A Wish and a Prayer: The crash of UTAGE flight 141

The cockpit of UTAGE flight 141 lies on a Beninese beach after the crash. (aviationaccidents.net)

On the 25th of December 2003, a Guinean Boeing 727 stopped over in Benin during a flight to Beirut and Dubai. As more and more passengers boarded the plane, the pilots started to become concerned about the weight. Expressing his displeasure to a company manager, the first officer said, “We’ll see if this airplane takes off, otherwise we’re going to drop into the sea!” But there was little he could do: despite being unsure how many passengers were even on board, there was a schedule to make, and as the airline’s only qualified 727 crew, they would be in trouble if they refused to fly. As the overloaded plane rumbled off down the runway, it failed to become airborne, struck a concrete building, landed back on the beach, and careened headlong into the Atlantic Ocean, where it broke apart and sank within seconds. At least 141 people died in the crash and during the struggle to escape the submerged airplane. To understand why they died, Benin called in French investigators to uncover the cause. What they found was disturbing: a series of failures on every level led to a plane taking off with its pilots unaware of the real weight and center of gravity, a sequence of events made possible only by the almost total absence of the sort of safety net that travelers around the world take for granted.

An old poster for Air Afrique. (republicoftogo.com)

From the 1960s to the 1990s, air travel between the Francophone countries of West and Central Africa was dominated by a single airline: Air Afrique, a company set up cooperatively by the governments of several countries to provide regular flights throughout the region. Although it was considered one of the best airlines in Africa, Air Afrique eventually fell on hard times, and in 2002 it ceased operations entirely. This left West Africa with an urgent question: how to get from one place to another by air?

One of the routes that lost service ran from Conakry, capital of Guinea, to Cotonou, the largest city in Benin. After the demise of Air Afrique, the only way to fly between these two cities was to connect through Paris, a ridiculous inconvenience that massively increased both cost and travel time. With ever-increasing demand for connecting flights and an almost total absence of supply, small airlines began to pop up all over West Africa, determined to fill the vast shoes of Air Afrique. One of these was Union des Transports Aériens de Guinée, officially abbreviated to UTAGE but more commonly referred to as UTA (not to be confused with the defunct French airline of the same name).

UTA was originally a regional carrier based in Sierra Leone, and later in Guinea, which operated short flights using a pair of old Eastern European turboprops. Although it operated entirely within West Africa, the airline was owned and run by members of the region’s Lebanese diaspora. They faced travel problems of their own: around the same time that Air Afrique went out of business, Lebanon’s national carrier, Middle East Airlines, also stopped offering flights to the region. UTA’s management saw an opportunity to solve this inconvenience and make a lot of money by killing two birds with one stone: they would acquire a jet and run flights from Conakry to Beirut, Lebanon, with a stop in Cotonou on the way. In June 2003, UTA purchased an ancient Boeing 727, hired a flight crew on lease from another airline, and started flying from Conakry to Cotonou to Beirut and back again every week. Or at least, that was the plan.

3X-GDO, the aircraft involved in the accident. UTA’s first 727, 3X-GDE, would have looked very similar. (Aviation Safety Network)

The very first time the 727 stopped in Beirut, Lebanese authorities smelled something fishy and decided to inspect the plane at the gate. They found that the Minimum Equipment List, the Air Operator Certificate, and the equipment checklists belonged to three different airlines, none of which were UTA. The plane also had no insurance and no documents related to the contract with the company they were leasing it from. And in addition to these, inspectors found no less than eight different mechanical problems, most of which were sufficient by themselves to bar the plane from taking off. Lebanon ordered UTA to correct the mechanical problems before the plane could leave Beirut, which they eventually did. After more than a month in Lebanese custody, the plane was cleared to leave the country on August 22nd, but only on the condition that it be taken to a boneyard in the United Arab Emirates.

In the meantime, UTA had rectified the problem by simply acquiring another 727. This aircraft had been operated by American Airlines from 1977 until 2001, at which point it was retired and sent to long-term storage in Victorville, California. The plane was then acquired by Wells Fargo Bank before being sold to a company called the Financial Advisory Group (FAG), which was nominally based in the US Virgin Islands but apparently conducted most of its operations out of an office in the UAE. FAG’s business was acquiring old airliners and leasing them to airlines in third-world countries, and it proceeded to do just that. In January 2003, FAG leased the 727 to Ariana Afghan Airlines, the beleaguered national airline of Afghanistan, but sometime in the next several months that deal apparently fell through. So FAG leased out the plane again, this time to an airline in Swaziland called Alpha and Omega Airways. Alpha and Omega Airways in turn sub-leased the plane to UTA while presenting itself as the owner, although the actual contract was signed by an FAG employee. Under the contract, FAG was to provide the flight crew and a maintenance base, while UTA would conduct line maintenance, pay operating costs, fulfil crew salaries, and keep documentation updated.

The extremely convoluted ownership history of the 727, 3X-GDO. (BEA)

Under this contract, UTA resumed weekly flights from Conakry to Beirut via Cotonou, and later added a leg to Dubai as well. It did all of this despite having only one qualified 727 flight crew; this crew simply flew all of the 727 flights, duty time limits be damned. This crew was replaced twice for reasons that remain unclear. The third crew, hired on the 8th of December, consisted of three Libyan pilots, all of whom had previously flown for Libyan Arab Airlines. Captain Najib al-Barouni was highly experienced, with over 11,000 total flying hours of which 8,000 were on the 727, and the unnamed first officer and flight engineer were also no rookies. Joining up with the same four flight attendants on each trip, this crew flew weekly from Conakry, to Cotonou, to Kufra Airport in the Libyan Sahara to pick up fuel, to Beirut, and finally to Dubai, before turning around and going back. When the plane stopped in Beirut, Lebanese authorities usually inspected it and produced a list of maintenance items which had to be addressed before it returned, and UTA invariably complied. This was, however, the only recorded maintenance UTA ever performed on the plane.

The planned route of flight 141. (Google)

On Christmas Day 2003, the crew once again reported for duty in Conakry to fly flight 141 to Cotonou, Beirut, and Dubai. Eighty-six passengers boarded in Conakry, in addition to the three pilots, four flight attendants, two mechanics, and a “transporter,” who was responsible for supervising cargo and paying airport fees. After an uneventful flight, the 727 arrived in Cotonou, whereupon nine passengers disembarked. Among those who stayed on were several members of UTA management, including the company’s director general and his family.

It was in Cotonou that events started to spiral out of control. Dozens of people were trying to catch last-minute flights to see relatives in Lebanon for Christmas, many of them with numerous gifts in tow. The first problem was that the boarding passes issued at the check-in stands at the airport didn’t include passengers’ names, nor was a boarding pass needed to get through the security checkpoint; as a result, passengers discovered that once they had shown their boarding pass to the gate agent and been assigned a seat, they could turn around and sell the boarding pass right back to someone else who wasn’t booked on the flight. Without a name or any other identifying information, the gate agents had no way of knowing which boarding passes had already been used and which had not.

Setting the scene: Cotonou International Airport. (Airports Data)

Meanwhile, a group of ramp agents set about loading the passengers’ bags onto the plane. At this point on a normal flight, the pilots would expect to receive a weight and balance sheet listing the number of passengers, the total number of checked bags and carry-ons, and the estimated weight and distribution of these bags. But behind the scenes, nobody actually knew any of these figures. The cockpit voice recording begins some thirty minutes before the time of departure, and right off the bat, the pilots can be heard discussing the loading of the airplane. Poor audio quality made some lines only partially intelligible, but others came through loud and clear.

“The sheets they gave us don’t have the load,” said the first officer. “What is that? Come on, come on… the sheets they gave us don’t have the weight, only passengers.”

“Don’t worry,” said the captain, “We have the passenger manifest, without weight.”

There followed some unintelligible discussions about the weight of the baggage.

“How many passengers on board?” someone asked. “How many passengers do we have?”

“They didn’t give us anything,” said the captain. “Fifty-five? Sixty-five? How many?” Evidently he was referring to the number of new passengers boarding in Cotonou, not the total.

“But, but, but,” said the first officer, engaged in a side conversation in Arabic with the UTA director general, who was sitting in the cockpit. “Each of them is bringing on board the airplane a 200-kilo suitcase — two hundred kilos! — that’s not possible. Get them to unload them and weigh them, then we will know.” While the captain and flight engineer discussed how much weight to put down for the baggage, the first officer continued to rant to the director. “If we manage to take off… the people… I tell you, it will be quite a performance if we manage to take off today… at least let them put the exact weight so that we know it, let them put the exact weight so we can calculate it.”

Some fragments of the cockpit conversation. (BEA)

“But the weight is indicated here,” said the director, evidently pointing at something.

“There is no weight,” said the first officer. “Each passenger came on board with a 20-kilo bag? It’s impossible, if you have an airplane with 100 passengers… if this airplane takes off today — you will see if this airplane takes off, otherwise we’re going to drop into the sea. You have 141. You will see when the aircraft will take off or we will crash into the sea.”

“I’m sorry,” said the director, a hint of exasperation in his voice, “as soon as we arrive in Beirut I’m going to tell him off… what can I do, what can I do! And on the return, I cannot do anything, I came, I made this problem, I cannot return.”

“No, don’t send the passengers back, but the baggage must stay here,” said the first officer.

“I will send six messages that more thirty-kilo hand luggage and hand baggage is not allowed,” said the director general.

By this point, the passengers had finished boarding. It was hard to say how many there were exactly, but it was apparently more than the number of seats. The 727 had 140 passenger seats, plus four flight attendant jump seats, two cockpit jump seats, and six extra seats for airline personnel. Every one of them had been filled, and then some. Both cockpit jump seats were occupied by airline executives, who had been displaced from their designated seats in the cabin due to the number of passengers. At least one passenger sat on the back of one of the flight attendants’ seats to be near his friends. According to the official manifest provided to the pilots, 74 people had boarded in Cotonou, coming out to a total of 149 passengers, although the crew and the director general apparently believed that there were 145. Nobody knows the real number, but it was probably somewhere between 153 and 160, after accounting for people who bought their boarding passes from other passengers at the gate.

The weight of baggage was equally mysterious. The pilots were given a load sheet that specified the number of bags, but no information (or contradictory information) about their weight. The crew knew there must be many overweight bags due to the number of Christmas gifts in the passengers’ luggage, but nobody had checked. Using the airline’s average bag weight of 35 kilograms would have produced a total weight of 4,675 kilos, but this was highly unrealistic, not just because many of the bags were probably heavier than average, but because the number of bags was itself unreliable. No bags had been recorded on the manifest for any of the passengers who disembarked in Cotonou, even though upon their arrival the baggage handlers removed ten bags belonging to these passengers. Who was to say how many bags the newly boarded passengers actually brought, let alone how much they weighed? The crew also couldn’t be sure how that load was distributed. In the absence of information suggesting otherwise, they assumed it was distributed correctly. But the baggage handlers actually had no formal training in aircraft loading, and they had put a disproportionately large number of heavy bags into the forward baggage compartment. This was a problem because the pilots must know the real weight distribution in order to correctly set the stabilizer for takeoff. Before every flight, the pilots adjust the stabilizer trim, which determines the pitch angle at which the plane is stable, in order to help it get off the ground.

How much nose-up stabilizer trim to apply before takeoff depends on the location of the plane’s center of gravity. The center of gravity, or CG, is the point where the plane would be perfectly balanced if you held it up on your finger tip. The location of the CG is expressed in terms of its position aftwards along the Mean Aerodynamic Chord (MAC), or the average width of the lifting surface. With a proper distribution of baggage, the center of gravity would have been located at 19% MAC, and this was the position that the pilots used for their calculations. But in reality, the uneven weight distribution had shifted the CG forward to 14% MAC. Therefore, while the pilots had calculated that they would need 6.75 units of nose up stabilizer trim to take off, they actually needed 7.75 units, because the front-heavy aircraft had an increased desire to pitch down.

How center of gravity is measured. (Antilived via Wikimedia)

On top of this, the plane was grossly over its maximum rated takeoff weight. The actual weight of the plane was around 85.5 metric tons, 4.8 tons more than the max takeoff weight for a Boeing 727–200. The pilots calculated their weight based off the information they had been given and determined a weight of 78 tons, which was within limits. But they were clearly skeptical of this value, because they selected 137 knots for their rotation speed, the speed at which they would attempt to pull up and lift off the runway. 137 knots was more in line with a weight of 85 tons, suggesting that they expected to be heavier than the load sheets indicated. But even if they thought their real weight was closer to 85 tons than 78, they probably didn’t realize that this was considered overweight: the maximum takeoff weight listed in the operations manual was 86.4 tons instead of 80.7, because it was meant for a different version of the 727!

As the crew taxied to the runway and prepared to take off, a flight attendant informed them that passengers were still standing in the aisles and refused to sit down, apparently because they were trying to stay near their friends. It took several minutes to get them under control, but once order was restored, the pilots uttered a quick prayer — Bismillah el Rahman el Rahim — and finally began the takeoff roll. After spooling up the engines to high power while sitting with the brakes on (an attempt to reduce their takeoff distance), they began to rumble off down the fairly short 2,400-meter runway. But at their real weight of 85.5 tons, in combination with an outside temperature of 32˚C (which reduces engine performance), this runway would only barely be long enough to get the overloaded plane into the air.

Satellite view of Cotonou Airport. (Google)

As the plane accelerated through 137 knots, the first officer pulled back on the controls to lift off, but to his surprise, his inputs had almost no effect. In fact, considerable effort would have been required to get the plane to climb normally, because the stabilizer setting was not high enough to compensate for the nose-heavy baggage loading.

“Rotate, rotate!” the captain shouted. “More, more, more! Pull, pull!”

The first officer hauled back on his controls, and the plane just barely eased off the runway about 350 meters before the end. But climbing was another story entirely.

Within seconds of the tires lifting off the runway, the plane flew past the end of the pavement and over the grass at a height of barely two meters. They could have climbed out, if not for an unfortunate obstruction: the concrete building housing the localizer equipment, located 63 meters beyond the end of the runway. Flying at a height of just 2.1 meters, the landing gear and belly of the plane slammed into the 2.4-meter-high localizer building, tearing off its heavy concrete roof and throwing it across a field. The impact ripped off the landing gear and tore out the ventral staircase in the tail, and the plane began to lose altitude. The 727 clipped the airport perimeter wall and slammed down onto the beach, where it cleared a drainage canal and skidded toward the tideline. Still traveling at considerable speed, flight 141 plowed straight into the Atlantic Ocean and broke apart. The tail section dropped off and the cockpit tore away like a pencil tip, while the main fuselage rolled upside down and came to rest on the shallow sea bottom with the floor sticking up through the gently sloshing waves.

My sketch of the moment of impact. (Own work)

Inside the plane, many passengers weren’t wearing their seat belts and were thrown in every direction on impact. Then as soon as the plane went into the sea, a terrifying wall of water swept through the cabin in seconds, smashing into passengers who were hanging from the ceiling and had no chance to undo their seat belts. The crash killed some people outright, but far more succumbed to drowning, unable to find an exit as salty water filled the inverted plane. Only a lucky few who were seated near the breaks in the fuselage managed to swim upward to safety. Among these were the occupants of the cockpit: although the first officer was killed instantly when his head struck the side of the plane on impact, the captain, flight engineer, and the two UTA executives riding in the jumpseats all managed to escape and swim to the beach. They and the surviving passengers were quickly pulled to safety by a growing crowd of onlookers, consisting of both beachgoers and people from nearby neighborhoods who had seen the crash. By the time emergency services arrived, quite literally thousands of people were swarming the crash site, hindering access and making it difficult to determine who needed medical attention. Some of the survivors had already wandered off or been taken to hospitals by good Samaritans, and dead bodies were lying uncovered on the strand. It took hours to bring the scene under control.

Pieces of the plane’s tail resting in the shallow water. (Naharnet)

As recovery crews began to search for the bodies, it became clear that there were more people on board the plane than was indicated on the flight manifest. 141 bodies were found in total, while 22 people survived — which meant that the number of passengers had to have been at least 153 (163 total occupants minus 10 crew), which didn’t correspond to the 140 available passenger seats, nor to the figure of 145 discussed by the pilots, nor the total of 149 indicated on the manifest. But that wasn’t the end of the confusion: beyond the 141 dead, there were seven people who were apparently on the flight and had been listed as missing, but DNA tests showed that none of these seven people could be matched with the 12 remaining unidentified bodies. That meant that there could have been up to seven bodies which were not recovered, putting the death toll as high as 148, and the total number of passengers as high as 160. Due to the inability to locate any more bodies, this discrepancy was never resolved. Investigators later considered the possibility that some of the 12 unidentified bodies belonged to beachgoers struck by the plane, but this was ruled out as unlikely due to the absence of any reports of missing Cotonou residents. All things considered, it seemed more likely that there had been more people on the plane than the manifests indicated, and that the last seven bodies had been swept out to sea or buried in the sand.

The cockpit of flight 141, from which two pilots and two airline executives were extracted alive. (aviationaccidents.net)

The crash left Benin in shock: this was not only the deadliest plane crash in the country’s history, but its first major air accident, period. Beninese authorities had no pre-existing expertise which would allow them to investigate the crash, so they did the right thing and called in foreign experts: specifically, the French BEA, one of the world’s leading accident investigation agencies. The experienced French investigators were used to investigating crashes that occurred because of long strings of subtle factors that had slipped through fairly robust safety nets, but in Africa, they were in for a surprise.

Another view of the aircraft’s wrecked tail section. (Bureau of Aircraft Accidents Archives)

The BEA found that simply acquiring reliable information was almost impossible. Record-keeping at UTA was apparently non-existent, and with the exception of the captain (who was presumably eager to clear his name), extracting testimony from people was like pulling teeth. Investigators couldn’t find any records of the exact hours flown by any of the pilots, and their activities had to be reconstructed by asking the pilots what flights they had undertaken; only then was it possible to determine that they frequently exceeded the 9-hour flying time limits imposed under Guinean law. But that was just the tip of a shockingly large iceberg.

Onlookers crowd around a section of the airplane. (China Daily)

Because of the reports of overloading and the fact that the plane clearly struggled to become airborne, investigators decided to take a closer look at its weight and balance. But where could they even begin? None of the documentation contained the actual empty weight of the airplane, and no less than six different figures were provided to investigators, ranging from 43.5 to 47.17 metric tons. Also unavailable was the plane’s empty center of gravity, and the maximum takeoff weight in the operations manual was for a different version of the 727. This was incredibly basic documentation that every airplane was supposed to have, but it was nowhere to be found! Investigators also could not locate any weight and balance data for the accident flight or any previous flights; although at least seven different load sheets related to the accident flight were provided, all were severely incomplete and none contained weight information. Not only was the final weight and balance sheet not filled out, no copies of passenger or baggage weight data could be found either. The only weight and balance-related documentation for this airplane was located in Lebanon by Lebanese authorities: six load sheets used by the plane during stops in Beirut, written on paper headed with “Alpha and Omega Airlines,” which appeared to have come from the plane’s previous owner (which it should be pointed out was called Alpha and Omega Airways, not Airlines). A fragment of one of these sheets was found in the wreckage, but its contents could not be determined. Taking all these factors into account, it was apparent that the pilots could not possibly have known the actual weight of the airplane or how it was distributed. They were even unsure of how many passengers they had on board!

Onlookers gather as debris from the crash washes up on the beach. (Bureau of Aircraft Accidents Archives)

Because of this complete lack of reliable loading information, the pilots were essentially left guessing about what settings to use for takeoff. They had been provided with a list of passengers which clearly showed fewer people than were really on board, and the list of bags was so incomplete as to be useless. It also contained no weight information even though it was clear that people were bringing heavy bags weighed down by the fruits of their Christmas shopping sprees. The first officer was so distrusting of the baggage numbers that he speculated to the UTA director general about whether the plane would take off or crash into the sea! By reverse engineering the plane’s weight and balance from its performance data, the BEA determined that the plane was 4.8 tons too heavy — and on a hot day with a runway length of just 2,400 meters, they actually needed to be considerably under the maximum in order to take off with the legally required margins. But without solid proof that the plane was overweight, it would have been extremely difficult for the pilots to justify refusing the takeoff, especially with airline executives and their families on board.

People stand near the remains of the cockpit. (Laurence Journal-World)

The sequence of events therefore went something like this: first, baggage handlers with no training loaded bags haphazardly, concentrating the weight in the forward hold. The bags were not weighed, preventing a determination of how many were abnormally heavy. In the concourse, passengers who had checked in resold their boarding passes to people looking for last minute flights, causing too many people to board the plane. Assuming that the baggage handlers had loaded the hold properly, the pilots selected a stabilizer position of 6.75 units nose up, which was one unit too low. The high temperature, which reduced engine performance, combined with the excess weight and caused the plane to reach takeoff speed only a short distance from the end of the runway. When the first officer tried to pull up, the weight imbalance made this more difficult than expected, and the plane failed to climb high enough to avoid striking the localizer building 63 meters past the end of the runway. After that, disaster was unavoidable, but without any one of the factors that extended the takeoff run, the plane would have cleared the building and climbed away safely.

Mangled wreckage of the plane was strewn across the beach. (Ramzi Haidar)

But the investigation wasn’t over: the BEA wanted to know how an airline could get away with dispatching flights without properly accounting for weight and balance. What they found was so shocking that it went beyond negligence and ventured into the realm of the absurd.

It turned out that almost all of the management positions at UTA were held by members of the same Lebanese family, none of whom had any technical aviation knowledge whatsoever. The chief pilot was also responsible for quality control and had never flown a 727. Besides its three aircraft, the airline’s only assets consisted of an office inside a building belonging to a Conakry-based travel agency, a rented check-in desk, and two rented shipping containers on the grounds of Conakry Airport, which were used to store “paperwork and mineral water.” The airline had no operations room, no briefing room, no flight safety department, and no remote bases to support the plane on its stopovers. No maintenance and inspection manual could be found. In addition to the weight figure corresponding to a different version of the 727, the flight crew operations manual also referred to several departments and positions which did not exist, including flight support manager, section dispatch manager, navigation section, procedures and publication section, and crew scheduling and records section. At several points the manual specifically mentioned operations in Jordan and Gaza, which were never served by UTA. UTA had been operating without a Guinea-approved Minimum Equipment List (MEL) until November 14th; the operations manual did contain a chapter called “Boeing 727 MEL,” but, bizarrely, its contents were in no way related even to the concept of a minimum equipment list. The document listing the plane’s empty center of gravity wasn’t from a 727 at all, and the operations department’s organization chart specified that the director of operations and chief pilot were responsible for a “fleet of L1011s,” an aircraft type that UTA had never operated. Company documents contained chapters relating to the operation of L1011s, Boeing 707s, Fokker F50s, and DHC8s, none of which were ever operated by UTA, along with training related to the 727 allegedly conducted in 2002, well before UTA first acquired a Boeing 727.

Another view of some of the mangled debris. (Ramzi Haidar)

Investigators could only conclude that all this “documentation” had been slapped together from documents belonging to other airlines in order to prove to Guinean authorities that the documentation existed (and the authorities evidently had signed off without actually reading any of it). The airline’s paper trail was so poor that the BEA couldn’t even figure out who was maintaining the airplane, if anyone. It was also evident that neither UTA nor Guinean authorities had put much thought into whether the airline was capable of operating a 727 between Africa and the Middle East. Even the most basic review of the airline’s facilities and personnel would have revealed that it was totally unprepared to take this step. Nevertheless, Guinea had approved the airline’s request to serve the Conakry-Cotonou-Beirut route without question. The study of the feasibility of the route — a required item in order to receive this approval — was said to have been carried out by a Dubai-based company called Gatwick Aviation, but investigators couldn’t find the document containing the company’s report. Regardless, it was apparent that Guinea had rubber stamped UTA’s request because restoring flights on the route was in the national interest.

All kinds of flotsam covered the beach after the crash. (Ramzi Haidar)

This highlighted a problem that was widespread throughout many African countries: airlines expected the government to be completely absent, and if the government stepped in to enforce a regulation, it would be perceived as retaliatory and probably political in origin. This was not the case in states which had managed to build a strong civil society, but many African countries went straight from colonial exploitation to decades of civil war and military dictatorships without a chance to develop one. Guinea effectively had to build a country from scratch: after Guineans voted in 1958 to become independent from France, nearly all French nationals in the country left in just three months, and on the way out they deliberately destroyed virtually everything they felt had come to Guinea with French colonization, from city planning documents to medicine stocks to electric lightbulbs. By 2003, Guinea was on only its second president since independence, and neither leader had devoted as much attention to developing a robust civil sector as he had to staying in power. The country’s economy mostly operated on an informal basis, including its airlines. Although Guinea had adopted the aviation regulations produced by the Chicago Convention and recommended by the International Civil Aviation Organization (ICAO), in practice they were nothing more than words on paper. ICAO was aware of this problem through its routine inspections of signatory nations; in fact, in 2001 ICAO reported that Guinea did not even have a system for issuing Air Operator Certificates to its airlines, and asked that it create one immediately. While Guinea began issuing AOCs later that year, it still had no regulatory mechanism for adding leased aircraft to the lessee’s certificate and no mechanism to validate an airline’s capability to operate a particular route.

Identifiable among the debris was the plane’s number two engine intake. (Ramzi Haidar)

The fact that Guinea was a member of ICAO, and that Guinean authorities had certified UTA under this regulation, was sufficient for Benin and Lebanon to allow UTA to fly to their airports. But they had no way of independently determining, except through experience and anecdotal evidence, whether Guinea was actually in compliance. Under the Chicago Convention, states are individually responsible for the safety of airlines and airplanes registered within their borders. ICAO exists to check whether states are complying with the Chicago Convention or not. The problem is that the results of these evaluations aren’t easily available to other states which need to consider whether to allow air traffic from a particular state to enter their airspace. There was a certain mutual trust that any state which had ratified the Chicago Convention and adopted its protocols was indeed following them. Some countries, like the USA, do have the capacity to evaluate this independently. But Benin and Lebanon most certainly did not. In their report, investigators wrote that ICAO should take an active role in helping non-complying states implement an aviation safety system, something which those in positions of political power may not understand how to do. They also called for increased transparency at the international level so that states could make informed decisions about what airlines to allow in their airspace.

The roof of the localizer building can be seen on the right, with the landing gear in the foreground. (Ramzi Haidar)

In its final report, the BEA issued several recommendations to Guinean authorities which effectively called for the wholesale creation of a civil aviation system, with features such as regulatory accountability and routine inspections. The BEA was used to issuing very targeted recommendations that specific organizations could complete in a defined timeframe, but such recommendations would be useless given the apparent absence of any organizations to submit them to. The bureau also asked ICAO to act more aggressively in informing member states of the actions needed to implement the Chicago Convention guidelines, including through the creation of step-by-step guides for countries to follow; and to clarify how to decide what company is the operator of an aircraft when the operator is unclear. Two further recommendations were issued to regulatory authorities in Europe and America, asking that new planes be designed to include devices that could automatically detect the plane’s weight and CG, and that older planes be retrofitted with these devices over time.

Although he was not primarily to blame for the crash, a Lebanese court in 2010 sentenced Captain Najib al-Barouni to 20 years in prison for negligence in connection to the accident; however, he had returned home to Libya and was not apprehended. The court also handed down the same sentence to Imad Saba, owner of the plane; Darwish Khazem, the head of UTA; UTA general manager Ahmed Khazem; and UTA director of operations Mohammed Khazem, of whom three of the four were present for the sentencing. They were also ordered to pay $930,000 to the families of the victims, most of whom were Lebanese.

A relative holds a picture of one of the victims of the crash. (Joseph Barrak)

The crash of UTAGE flight 141 shows that even in a lawless environment, it’s better to err on the side of safety. We know that UTA could have run a tighter operation without inflicting undue economic hardship, because they always found enough funds to take action when Lebanon ordered them to fix their planes. But they should have taken these steps without relying on Lebanon to force their hand. If UTA had done the bare minimum to safely operate a 727, the crash would not have happened — instead, they lost a plane full of people, including numerous airline employees and their families, resulting in the near-immediate demise of the airline. Maybe if they had made an effort, the airline would still be around today. The fact that it isn’t is a stark reminder that safety really does pay.

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Analyzer of plane crashes and author of upcoming book (soon™). Contact me via @Admiral_Cloudberg on Reddit or by email at kylanddempsey@gmail.com.