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B732, vicinity Tamanrassat Algeria, 2003

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Summary
On 6 March 2003, a Boeing 737-200 being operated by Air Algerie had just become airborne during a daylight departure when the left hand engine suddenly failed just after the PF had called for “gear up”. Shortly afterwards, the aircraft commander, who had been PNF for the departure, took control but the normal pitch attitude was not reduced to ensure that a minimum airspeed of V2 was maintained and landing gear was not retracted. The aircraft lost airspeed, stalled and impacted the ground approximately 1nm from the point at which it had become airborne. A severe post crash fire occurred and the aircraft was destroyed and all on board except one passenger, were killed.
Event Details
When March 2003
Actual or Potential
Event Type
Airworthiness, Fire Smoke and Fumes, Human Factors, Loss of Control
Day/Night Day
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft BOEING 737-200
Operator Air Algerie
Domicile Algeria
Type of Flight Public Transport (Passenger)
Origin Tamanrasset
Intended Destination Noumerat/Ghardaïa
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Take Off
TOF
Location - Airport
Airport vicinity Tamanrasset
General
Tag(s) Inadequate Aircraft Operator Procedures
FIRE
Tag(s) Post Crash Fire
HF
Tag(s) Ineffective Monitoring,
Procedural non compliance,
Inappropriate crew response (technical fault),
Inappropriate crew response - skills deficiency
LOC
Tag(s) Loss of Engine Power,
Flight Management Error,
Aircraft Flight Path Control Error
AW
System(s) Electrical Power,
Engine - General
Contributor(s) Component Fault in service
Safety Net Mitigations
Stall Protection Available but ineffective
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Non-aircraft damage Yes
Injuries Few occupants
Fatalities Most or all occupants ()
Causal Factor Group(s)
Group(s) Aircraft Operation,
Aircraft Technical
Safety Recommendation(s)
Group(s) Aircraft Operation
Investigation Type
Type Independent

Description

On 6 March 2003, a Boeing 737-200 being operated by Air Algerie had just become airborne during a daylight departure when the left hand engine suddenly failed just after the PF had called for “gear up”. Shortly afterwards, the aircraft commander, who had been PNF for the departure, took control but the normal pitch attitude was not reduced to ensure that a minimum airspeed of V2 was maintained and landing gear was not retracted. The aircraft lost airspeed, stalled and impacted the ground approximately 1nm from the point at which it had become airborne. A severe post crash fire occurred and the aircraft was destroyed and all on board except one passenger, were killed.

The Investigation

The Accident Investigation was carried out by a specially established Commission of Inquiry. The Final Report of this Commission stated that “The accident was caused by the loss of an engine during a critical phase of flight, the non-retraction of the landing gear after the engine failure, and the Captain, the PNF, taking over control of the airplane before having clearly identified the problem.”

It is also stated in the Final Report that “The following factors probably contributed to the accident:

  • the perfunctory flight preparation, which meant that the crew were not equipped to face the situation that occurred at a critical moment of the flight;
  • the coincidence between the moment the failure occurred and the request to retract the landing gear;
  • the speed of the event that left the crew little time to recover the situation;
  • maintaining an inappropriate rate of climb, taking into account the failure of one engine;
  • the absence of any teamwork after the engine failure, which led to a failure to detect and correct parameters related to the conduct of the flight (speed, rate of climb, configuration, etc.);
  • the takeoff weight being close to the maximum with a high aerodrome altitude and high temperature;
  • the rocky environment around the aerodrome, unsuitable for an emergency landing.”

The Commission of Inquiry made Safety Recommendations as follows:

  • Air Algérie, along with other operators, ensure that their CRM-type training programs effectively heighten crew awareness of the strict respect required for handover procedures and task-sharing.
  • The Civil Aviation and Meteorology Directorate set up an organisation to inspect the application and conformity of the procedures in training programs for flight crews.
  • The Civil Aviation and Meteorology Directorate ensure that Air Algérie and other operators set up a flight safety program that associates feedback and the systematic analysis of flight data.
  • The Ministry of Transport set up a permanent organisation for the investigation of civil aviation accidents and incidents.

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