
Aircraft Operation, Aircraft Technical
Safety Recommendation(s)
Group(s): 
Aircraft Operation
Investigation Type
Type: 
Independent

Description

On 6 March 2003, a Boeing 737-200 being operated by Air Algerie had just become airborne during a daylight departure when the left hand engine suddenly failed just after the PF had called for “gear up”. Shortly afterwards, the aircraft commander, who had been PNF for the departure, took control but the normal pitch attitude was not reduced to ensure that a minimum airspeed of V2 was maintained and landing gear was not retracted. The aircraft lost airspeed, stalled and impacted the ground approximately 1nm from the point at which it had become airborne. A severe post crash fire occurred and the aircraft was destroyed and all on board except one passenger, were killed.

The Investigation

The Accident Investigation was carried out by a specially established Commission of Inquiry. The Final Report of this Commission stated that “The accident was caused by the loss of an engine during a critical phase of flight, the non-retraction of the landing gear after the engine failure, and the Captain, the PNF, taking over control of the airplane before having clearly identified the problem.”

It is also stated in the Final Report that “The following factors probably contributed to the accident:

  • the perfunctory flight preparation, which meant that the crew were not equipped to face the situation that occurred at a critical moment of the flight;
  • the coincidence between the moment the failure occurred and the request to retract the landing gear;
  • the speed of the event that left the crew little time to recover the situation;
  • maintaining an inappropriate rate of climb, taking into account the failure of one engine;
  • the absence of any teamwork after the engine failure, which led to a failure to detect and correct parameters related to the conduct of the flight (speed, rate of climb, configuration, etc.);
  • the takeoff weight being close to the maximum with a high aerodrome altitude and high temperature;
  • the rocky environment around the aerodrome, unsuitable for an emergency landing.”

The Commission of Inquiry made Safety Recommendations as follows:

  • Air Algérie, along with other operators, ensure that their CRM-type training programs effectively heighten crew awareness of the strict respect required for handover procedures and task-sharing.
  • The Civil Aviation and Meteorology Directorate set up an organisation to inspect the application and conformity of the procedures in training programs for flight crews.
  • The Civil Aviation and Meteorology Directorate ensure that Air Algérie and other operators set up a flight safety program that associates feedback and the systematic analysis of flight data.
  • The Ministry of Transport set up a permanent organisation for the investigation of civil aviation accidents and incidents.

Related Articles

Further Reading

SKYbrary Partners:

Safety knowledge contributed by: