Crash of an ATR72-212 in San Juan

Date & Time: May 9, 2004 at 1450 LT
Type of aircraft:
Operator:
Registration:
N438AT
Survivors:
Yes
Schedule:
Mayaguez - San Juan
MSN:
438
YOM:
1995
Flight number:
AA5401
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6071
Captain / Total hours on type:
3814.00
Copilot / Total flying hours:
2000
Copilot / Total hours on type:
20
Aircraft flight hours:
19276
Aircraft flight cycles:
18086
Circumstances:
Flight 5401 departed Mayagüez, Puerto Rico, for San Juan about 14:15. The captain was the nonflying pilot for the flight, and the first officer was the flying pilot. The takeoff, climb, and en route portions of the flight were uneventful. At 14:37, as the flight approached the San Juan traffic area, the ATIS reported that winds were 060 degrees at 17 knots and gusting at 23 knots. Shortly thereafter, the captain briefed a Vref (the minimum approach airspeed in the landing configuration before the airplane reaches the runway threshold) of 95 knots and told the first officer to "stand by for winds." At 14:43 SJU Terminal Radar Approach Control cautioned the pilots of possible wake turbulence from a preceding Boeing. The captain told the first officer to slow down to about 140 kts. At 14:46, the local controller cleared the airplane to land on runway 08. The first officer turned the airplane left toward runway 08 and transitioned to the visual approach slope indicator. At 14:49, the captain stated, "you better keep that nose down or get some power up because you're gonna balloon." The airplane descended below the glideslope, causing a GPWS "glideslope" alert. The airplane was about 45 feet above ground level and traveling at 110 knots indicated airspeed when it crossed the runway 08 threshold. After the airplane crossed the runway threshold, the captain stated, "power in a little bit, don't pull the nose up, don't pull the nose up." At 14:49:39, the captain stated, "you're ballooning," and the first officer replied, "all right." The airplane touched down for the first time about 14:49:41 and about 1,600 feet beyond the runway 08 threshold with vertical and lateral loads of about 1.3 Gs and -0.10 G, respectively. Upon touchdown the captain stated, "get the power," and, 1 second later, "my aircraft." The first officer responded, "your airplane." The airplane had skipped to an altitude of about 4 feet and touched down again two seconds later about 2,200 feet beyond the runway 08 threshold. The airplane then pitched up to an angle of 9° while climbing to an altitude of 37 feet and the engine torque increased from 10 to 43 percent. About 14:49:49, the pitch angle decreased to -3°, and the engine torque started to decrease to 20 percent with the pitch angle decreasing to -10°. The airplane touched down a third time about 14:49:51 at a bank angle of 7° left wing down and about 3,300 feet beyond the runway 08 threshold and with vertical and lateral loads of about 5 Gs and 0.85 G. The ATR pitched up again to 24 feet and landed a fourth time about 14:49:56 (about 15 seconds after the initial touchdown) and about 4,000 feet beyond the runway 08 threshold. This time the airplane pitched down to -7° and that it was banked 29° left wing down. The airplane came to a complete stop on a grassy area about 217 feet left of the runway centerline and about 4,317 feet beyond the runway threshold.
Probable cause:
The captain’s failure to execute proper techniques to recover from the bounced landings and his subsequent failure to execute a go-around.
Final Report:

Ground accident of a McDonnell Douglas MD-82 in Trieste

Date & Time: Apr 20, 2004 at 1038 LT
Type of aircraft:
Operator:
Registration:
I-DAWR
Survivors:
Yes
Schedule:
Rome – Trieste
MSN:
49208/1190
YOM:
1985
Flight number:
AZ1357
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
92
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7988
Captain / Total hours on type:
3800.00
Copilot / Total flying hours:
5724
Aircraft flight hours:
41745
Aircraft flight cycles:
34235
Circumstances:
Following an uneventful flight from Rome-Ciampino Airport and a normal landing at Trieste-Ronchi dei Legionari Airport runway 09, the crew vacated the runway and continued via taxiway Bravo to the apron. The copilot was the pilot-in-command and he was facing sun while approaching the ramp. At the last moment, the captain noticed a dump truck on the right side of the taxiway. He took over controls and elected to turn to the left but the aircraft collided with the truck. The outer part of the right wing was torn off for about 3,5 metres and the fuselage was bent. Also, a fuel tank ruptured, causing a spill on the taxiway. The captain immediately stopped the airplane and all 96 occupants evacuated safely. It appeared that construction works were in progress near the taxiway Bravo. A Notam was not issued about this and the tower controller had not informed the crew either.
Probable cause:
The analysis of the technical, operational and organizational context in which the event took place (impact of the end of the right wing of the aircraft, during taxiing, against the rear body of a truck that was parked for work within the protection area of the taxiway that leads from the Bravo connection to the parking area) has allowed to determine the following causes, which are attributable to human and environmental factors.
- Failure to close the Bravo taxiway with the issue of the relative NOTAM of the works in progress.
- Failure of the Torre control to provide the pilots with essential information on the condition of the airport, as provided for by ICAO in ICAO Doc. 4444 PANS-ATM.
- Vertical and horizontal ground signs do not correspond to those specified in ICAO Annex 14.
- Failure to comply with the ENAC circular (APT-11), applicable for the type of work in progress at the airport.
- Insufficient surveillance of the airport area affected by the works by ENAC and the airport management company Aeroporto FVG.
- Lack of an airport Safety Management System .
- Inadequate surveillance of the external space during taxiing by the flight crew, resulting in incorrect assessment of the position of the aircraft with respect to the obstacle.
Final Report:

Crash of a Cessna 208B Grand Caravan in Lake Manyara

Date & Time: Mar 17, 2004 at 0615 LT
Type of aircraft:
Operator:
Registration:
5H-MUA
Flight Phase:
Survivors:
Yes
Schedule:
Arusha – Lake Manyara – Klein’s Camp – Grumet – Seronera – Lake Manyara – Arusha
MSN:
208B-0487
YOM:
1995
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14000
Circumstances:
The aircraft was operating a scheduled flight starting from its base at Arusha. It was to call at Lake Manyara, Klein’s Camp, Grumet and Seronera before returning to Arusha via Lake Manyara. 5H-MUA took off from Arusha at 0530 hours. It was carrying one pilot and 3 passengers. The VFR flight to Lake Manyara was uneventful and the aircraft landed at Lake Manyara at 0555 hours. Five more passengers joined the flight here and 5H-MUA subsequently took off for Klein’s Camp at 0615 hours. During initial climb, the engine failed. The pilot feathered the propeller and attempted an emergency landing on a road. But he was forced to make an evasive manoeuvre because of a truck. The aircraft lost speed and height, collided with a stone wall beside the road and came tor rest. All nine occupants were rescued, among them five were seriously injured.
Probable cause:
Engine failure for undetermined reasons.
Final Report:

Crash of a Dornier DO.28D-2 Skyservant near Guayaquil

Date & Time: Mar 5, 2004 at 1755 LT
Type of aircraft:
Registration:
HC-CBK
Flight Phase:
Survivors:
Yes
Schedule:
Machala – Guayaquil
MSN:
4080
YOM:
1971
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
2977
Circumstances:
En route from Machala to Guayaquil, while cruising at an altitude of 6,000 feet in rain showers, the left engine lost power. The crew shut down the engine and feathered the propeller then decided to continue at an altitude of 600 feet and a speed of 80 knots. Several attempts to restart the left engine were unsuccessful when the right engine lost power as well. Unable to maintain a safe altitude, the crew attempted an emergency landing when the aircraft crashed in a river, some 23 km south of Guayaquil. All 14 occupants escaped with minor injuries and the aircraft was damaged beyond repair.
Probable cause:
A possible failure of the hydraulic pump on the left engine due to poor maintenance.

Crash of an Airbus A300B4-203 in Jeddah

Date & Time: Mar 1, 2004 at 0140 LT
Type of aircraft:
Operator:
Registration:
AP-BBA
Flight Phase:
Survivors:
Yes
Schedule:
Jeddah - Quetta
MSN:
114
YOM:
1980
Flight number:
PK2002
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
261
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll on runway 34 at Jeddah-King Abdulaziz Airport, ATC informed the crew about a fire on the left main gear. The captain rejected takeoff and was able to stop the aircraft within the remaining distance. All 273 occupants evacuated safely but the aircraft was considered as damaged beyond repair.
Probable cause:
It was determined that both tyres on the left main gear burst during the takeoff roll. Debris punctured a fuel tank in the left wing and other parts were ingested by the left engine.

Crash of a Fokker 50 in Sharjah: 43 killed

Date & Time: Feb 10, 2004 at 1138 LT
Type of aircraft:
Operator:
Registration:
EP-LCA
Survivors:
Yes
Schedule:
Kish Island - Sharjah
MSN:
20273
YOM:
1993
Flight number:
IRK1770
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
40
Pax fatalities:
Other fatalities:
Total fatalities:
43
Captain / Total flying hours:
6440
Captain / Total hours on type:
1516.00
Copilot / Total flying hours:
3978
Copilot / Total hours on type:
517
Aircraft flight hours:
20466
Aircraft flight cycles:
19845
Circumstances:
The aircraft was operating as a scheduled flight from Kish Island, Iran to Sharjah, UAE with the captain initially as the pilot flying (PF). During the cruise and just prior to descent, the captain unexpectedly handed over control of the aircraft to the First Officer prior to the approach to Sharjah. The first officer did not accept this willingly and stated that he was not confident of his ability to conduct a VOR/DME approach into Sharjah. This statement was not consistent with his previous experience and could indicate either a cultural or professional issue. The captain insisted the first officer fly the aircraft and encouraged and instructed him during the approach. At 11:24 hours local time, the aircraft contacted Dubai Arrivals and was cleared from 9000 ft to 5000 ft and instructed to expect a VOR/DME approach to runway 12 at Sharjah International Airport. At 11:29 hours the aircraft was further cleared to 2500 ft and cleared for the approach. The aircraft was under its own navigation and the daylight conditions were fine with excellent visibility. At 11:35 hours the aircraft was instructed to contact Sharjah Tower and the pilot reported that the aircraft was established on the VOR final approach for runway 12. The Tower cleared IRK7170 to land and advised that the wind was calm. At that point the aircraft was slightly above the approach profile. The initial speed for the approach was at least 50 kt high at approximately 190 kt with no flap and no landing gear. The aircraft should have been configured with landing gear down and flap 10° during the approach and stabilized at 130 kt prior to the MDA. Approaching the MDA at flight idle setting, the autopilot was disengaged and the first Officer called for flap 10 at 186 kt (limiting speed of 180 kt) and flap 25 was selected by the Captain, a setting uncalled for by the Pilot Flying at 183 kt (limiting speed of 160 kt), and the landing gear was called for and selected at approximately 185 kt (limiting speed of 170 kt). The captain then took control of the aircraft and shortly afterwards the ground range selectors were heard by Cockpit Voice Recorder to be lifted and the power levers moved from the flight idle stop into the ground control range. The left propeller then went to full reverse whilst the right propeller remained in positive pitch within the ground control range. The aircraft descended in an extreme nose low left bank attitude until impact. The aircraft crashed 2.6 nm from the runway onto an unprepared sandy area adjacent to a road and residential buildings. The aircraft broke apart on impact and a fire started immediately. Three passengers suffered injuries while 43 other occupants were killed.
Probable cause:
During the final approach, the power levers were moved by a pilot from the flight idle position into the ground control range, which led to an irreversible loss of flight control. The following contributing factors were identified:
1. By suddenly insisting the First Officer fly the final approach, the pilot in command created an environment, which led to a breakdown of crew resource management processes, the non observance of the operator’s standard operating procedures and a resultant excessive high approach speed.
2. An attempt to rectify this excessive high approach speed most likely resulted in the non compliance with the Standard Operating Procedures and the movement of the power levers below flight idle.
3. The unmodified version of the Skid Control Unit failed to provide adequate protection at the time of the event.
Final Report:

Crash of a Cessna 208B Grand Caravan off Pelée Island: 10 killed

Date & Time: Jan 17, 2004 at 1638 LT
Type of aircraft:
Operator:
Registration:
C-FAGA
Flight Phase:
Survivors:
No
Schedule:
Pelée Island – Windsor
MSN:
208B-0658
YOM:
1998
Flight number:
GGN125
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
3465
Captain / Total hours on type:
957.00
Aircraft flight hours:
7809
Circumstances:
On 17 January 2004, the occurrence pilot started his workday in Toronto, Ontario, reporting for duty at 0445 eastern standard time. In the morning, he completed flights in the Cessna 208B Caravan from Toronto to Windsor, Ontario, Windsor to Pelee Island, Ontario, and then Pelee Island to Windsor where the aircraft landed at 0916. At approximately 1500, the pilot received local weather and passenger information by telephone from the Pelee Island office personnel. The 1430 weather was reported as follows: ceiling 500 feet obscured, visibility two miles. There were eight male passengers for pick up at Pelee Island. One additional passenger was travelling with the pilot. There was no discussion concerning the amount of cargo to be carried or the passenger weights. At 1508, the pilot received a faxed weather package that he had requested from the Flight Information Centre (FIC) in London, Ontario. At 1523, the aircraft was refuelled in preparation for the scheduled 1600 departure to Pelee Island. The passengers were loaded earlier than usual to allow time for aircraft de-icing, as wet snow had accumulated on the fuselage and wings since the previous flight. At 1555, the aircraft was de-iced with Type 1 de-icing fluid, and it departed for Pelee Island at 1605 on an instrument flight rules (IFR) flight plan as Flight GGN125. At 1615, the pilot advised the Cleveland Control Centre, Ohio, United States, that he had Pelee Island in sight, was cancelling IFR, and was descending out of 5000 feet. The pilot also advised Cleveland that he would be departing IFR out of Pelee Island in about 20 minutes as GGN126 and asked if a transponder code could be issued. The Cleveland controller issued a transponder code and requested a call when GGN126 became airborne. The pilot advised that the flight would depart on Runway 27 then turn north. These were the last recorded transmissions from the aircraft. The aircraft landed at 1620. While on the ramp, two individuals voiced concern to the pilot that there was ice on the wing. Freezing precipitation was falling. The pilot was observed to visually check the leading edge of the wing; however, he did not voice any concern and proceeded with loading the passengers and cargo. At approximately 1638, GGN126 departed Pelee Island for Windsor. After using most of the runway length for take-off, the aircraft climbed out at a very shallow angle. No one on the ground observed the aircraft once it turned toward the north; however, witnesses who were not at the airport reported that they heard the sound of a crash, then no engine noise. A normal flight from Pelee Island to Windsor in the Cessna Caravan takes 15 to 20 minutes. Shortly after the aircraft departed, the ticket agent in Windsor received a call from Pelee Island reporting that a crash had been heard. At 1705, when the aircraft had not arrived, the ticket agent called Windsor tower. The pilot had not made contact with any air traffic services (ATS) facility immediately before or after departure, so there was nothing in the ATS system to indicate that the aircraft had taken off. It was, therefore, unaccounted for. There was no signal heard from the emergency locator transmitter (ELT). At 1710, the Windsor tower controller contacted the Rescue Coordination Centre in Trenton, Ontario, and a search was initiated. At 1908, the aircraft empennage and debris were spotted by a United States Coast Guard (USCG) helicopter on the frozen surface of the lake, about 1.6 nautical miles (nm) from the departure end of the runway. There were no survivors. The empennage sank beneath the surface some four hours later. The wreckage recovery was not fully completed until 13 days later.
Probable cause:
Findings as to Causes and Contributing Factors:
1. At take-off, the weight of the aircraft exceeded the maximum allowable gross take-off weight by at least 15 per cent, and the aircraft was contaminated with ice. Therefore, the aircraft was being flown significantly outside the limitations under which it was certified for safe flight.
2. The aircraft stalled, most likely when the flaps were retracted, at an altitude or under flight conditions that precluded recovery before it struck the ice surface of the lake.
3. On this flight, the pilotís lack of appreciation for the known hazards associated with the overweight condition of the aircraft, ice contamination, and the weather conditions was inconsistent with his previous practices. His decision to take off was likely adversely affected by some combination of stress and fatigue.
Findings as to Risk:
1. Despite the abbreviated nature of the September 2001 audit, the next audit of Georgian Express Ltd. was not scheduled until September 2004, at the end of the 36-month window.
2. The internal communications at Transport Canada did not ensure that the principal operations inspector responsible for the air operator was aware of the Pelee Island operation.
3. The standard passenger weights available in the Aeronautical Information Publication at the time of the accident did not reflect the increased average weight of passengers and carry-on baggage resulting from changes in societal-wide lifestyles and in travelling trends.
4. The use of standard passenger weights presents greater risks for aircraft under 12 500 pounds than for larger aircraft due to the smaller sample size (nine passengers or less) and the greater percentage of overall aircraft weight represented by the passengers. The use of standard passenger weights could result in an overweight condition that adversely affects the safety of flight.
5. The Cessna Caravan de-icing boot covers up to a maximum of 5% of the wing chord. Research on this wing has shown that ice accumulation beyond 5% of the chord can result in degradation of aircraft performance.
6. At the Pelee Island Airport, the air operator did not provide the equipment that would allow an adequate inspection of the aircraft for ice during the pre-flight inspection and did not provide adequate equipment for aircraft de-icing.
7. Repetitive charter operators are not considered to be scheduled air operators under current Transport Canada regulations, and, therefore, even though the charter air operator may provide a service with many of the same features as a scheduled service, Transport Canada does not provide the same degree of oversight as it does for a scheduled air operator.
8. A review of the Canadian Aviation Regulations regarding simulator training requirements indicates that there is no requirement to conduct recurrent simulator training if currency and/or pilot proficiency checks do not lapse.
9. Commercial Air Service Standard 723.91(2) does not clearly indicate whether there is a requirement for simulator training following expiration of a pilot proficiency check.
10. Incorrect information on the passenger door placards, an incomplete safety features card, and the fact that the operating mechanisms and operating instructions for the emergency exits were not visible in darkness could have compromised passenger egress in the event of a survivable accident.
11. The dogs being carried on the aircraft were not restrained, creating a hazard for the flight and its occupants.
Final Report:

Crash of a Yakovlev Yak-40 in Tashkent: 37 killed

Date & Time: Jan 13, 2004 at 1927 LT
Type of aircraft:
Operator:
Registration:
UK-87985
Survivors:
No
Schedule:
Termez - Tashkent
MSN:
9 54 08 44
YOM:
1975
Flight number:
UZB1154
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
37
Aircraft flight hours:
37000
Circumstances:
Following an uneventful flight from Termez, the crew started the descent to Tashkent-Yuzhny Airport by night and marginal weather conditions. The visibility was limited due to foggy conditions with an RVR between 600 and 900 metres for runway 08L. The captain continued the approach with an excessive rate of descent, causing the aircraft to pass below the MDA without any visual contact with the ground. At an altitude of 165-170 metres, the captain positioned the airplane in a flat attitude then continued the descent at a distance of 2 km from the runway threshold, but this time with an insufficient rate of descent. The aircraft passed over the runway threshold at a height of about 30-40 metres and flew over the runway for a distance of 3,3 km. The captain established a visual contact with the runway lights, elected to land but failed to realize he was in fact approaching the end of the runway which is 4 km long. He reduced both engines power to idle, activated the thrust reversers when he realized his mistake and attempted a go-around. The aircraft collided with a 2 metres high concrete wall located 260 metres past the runway end, lost its right wing and crashed in a drainage ditch located along the perimeter fence, bursting into flames. The aircraft was totally destroyed and all 37 occupants were killed, among them Richard Conroy, special UNO representative in Uzbekistan.
Probable cause:
The following factors were identified:
- The crew failed to maintain a correct approach pattern maybe following a wrong setting of the approach selector in SP mode instead of ILS mode,
- The crew decided to continue the approach without establishing any visual contact with the approach light and runway light system,
- The crew failed to comply with published procedures,
- The crew failed to initiate a go-around procedure.

Crash of a De Havilland DHC-6 Twin Otter in Sturt Island

Date & Time: Jan 5, 2004
Operator:
Registration:
P2-KSG
Flight Phase:
Survivors:
Yes
MSN:
509
YOM:
1976
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from a grassy runway (780 metres long), the pilot noted standing water on the ground. He attempted to take off prematurely to avoid these puddles but the aircraft stalled and crash landed. All three occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Boeing 727-223 in Cotonou: 141 killed

Date & Time: Dec 25, 2003 at 1459 LT
Type of aircraft:
Operator:
Registration:
3X-GDO
Flight Phase:
Survivors:
Yes
Schedule:
Conakry - Cotonou - Kufra - Beirut - Dubai
MSN:
21370
YOM:
1977
Flight number:
GIH141
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
153
Pax fatalities:
Other fatalities:
Total fatalities:
141
Captain / Total flying hours:
11000
Captain / Total hours on type:
8000.00
Aircraft flight hours:
67186
Aircraft flight cycles:
40452
Circumstances:
Flight GIH 141 was a weekly scheduled flight, performed by the Union des Transports Africains (UTA), between Conakry (Guinea), Cotonou (Benin), Beirut (Lebanon) and Dubai (United Arab Emirates). A stopover at Kufra (Libya) was planned between Cotonou and Beirut. Having departed from Conakry at 10 h 07 with eighty-six passengers, including three babies, and ten crew members, the Boeing 727-223 registered 3X-GDO landed at Cotonou Cadjèhoun on 25 December 2003 at 12 h 25. Nine passengers disembarked. Sixty-three persons, including two babies, checked in at the airport check-in desk. Ten others, including one baby, boarded from an aircraft that had arrived from Lomé (Togo). Passenger boarding and baggage loading took place in a climate of great confusion. The airplane was full. In the cockpit, two UTA executives were occupying the jump seats. Faced with the particularly large number and size of the hand baggage, the chief flight attendant informed the Captain of the situation. The ground handling company’s agents began loading the baggage in the aft hold when one of the operator’s agents, who remains unidentified, asked them to continue loading in the forward hold, which already contained baggage. When the operation was finished, the hold was full. During this time, the crew prepared the airplane for the second flight segment. The co-pilot was discussing his concerns with the UTA executives, reminding them of the importance of determining the precise weight of the loading of the airplane. The flight plan for Kufra, signed by the Captain, was filed with the ATC office but the meteorological dossier that had been prepared was not collected. Fuel was added to fill up the airplane’s tanks (14,244 liters, or 11.4 metric tons). The accompanying mechanics added some oil. The Captain determined the limitations for the flight and selected the following configuration: flaps 25°, air conditioning units shut down. At 13 h 47 min 55, the crew began the pre-flight checklist. Calm was restored in the cockpit. At 13 h 52 min 12, flight GIH 141 was cleared to roll. The co-pilot was pilot flying (PF). The elevator was set at 6 ¾, it was stated that the takeoff would be performed with full power applied with brakes on, followed by a climb at three degrees maximum to gain speed, with no turn after landing gear retraction. As the roll was beginning, a flight attendant informed the cockpit that passengers who wanted to sit near their friends were still standing and did not want to sit down. The airline’s Director General called the people in the cabin to order. Take-off thrust was requested at 13 h 58 min 01, brake release was performed at 13 h 58 min 15. The airplane accelerated. In the tower, the assistant controller noted that the take-off roll was long, though he did not pay any particular attention to it. At 13 h 59, a speed of a hundred and thirty-seven knots was reached. The Captain called out V1 and Vr. The co-pilot pulled back on the control column. This action initially had no effect on the airplane’s angle of attack. The Captain called « Rotate, rotate »; the co-pilot pulled back harder. The angle of attack only increased slowly. When the airplane had hardly left the ground, it struck the building containing the localizer on the extended runway centerline, at 13 h 59 min 11. The right main landing gear broke off and ripped off a part of the underwing flaps on the right wing. The airplane banked slightly to the right and crashed onto the beach. It broke into several pieces and ended up in the ocean. The two controllers present in the tower heard the noise and, looking in the direction of the takeoff, saw the airplane plunge towards the ground. Immediately afterwards, a cloud of dust and sand prevented anything else being seen. The fire brigade duty chief stated that the airplane seemed to have struck the localizer building. The firefighters went to the site and noticed the damage to the building and the presence of a casualty, a technician who was working there during the takeoff. Noticing some aircraft parts on the beach, they went there through a service gate beyond the installations. Some survivors were still in the wreckage, others were in the water or on the beach. Some inhabitants from the immediate vicinity crowded around, complicating the rescuers’ task. The town fire brigade, the Red Cross and the Cotonou SAMU, along with some members of the police, arrived some minutes later.
Probable cause:
The accident resulted from a direct cause:
• The difficulty that the flight crew encountered in performing the rotation with an overloaded airplane whose forward center of gravity was unknown to them; and two structural causes:
• The operator’s serious lack of competence, organization and regulatory documentation, which made it impossible for it both to organize the operation of the route correctly and to check the loading of the airplane;
• 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.
The following factors could have contributed to the accident:
• The need for air links with Beirut for the large communities of Lebanese origin in West Africa;
• The dispersal of effective responsibility between the various actors, in particular the role played by the owner of the airplane, which made supervision complicated;
• The failure by the operator, at Conakry and Cotonou, to call on service companies to supply information on the airplane’s loading;
• The Captain’s agreement to undertake the take-off with an airplane for which he had not been able to establish the weight;
• The short length of the runway at Cotonou;
• The time of day chosen for the departure of the flight, when it was particularly hot;
• The very wide margins, in particular in relation to the airplane’s weight, which appeared to exist, due to the use of an inappropriate document to establish the airplane’s weight and balance sheet;
• The existence of a non-frangible building one hundred and eighteen meters after the runway threshold.
Final Report: