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B738, vicinity Douala Cameroon, 2007 (LOC HF)

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Summary
On 5 May 2007, a Kenya Airways Boeing 737-800 departing Douala at night crashed shortly after take-off after an attempt at recovery after late recognition of a progressive right roll which led to spiral dive was unsuccessful. The Investigation was unable to establish the reason for the unintended roll but noted that it was not possible to determine whether the pilots, and in particular the aircraft commander, had been aware of the fact that the AP was not engaged.
Event Details
When May 2007
Event Type HF, 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) Inappropriate crew response (automatics)
Manual Handling
Procedural non compliance
Spatial Disorientation
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:

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