UTAGE Flight 141
|This article needs additional citations for verification. (June 2009) (Learn how and when to remove this template message)|
The aircraft involved in the crash while still operating as American Airlines
|Date||25 December 2003|
|Summary||Failure to take off due to aircraft overload|
|Site||Cotonou Airport, Benin|
|Injuries (non-fatal)||24 ( including 2 on ground)|
|Survivors||22 (initially 35)|
|Aircraft type||Boeing 727-223|
|Operator||Union des Transports Aériens de Guinée (UTAGE)|
|Flight origin||Conakry International Airport, Conakry, Guinea|
|2nd stopover||Cotonou Airport, Cotonou, Benin|
|3rd stopover||Kufra Airport, Kufra, Libya|
|Last stopover||Rafic Hariri Int'l Airport, Beirut, Lebanon|
|Destination||Dubai International Airport, Dubai, United Arab Emirates|
UTAGE Flight 141 was a chartered international passenger flight operated by Guinean regional airlines Union des Transports Aériens de Guinée flying from Cotonou Airport in Benin's capital Cotonou to Kufra Airport in Kufra, Libya. On 25 December 2003 the aircraft crashed in the Bight of Benin, killing at least 144 people, most of them Lebanese. Shortly after the crash, 35 survivors were found by a search and rescue team. Some of them were pronounced dead upon reaching the hospital.
Flight 141 was flown by an ex-American Airlines Boeing 727-223, 3X-GDO. The airliner's route was Conakry International Airport – Cotonou Cadjehoun Airport – Kufra Airport – Beirut International Airport – Dubai International Airport. The final report, which was published by France's Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile, concluded that the crash occurred due to airplane overload, as the plane's actual weight has exceeded its maximum weight capacity, thus decreasing its performance, especially when taking-off. Flight 141 did take off, but because it took for it too long to take off, the plane hit a localizer building and plunged to the ocean. The report also blamed the airport's lack of facilities.
This was the 100th aviation accident involving the Boeing 727. Currently, it is held as the deadliest plane crash in Benin's aviation history and the 11th worst accident involving the Boeing 727.
Flight 141 was a weekly scheduled flight, performed by the Union des Transports Africains de Guinée (UTAGE), 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 10:07 with eighty-six passengers, including three babies, and ten crew members, the Boeing 727-223 landed at Cotonou Cadjèhoun on 25 December 2003 at 12:25 where 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 with great confusion since the airplane was full. In the cockpit, two UTAGE executives used 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 they were 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 UTAGE 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. The accompanying mechanics added some oil.
At 13:52, Flight 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.
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 13:59, 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 13:59. This, resulting in the building's roof to flung 11 meters to the air, and seriously injuring two people in the building. The right main landing gear broke off and ripped off a part of the underwing flaps on the right wing. Survivors of the crash recalled that the plane was struggling to take off while passengers were screaming. The airplane banked slightly to the right with one of its wheels struck the upper perimeter fence and the plane slammed onto the beach. As it slid, it broke into several pieces. The cockpit started to detach, with its right wing and engines followed. It ended up in the ocean, ejecting dead bodies and passengers from the aircraft. The wreckage submerged in upside down condition.
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 from being seen.
The Boeing 727-223 serial number 21370 was registered N865AA from June 1977 to January 2003. It was operated by American Airlines before being stored on 18 October 2001, through the Pegasus Aviation Group, in the Mojave Desert in California. It was not possible to obtain the number of flying hours it had performed up to then. On 20 February 2002, it became the property of Wells Fargo Bank Northwest. In January 2003, the airplane was sold to the Financial Advisory Group whose headquarters was in Miami (Florida). This company owns transport category aircraft that it leases to various operators. It is apparently currently based in the Virgin Islands, according to information provided by its office in Sharjah (United Arab Emirates), an office that appears to have managed the airplane from the time of its purchase and was the only interlocutor for its successive operators.
On 15 January 2003, an FAA authorization allowed the new operator, Ariana Afghan Airlines, to undertake a ferry flight to Afghanistan under the YA-FAK registration. This authorization was subject to the obligation to perform the flight with a crew designated by the FAA and, before any new period of operation, to applying the conditional Airworthiness Directives to the airplane. From 23 June 2003, the airplane was operated by Alpha Omega Airways in Swaziland under the 3D-FAK registration. On 8 July, this operator, presenting itself as the owner of the airplane, leased it with a crew for thirty days to UTAGE, which operated it from 9 July 2003 onwards. On 13 October, UTAGE signed a second lease for the same airplane, this time with FAG.
On 15 October 2003, the Guinean DNAC (Direction Nationale de l’Aviation Civile) registered the airplane under the registration 3X-GDO and, while waiting for UTAGE to write its own documentation, approved the Flight Manual for three months that had originally been approved by the FAA, along with the Minimum Equipment List (MEL) and the maintenance manual issued by American Airlines.
Passengers and crew
As the accident happened on Christmas Day, many of the passengers were workers who were flying back home to Lebanon to enjoy the holidays with their families. Over a hundred of the passengers were Lebanese, while the rest of them were from Togo, Guinea, Libya, Sierra Leone, Palestine, Syria, Nigeria, and Iran.
Exact passenger numbers are impossible to determine, as it is thought that there were more passengers aboard than were listed on the manifest.
To this day, given the difficulties encountered in finding and identifying the victims, due to the extent of the disaster and the imprecision of the information concerning the people on board, between 140 and 148 fatalities can be recorded. There were 22 survivors, including the Captain, the Flight Engineer and the Director General of the airline. The technician who was in the building struck by the airplane was also seriously injured. Some passengers who survived the initial crash died while being hospitalised.
The Captain was a former pilot of Libyan Arab Airlines, where he flew on Boeing 727, the Captain joined the FAG (Financial Advisory Group) on 11 March 2003, with availability until 10 March 2004. In this context, he had first worked for three months for Royal Jordanian Airlines then for six months for Trans Air Benin. During the latter period, he regularly landed a Boeing 727 at Pointe Noire and at Cotonou. On 8 December 2003, he had performed his first flight for UTAGE. He has an experience of 11,000 flying hours in total including 5,000 as Captain; and 8,000 flying hours on type including 5,000 as Captain; The co-pilot had joined FAG on secondment from Libyan Arab Airlines. Like the Captain, he had performed his first flight for UTAGE on 8 December 2003 and had done exactly the same things since that date.
The Flight Engineer has a total experience of 14,000 flying hours in total, all on the Boeing 727-700; The Flight Engineer had joined FAG on secondment from Libyan Arab Airlines. Like the Captain, he had performed his first flight for UTAGE on 8 December 2003 and had done exactly the same things since that date.
The Government of Benin established a National Commission of Inquiry to investigate the accident, as outlined by Decree No 2003-563 of 26 December 2003. The commission's president established Order No 3451/MDN/DC/SA of 30 December 2003, which gave the Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile (BEA), the aviation investigation agency of France, the responsibility of conducting the technical investigation.
The flap was set on 25° and stabilizer on 6 ¾, which are confirmed both by the testimony and the observations made on the wreckage, as well as the declared weight of 78 tons, show that the center of gravity allowed for by the crew was 19%. This value is consistent with a normally balanced airplane.
However, it is not known what the load distribution was in the holds, or even in the cabin, since no loading plan was made. The only thing that could be determined was that the forward hold was full of baggage. Equally, the airplane’s dry operating index, that is to say its empty center of gravity, could not be identified. On the documents from Lebanon, two different indices had been used. It was not therefore possible to reconstitute the airplane’s center of gravity as it was on 25 December.
The graphs obtained from the recorded parameters show that, when the stick was pulled back, the elevator was immediately set in pitch-up position, but that the airplane’s response time was very slow compared to the usual time, the nose lifting off late while the acceleration was continuing. Such a situation at the beginning of the climb-out indicates either a limitation in the elevator’s operation or an airplane with a center of gravity that is too far forward. Checks on the wreckage did not reveal any evidence that would support the theory that there was a malfunction of the airplane’s elevator system. The calculations made on the basis of airplane performance during take-off gave a center of gravity value of 14%, that is to say a forward balance that would require a stabilizer setting of 7 ¾. The eight previous take-offs were also analyzed. These show that during the previous take-off from Cotonou (flight No 8) the pitch-up control input had immediately been followed by an increase in the airplane’s angle of attack. The previous day, on flight No 2, the rotation had been performed spontaneously at a speed of around one hundred knots, without any elevator input, and there had then been some stick push so as to control the rotation.
The BEA wrote the original accident report and translated the report into English. The final report concluded that 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.
- "report translation 3x-o031225a." Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile. Retrieved on 9 June 2009.
- "Survivors of Benin crash arrive home". ABC.
- "Benin air crash dead flown home". BBC.
- BEA final report, p.7
- "Plane crash in Benin kills at least 111." CBC. Friday 26 December 2003. Retrieved on 9 June 2009.
- Accident description at the Aviation Safety Network (Summary of the French accident investigation)
- Cockpit Voice Recorder transcript and accident summary
- Bureau d'Enquêtes et d'Analyses pour la sécurité de l'Aviation Civile
- "Accident d'un Boeing 727 à Cotonou le 25 décembre 2003." (French) (Archive)
- Summary of the English translation of investigation (Archive)
- Original French report (French) (HTML) (Archive)