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

FOREWORD

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.

SYNOPSIS

Date and time Aircraft
Thursday 25 December 2003 Type : Boeing 727-223
at 13 h 59 ([1]) Registration : 3X-GDO
   
Site of accident Owner
Cotonou Cadjèhoun Aerodrome
(Republic of Benin)
Financial Advisory Group
Sharjah (United Arab Emirates)
  Operator
  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  

Summary

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 ([2]) to nominate Accredited Representatives to participate in the investigation, in accordance with the provisions of Annex 13 to the Chicago Convention.

Casualties

Crew members

Passengers

Others

Fatal

5

133 *

*

Serious

5

17

1

Light/none

-

-

-

 

 

 

3 - CONCLUSIONS

3.1 Findings

3.1.1 Personnel

3.1.2 Operations

3.1.3 The flight

3.2 Causes

The accident resulted from a direct cause:

and two structural causes:

The following factors could have contributed to the accident:

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:

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:

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:

Full report in PDF (5.78 MB)

 

 

 


[1] 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

[2] Guinea, United States, Lebanon.

[*] Some doubts remain as to the total number of passengers.