B738, vicinity Douala Cameroon, 2007
B738, vicinity Douala Cameroon, 2007
Summary
On 5 May 2007, a Kenya Airways Boeing 737-800 departing Douala at night crashed shortly after take-off following an unsuccessful attempt at recovery after late recognition of a progressive right roll which led to spiral dive. The Investigation was unable to positively establish the reason for the unintended roll, but noted that it ad not been possible to determine whether the pilots, and in particular the aircraft commander, had been aware of the fact that the AP was not engaged.
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
Climb
Location
Location - Airport
Airport
General
Tag(s)
Inadequate Aircraft Operator Procedures
HF
Tag(s)
Inappropriate crew response (automatics),
Manual Handling,
Procedural non compliance,
Spatial Disorientation,
AP/FD and/or ATHR status awareness
LOC
Tag(s)
AP Status Awareness,
Flight Management Error,
Extreme Bank,
Extreme Pitch
Outcome
Damage or injury
Yes
Aircraft damage
Hull loss
Non-aircraft damage
Yes
Non-occupant Casualties
No
Occupant Fatalities
Most or all occupants
Off Airport Landing
Yes
Ditching
Yes
Causal Factor Group(s)
Group(s)
Aircraft Operation
Safety Recommendation(s)
Group(s)
Aircraft Operation
Investigation Type
Type
Independent
Description
On 5 May 2007, a Boeing 737-800 operated by Kenya Airways on a scheduled passenger flight from Abidjan to Nairobi with a planned stopover at Douala, Cameroon crashed shortly after a dark night take-off from Douala. Loss of control was followed by a high speed inpact with terrain. All 114 occupants on board were killed and the aircraft was destroyed by the ground impact.
Investigation
The investigation of the accident was carried out in accordance with Annex 13 guidelines by a Special Accident Investigation Commission established by the Republic of Cameroon CAA. This found that after take-off from Douala, the AP had not been initially engaged and the aircraft had exhibited a slight tendency to roll to the right “due to the combined effects of the inherent asymmetry from construction and the slightly right positioning of the rudder trim”. The Investigation concluded that this tendency could have been easily corrected with left aileron input, but this was not done. After the bank angle had progressively increased without any compensation for it from the PF, a spiral dive was entered from which a late attempt to regain control was not successful and terrain impact followed. The Investigation was unable to positively establish whether flight crew lack of awareness of AP engagement status lacking but noted that the AP had not been engaged until a very late stage in the flight.
Probable Cause
The Investigation found that:
"The airplane crashed after loss of control by the crew as a result of spatial disorientation (non recognized or subtle type transitioning to recognized spatial disorientation), after a long slow roll, during which no instrument scanning was done, and in the absence of external visual references in a dark night."
"Inadequate operational control, lack of crew coordination, coupled with the non-adherence to procedures of flight monitoring, confusion in the utilization of the AP, have also contributed to this situation."
Safety Recommendations
The Investigating Commission made three Safety Recommendations, the first two of which are addressed primarily to the CAA of Kenya (KCAA):
- “KCAA and all State Administrations that issue licenses for aviation operations should ensure that they harness the necessary structures and means to approve and follow up amendments and revisions of manuals.”
- “KCAA and all State Administrations that issue licenses to aviation operations, ensure that companies put in place an organization that enhance the application of manuals, and decision making in matters of safety especially as concerns technical flight crews.”
The third Recommendation had no specified addressee:
- “It is strongly recommended that all flight crew receive formalized upset recovery training.”
- The Final Report of the Investigation conducted by the Cameroon CAA is at: Technical Investigation into the accident of the B737-800 registration 5Y-KYA operated by Kenya Airways that occurred on the 5th of May 2007 in Douala (note the large file size - 40Mb)
Related Articles
- Loss of Control
- Bank Angle Awareness
- Cross-checking Process
- Flight Instrument Presentation of Aircraft Attitude
- Recovery from Unusual Aircraft Attitudes
- Situational Awareness (OGHFA BN)
- Spatial Disorientation (OGHFA SE)
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