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B738, vicinity Douala Cameroon, 2007 (LOC HF)
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| Summary | |
| On 5 May 2007, a Boeing 737-800 operated by Kenya Airways on a scheduled passenger flight from Abidjan to Nairobi, with a planned stopover at Douala, Cameroon, crashed shortly after a dark night take-off from Douala. At approximately 1000 ft. agl with the Captain acting as PF, the aircraft began a slow right roll which increased and subsequently led to a spiral dive from which a late attempt at recovery was unsuccessful and impact with the terrain followed. All 114 occupants on board were killed and the aircraft was destroyed by the ground impact. | |
 | |
| Event Details | |
|---|---|
| When | May 2007 |
| Event Type | LOC |
| Day/Night | Night |
| Flight Conditions | VMC |
| Flight Details | |
|---|---|
| Aircraft | BOEING 737-800 |
| Operator | Kenya Airways |
| Domicile | Kenya |
| Type of Flight | Public Transport (Passenger) |
| Origin | Douala |
| Intended Destination | Nairobi/Jomo Kenyatta |
| Flight Phase | Climb |
| ICL / ENR | |
| Location - Airport | |
|---|---|
| Airport vicinity | Douala |
| General | |
|---|---|
| Tag(s) | Inadequate Aircraft Operator Procedures |
| HF | |
|---|---|
| Tag(s) | Spatial Disorientation Ineffective Monitoring Violation Manual Handling Procedural non compliance Inappropriate crew response (automatics) |
| LOC | |
|---|---|
| Tag(s) | AP Status Awareness Flight Management Error Flight Control Error Extreme Bank Extreme Pitch |
| Outcome | |
|---|---|
| Damage or injury | Yes |
| Aircraft damage | Hull loss |
| Fatalities | Most or all occupants |
| Causal Factor Group(s) | |
|---|---|
| Group(s) | Aircraft Operation |
| Safety Recommendation(s) | |
|---|---|
| Group(s) | Aircraft Operation |
| Investigation Type | |
|---|---|
| Type | Independent |
Contents |
Description
On 5 May 2007, a Boeing 737-800 operated by Kenya Airways on a scheduled passenger flight from Abidjan to Nairobi with a planned stopover at Douala, Cameroon crashed shortly after a dark night take-off from Douala. Loss of control was followed by a high speed inpact with terrain. All 114 occupants on board were killed and the aircraft was destroyed by the ground impact.
The Investigation
The investigation of the accident was carried out in accordance with Annex 13 guidelines by a Special Accident Investigation Commission established by the Republic of Cameroon CAA which found that after take-off from Douala, the aircraft exhibited a slight tendency to roll slightly to the right “due to the combined effects of the inherent asymmetry from construction and the slightly right positioning of the rudder trim”. According to the investigation report, that tendency could have been easily corrected with left aileron input, which was not made. After the bank angle has increased considerably and had not been matched by any useful response from the PF, a spiral dive was entered from which a late attempt to regain control was not successful and terrain impact followed. The Investigation was unable to establish whether flight crew awareness of autopilot (AP) engagement status was maintained but noted that the AP had not been engaged until a very late stage of the flight.
Probable Cause
The Investigation found that:
"The airplane crashed after loss of control by the crew as a result of spatial disorientation (non recognized or subtle type transitioning to recognized spatial disorientation), after a long slow roll, during which no instrument scanning was done, and in the absence of external visual references in a dark night."
"Inadequate operational control, lack of crew coordination, coupled with the non-adherence to procedures of flight monitoring, confusion in the utilization of the AP, have also contributed to this situation."
Safety Recommendations
The Investigating Commission made three Safety Recommendations, the first two of which are addressed primarily to the CAA of Kenya (KCAA):
- “KCAA and all State Administrations that issue licenses for aviation operations should ensure that they harness the necessary structures and means to approve and follow up amendments and revisions of manuals.”
- “KCAA and all State Administrations that issue licenses to aviation operations, ensure that companies put in place an organization that enhance the application of manuals, and decision making in matters of safety especially as concerns technical flight crews.”
The third Recommendation had no specified addressee:
- “It is strongly recommended that all flight crew receive formalized upset recovery training.”
- The Final Report of the Investigation conducted by the Cameroon CAA is at: Technical Investigation into the accident of the B737-800 registration 5Y-KYA operated by Kenya Airways that occurred on the 5th of May 2007 in Douala (note the large file size - 40Mb)
Related Articles
- Loss of Control
- Bank Angle Awareness
- Cross-checking Process
- Flight Instrument Presentation of Aircraft Attitude
- Recovery from Unusual Aircraft Attitudes
- Situational Awareness (OGHFA BN)
- Spatial Disorientation (OGHFA SE)
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