|Final report Accident on 25 December 2003
at Cotonou Cadjèhoun aerodrome (Benin)
to the Boeing 727-223 registered 3X-GDO
operated by UTA (Union des Transports Africains)
|report translation 3x-o031225a
By application of Decree No 2003-563 of 26 December 2003, the government of the Republic of Benin set up a National Commission of Inquiry to shed light on the causes of the accident that occurred on 25 December 2003 at Cotonou Cadjèhoun. By Order No 3451/MDN/DC/SA of 30 December 2003, the President of this Commission delegated the technical investigation to the BEA (Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile), the French aircraft accident investigation bureau.
This report presents the technical conclusions reached by the BEA on the circumstances and causes of this accident. In accordance with Annex 13 of the Convention on International Civil aviation and with the legislation that regulates the BEA's activities (Book VII of the French Civil Aviation Code), the investigation into this accident is intended neither to apportion blame nor to assess individual or collective responsibility. The sole objective is to draw lessons from this occurrence which may help to prevent future accidents or incidents. Consequently, the use of this report for any purpose other than for the prevention of future accidents could lead to erroneous interpretations.
This investigation was greatly slowed down by the wide dispersion of those in positions of responsibility and the difficulties encountered by the investigators in obtaining precise information, usually gathered in the first few days, and regulatory documents relating to the airplane and the flight. This is in itself the first conclusion of the investigation.
The BEA thanks the Captain and the Chief Flight Attendant, whose help was invaluable. Their precise answers, which were strictly consistent with the two recordings and the findings, enabled the investigators to better understand the history of the flight and the crew's actions.
SPECIAL FOREWORD TO ENGLISH EDITION
This report has been translated and published by the BEA to make its reading easier for English-speaking people.
As accurate as the translation may be, the original text issued in French by the Republic of the Ivory Coast is the work of reference.
| Date and time
| Thursday 25 December 2003
|| Type : Boeing 727-223
| at 13 h 59 ()
|| Registration : 3X-GDO
| Site of accident
| Cotonou Cadjèhoun Aerodrome
(Republic of Benin)
| Financial Advisory Group
Sharjah (United Arab Emirates)
|| Union des Transports Africains
|Type of flight
|Public transport of passengers
|| Persons on board
|Scheduled Flight GIH 141
Crew 10 Passengers 150*, including six babies
|Conakry - Cotonou - Beirut - Dubai
On 25 December 2003, arriving from Conakry (Guinea), the Boeing 727-223 registered 3X-GDO undertaking flight GIH 141 to Kufra (Libya)
and Beirut (Lebanon) and Dubai (United Arab Emirates) stopped over at Cotonou.
During takeoff the airplane, overloaded in an anarchic manner,
was not able to climb at the usual rate and struck an airport building located a hundred and eighteen meters past the runway end
on the extended runway centerline, crashed onto the beach and ended up in the ocean.
The government of the Republic of Benin set up a National Commission of Inquiry to shed light on the causes of the accident.
The President of the Commission delegated the technical investigation to the BEA, the French aircraft accident investigation bureau,
and invited the States involved () to nominate Accredited Representatives to participate in the investigation,
in accordance with the provisions of Annex 13 to the Chicago Convention.
3 - CONCLUSIONS
- Both pilots possessed Air Transport Pilot Licenses (ATPL) issued by Libya, not validated by Guinea.
- Both pilots possessed Commercial Pilot licenses (CPL) issued by the United Kingdom and validated by Guinea.
- The Flight Engineer possessed a license issued by Libya and validated by Guinea.
- The flight crew had been recruited by the owner of the airplane; they were paid by the operator.
- The flight crew exceeded, on each rotation, the flying time limits recommended by the State of Operator.
- The cabin crew possessed valid licenses. They did not have a written contract with the operator.
- The cabin crew exceeded, on each rotation, the flying time limits and the flight service periods defined by the operator.
- The controller on duty in the Cotonou tower possessed the necessary qualifications. A controller who was being trained assisted him.
- The operator had only one crew to operate the B727.
- All of the flights took place with the participation of two on-board mechanics and a security escort.
- The airplane had replaced another Boeing 727, registered 3X-GDM, which had been forced to leave empty, on a ferry flight, after a technical inspection carried out at the time of its first flight to Beirut.
- The airplane was leased. Its owner had purchased it in January 2003. At that time it was in storage in the Mojave Desert in the USA.
- After the purchase, the airplane underwent some work, in particular engine changes, about which no information has been obtained.
- No maintenance documents subsequent to the purchase of the aircraft, including for the period of operation by UTA, could be provided.
- The airplane was operated successively by three operators under the remit of Afghanistan, Swaziland and Guinea respectively.
- The airplane was registered successively in Afghanistan, Swaziland and Guinea. Each of these countries issued a Certificate of Airworthiness for it with no restrictions on its validity. Each of the three successive Certificates of Registration mentioned the operator as the owner of the aircraft.
- During stopovers in Lebanon, the airplane was subject to technical inspections that brought to light failures to comply with regulations relating to documentation and equipment. At the time of those findings, the airplane was registered in Swaziland. The points raised were corrected before the airplane was registered by Guinea.
- The Guinean DNAC applied the technical procedures defined by ICAO, though it had neither regulations for detailed application nor the means to inspect the application thereof.
- According to the lease, maintenance of the airplane was the responsibility of the owner and the updating of its maintenance documents was up to the operator.
- The operator had neither the material infrastructure nor the skills required to operate a large transport airplane.
- The revised Operations Manual had been approved by the Guinean civil aviation authority several months after the beginning of operations.
- The Operations Manual was incomplete, contained numerous inconsistencies and was unsuitable for the needs of operations with the Boeing 727.
- The Operations Manual did not have a chapter on the loading and balance of the airplane.
- The corrected basic weight and the corrected dry operating index were not included in the available documentation. The operator was not able to provide them to the investigators.
- The crew did not have the appropriate documents to prepare the flight. The document used to establish the center of gravity, drawn up by the previous operator, showed limits that exceeded the airplane's performance capacities.
- The Operations Manual did not define the limitations on flying time and work periods for the flight crew.
- The service companies at Conakry and Cotonou had no written contracts with the operator that defined the services to be provided.
- Seats were not attributed during check-in and the boarding cards were not nominative.
3.1.3 The flight
- 3X-GDO was supposed to carry out the flight from Cotonou to Beirut, with a stopover at Kufra. It was the second stop on the scheduled weekly flight GIH 141 from Conakry to Dubai.
- On 25 December 2003, the meteorological conditions were compatible with the operation of the planned flight.
- The co-pilot was Pilot Flying.
- Passenger boarding and airplane loading were performed without any overall supervision and with a complete lack of rigor.
- The airplane was full and there was a large quantity of large hand baggage. The forward hold was full.
- No overall document relating to boarding and loading (passengers, baggage) could be supplied. There were seven different manifests, all badly completed.
- Calculations showed that an undeclared load of around three tons was probably on board during the flight from Conakry to Cotonou.
- The flight crew knew that the airplane was heavily loaded. They did not know the distribution of the load in the airplane's holds.
- On the basis of these indications and of their experience, the flight crew decided on a configuration and a take-off technique.
- They decided on a take-off weight of seventy-eight tons, which was compatible with the runway limitation, and a center of gravity of 19% that corresponded to a correctly distributed load.
- In fact, the airplane weight was about eighty-five and a half tons and the center of gravity 14%, that is to say much further forward.
- Forty-five seconds after brake release, the Captain ordered the rotation, which the co-pilot immediately carried out.
- The real rotation only occurred two seconds later, when the co-pilot increased his control column input.
Five seconds later, the wheels left the ground.
- Fifty-six seconds after brake release, the airplane struck a building made of reinforced concrete,
two meters forty-five high, located one hundred and eighteen meters from the end of the runway.
- The recorded number of victims and survivors exceeds the number of people who were presumed to be on board,
whether according to the manifests or based on the number of seats available.
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.
4 - RECOMMENDATIONS
4.1 Approval and oversight of operators
The investigation showed the importance for safety of both good organization by operators and, further, of supervision exercised by national authorities before and after the approval of an operator. This necessarily implies the drawing up and approval of complete written documentation, as well as the time to do this. Furthermore, whatever the quality or training of the inspectors may be, it is difficult to undertake such oversight in a rigorous and objective manner in the absence of any precise regulations. The BEA thus recommends that:
- Guinea and all States that wish to issue Air Transport 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.
4.2 International Organization
The investigation showed that weakness in regulatory structures and in the means for oversight of safety in certain States made it
impossible to guarantee an appropriate level of safety for passengers and people on the ground, including on other States' territory.
These weaknesses are the result of several factors, including the priority often given to economic considerations and the belief that safety largely depends on the decisions taken in real time by the front line actors, in particular the Captain. This situation tends to call into question the international organization of air transport, based as it is on confidence and the recognition by each State of the approvals and certificates issued by other States. This leads to multiple checks and direct inspections, with all of the negative consequences that this has on the direct and indirect costs of air transport,
and poses the risk of the appearance of a two-speed world safety system.
The BEA notes the initiatives taken by the ICAO on the occasion of the 35th session of the Assembly (September-October 2004),
in particular the findings and proposals in WP 63. The investigation shows the relevance and urgency of the measures proposed.
Consequently, the BEA recommends that:
- 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 endeavoring to ensure, where necessary, that States be made aware of their responsibilities in this area;
- the ICAO Council 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;
- the ICAO Council 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;
- the ICAO Council, 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, re-organize them to support and complete ICAO's actions.
4.3 Autonomous systems for measuring weight and balance
Knowing the true weight and balance of the airplane would most likely have enabled the crew to avoid the accident.
In addition, erroneous estimates of these parameters are quite likely during operations.
Onboard autonomous systems are, however, available and they give an indication of the airplane's weight and balance
that is sufficient to attract the crew's attention in case of an abnormal situation.
Consequently, the BEA recommends that:
- the civil aviation authorities, in particular the FAA in the United States and the EASA in Europe, 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;
- the civil aviation authorities 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.
Full report in PDF
 Except where otherwise noted,
the times shown in this report are expressed in Universal Time Coordinated (UTC).
One hour should be added to obtain the legal time applicable in Benin on the day of the accident
 Guinea, United States, Lebanon.
[*] Some doubts remain as to the total number of passengers.