If you wish to contribute or participate in the discussions about articles you are invited to join SKYbrary as a registered user

 Actions

A310, vicinity Abidjan Ivory Coast, 2000

From SKYbrary Wiki

Summary
On 30 January 2000, an Airbus 310 took off from Abidjan (Ivory Coast) at night bound for Lagos, Nigeria then Nairobi, Kenya. Thirty-three seconds after take-off, the airplane crashed into the Atlantic Ocean, 1.5 nautical miles south of the runway at Abidjan Airport. 169 persons died and 10 were injured in the accident.
Event Details
When January 2000
Actual or Potential
Event Type
CFIT, HF
Day/Night Night
Flight Conditions VMC
Flight Details
Aircraft AIRBUS A-310
Operator Kenya Airways
Domicile Kenya
Type of Flight Public Transport (Passenger)
Origin Abidjan/Port Bouet Airport
Intended Destination Lagos/Murtala Muhammed International Airport
Flight Phase Climb
ICL / ENR
Location - Airport
Airport vicinity Abidjan/Port Bouet Airport
CFIT
Tag(s) Into water
HF
Tag(s) Ineffective Monitoring
Manual Handling
Procedural non compliance
Inappropriate crew response (automatics)
Safety Net Mitigations
Malfunction of Relevant Safety Net No
GPWS Available but ineffective
Stall Protection Available but ineffective
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Injuries Few occupants
Fatalities Most or all occupants (†)
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation
Aircraft Airworthiness
Investigation Type
Type Independent

Description

On 30 January 2000, an Airbus 310 took off at night from Abidjan (Ivory Coast) bound for Lagos, Nigeria then Nairobi, Kenya. Thirty-three seconds after take-off, the airplane crashed into the Atlantic Ocean, 1.5 nautical miles south of the runway at Abidjan Airport. 169 persons died and 10 were injured in the accident.

The departure time for the flight was scheduled for 21:00 - the copilot was pilot flying and the captain was pilot monitoring. Less than 5 minutes to 21:00, the crew was given start-up clearance. A few minutes later, the Captain reported to the ground mechanic “we have two normal start-ups”.

At 21:07:35 the airplane began to taxi. The tower controller issued take-off clearance and asked the crew to call back upon reaching flight level 40. 32 seconds after the application of take-off power, the Captain announced “V1 and Rotate”.

“At 21 h 08 min 57 s, the copilot announced "Positive rate of climb, gear up". Less than two seconds later the stall warning sounded. At 21 h 09 min 07 s, the automatic call out (AC) announced 300 feet. At 21 h 09 min 14 s, the copilot asked "what’s the problem?". From 21 h 09 min 16 s, the AC announced successively 200, 100, 50, 30, 20 and 10 feet. Meanwhile, at 21 h 09 min 18 s, the copilot ordered the aural warning to be cut. Two seconds later, the GPWS sounded the “Whoop…” alarm followed, a half a second later, by the AC announcement of 50 feet. At 21 h 09 min 22 s, an aural master warning started, immediately followed by an order from the Captain to climb: "Go up!", though this was preceded six tenths of a second by the AC announcement of 10 feet.

At 21 h 09 min 23.9 s, end of the master warning, followed immediately within a tenth of a second by the noise of the impact.”

The Investigation

The Commission of Inquiry concluded that the cause of the accident to flight KQ 431 was a collision with the sea that resulted from the partial application of stall recovery procedure. Pilot flying pushed forward on the control column to stop the stick shaker, following the initiation of a stall warning on rotation, while the airplane was not in a true stall situation. He did not apply TOGA (Take-off/Go Around) thrust on the engines. The investigators were not able to determine whether the other two actions were performed: wing levelling and speed brake retraction check.

Recommendations

The following three recommendations were made in connection to the accident:

  • “…the Commission of Inquiry recommended, on 9 August 2001, that Civil Aviation Authorities ask training organizations and operators under their authority to integrate into type rating and recurrent training programs, for crews of all aircraft likely to be subject to false stall warnings, the elements necessary to recognize and manage such a false alarm during phases of flight close to the ground.”

During the investigation it was found that a new recovery from approach to stall procedure was published after the accident. In connection to this, the Commission of Inquiry recommended that:

  • “…the French DGAC ensure that Airbus harmonizes the procedures in the FCOM (Flight Crew Operations Manual) with those taught during type rating training.”

The third and final recommendation addresses the means to provide a comprehensive SAR operation at water for coastal airports:

  • “…civil aviation authorities responsible for coastal airports or those near water ensure that appropriate equipment (aerial, maritime, etc.) be put in place so as to ensure immediate intervention at an accident site located in an area near a coastal airport.”

Related Articles

Further Reading

  • Report 5y-n000130, translated and published by Bureau d’Enquetes et d’Analyses pour la Securite de l’Aviation (BEA)