Accident
Last updated: 22 October 2014
Status:Schlussbericht
Datum:Donnerstag 25 Dezember 2003
Zeit:14:59
Flugzeugtyp:Silhouette image of generic B722 model; specific model in this crash may look slightly different
Boeing 727-223
Fluggesellschaft:Union des Transports Africains de Guinée
Kennzeichen: 3X-GDO
Werknummer: 21370/1276
Baujahr: 1977-06-29 (26 years 6 months)
Betriebsstunden:67186
Anzahl Zyklen der Zelle:40452
Triebwerk: 3 Pratt & Whitney JT8D-9A (HK3)
Besatzung:Todesopfer: 5 / Insassen: 10
Fluggäste:Todesopfer: 136 / Insassen: 153
Gesamt:Todesopfer: 141 / Insassen: 163
Sachschaden: Zerstört
Konsequenzen: Written off (damaged beyond repair)
Unfallort:Cotonou Airport (COO) (   Benin) show on map
Flugphase: Start (TOF)
Betriebsart:Internationaler Linienflug
Flug von:Cotonou Airport (COO/DBBB), Benin
Flug nach:Kufrah Airport (AKF/HLKF), Libyen
Flugnummer: 141
Unfallbericht:
Union des Transports Africains de Guinée operated two flights a week from Conakry, Guinea to Beirut and Dubai with their newly acquired ex-American Airlines Boeing 727. On December 25, UTA Flight 141 departed Conakry, Guinea for a scheduled flight to Beirut, Lebanon with a planned intermediate stop at Cotonou, Benin and a planned technical stop at Kufrah, Libya. The flight departed at 10:07 carrying 86 passengers and a crew of 10. It arrived at Cotonou at 12:25 were nine passengers disembarked. A total of 63 persons checked in at the airport check-in desk. Ten others 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 and it is thought that there were more passengers aboard the plane than had officially checked in. 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. Meanwhile the ground handling company’s agents began loading the baggage in the aft hold when one of the operator’s agents 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 Captain determined the limitations for the flight and selected the following configuration: flaps 25°, air conditioning units shut down.
At 13:47, the crew began the pre-flight checklist. Calm was restored in the cockpit. At 13:52, they were cleared to roll. The co-pilot was pilot flying (PF). The elevator was set at 6 3/4, 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.
It was warm outside at a temperature of 32 deg. C with a light breeze as the flight received permission to takeoff from runway 24. Runway 06/24 is an asphalt runway, measuring 2400 (7874 feet) meters with a 55m (180 feet) overrun zone.
At 13:58:01 the thrust levers were advanced. Fourteen seconds later the brakes were released and the 727 accelerated down the runway. Forty-six seconds after brake release the captain announced V1 and VR speeds. At that moment the aircraft was 1620 m down the runway at a speed of 137 kts. The copilot tried to rotate the plane, but seven seconds later, at a speed of 148 kts and 2100 m down the runway, the nose just slowly rose. The 727 barely climbed, causing the main undercarriage to strike localizer antennas. It then struck the roof of a 2-3 meters high small building housing radio equipment. The operator inside the building suffered injuries. The plane continued, smashed through the concrete airport boundary fence, crashed and broke up on the shoreline.
The exact number of occupants and fatalities could not be established with certainty. It is thought that 133 passengers died in the crash with an additional three people of which it was not possible to establish if they were passengers or passers-by on the beach. Most probably however, they were passengers.


CAUSES:
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.

Informationsquelle:
» AFP
» BEA
» Boeing
» Le Matinal Online
» Reuters

Official accident investigation report
investigating agency: Bureau d'Enquêtes et d'Analyses (BEA) - France
report status: Final
report number: Report 3x-o031225
download report: Report 3x-o031225
cover

Fotos

photo of Boeing 727-223 3X-GDO
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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Cotonou Airport to Kufrah Airport as the crow flies is 2970 km (1856 miles).

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