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B738, vicinity Douala Cameroon, 2007

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Summary
On 5 May 2007, a Kenya Airways Boeing 737-800 departing Douala at night crashed shortly after take-off following an unsuccessful attempt at recovery after late recognition of a progressive right roll which led to spiral dive. The Investigation was unable to positively establish the reason for the unintended roll, but noted that it ad not been 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
Actual or Potential
Event Type
Human Factors, Loss of Control
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 International Airport
Intended Destination Nairobi/Jomo Kenyatta
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Climb
ICL / ENR
Location - Airport
Airport vicinity Douala International Airport
General
Tag(s) Inadequate Aircraft Operator Procedures
HF
Tag(s) Inappropriate crew response (automatics),
Manual Handling,
Procedural non compliance,
Spatial Disorientation,
AP/FD and/or ATHR status awareness
LOC
Tag(s) AP Status Awareness,
Flight Management Error,
Flight Control Error"Flight Control Error" is not in the list (Airframe Structural Failure, Significant Systems or Systems Control Failure, Degraded flight instrument display, Uncommanded AP disconnect, AP Status Awareness, Non-normal FBW flight control status, Loss of Engine Power, Flight Management Error, Environmental Factors, Bird or Animal Strike, ...) of allowed values for the "LOC" property.,
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

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.

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. This found that after take-off from Douala, the AP had not been initially engaged and the aircraft had exhibited a slight tendency to roll to the right “due to the combined effects of the inherent asymmetry from construction and the slightly right positioning of the rudder trim”. The Investigation concluded that this tendency could have been easily corrected with left aileron input, but this was not done. After the bank angle had progressively increased without any compensation for it 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 positively establish whether flight crew lack of awareness of AP engagement status lacking but noted that the AP had not been engaged until a very late stage in 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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