How AIB crash reports expose pilots’ incompetence, poor regulation
The Accident Investigation Bureau (AIB) released final report of Dana Air crash of June 3, 2012 which killed 153 souls on board including six crew members, blaming the pilot for failing to land at the nearest airport when the aircraft lost first engine.
The plane crash occurred at IjuIshaga area of Lagos with six people on ground also losing their lives.
AIB commissioner, Engr. Akin Olateru who released the final report alongside those of three other accidents noted that the crash would have been prevented if the captain had made the right decision.
He said the aircraft, a Boeing MD83 with registration number 5N-RAM, which took off from Abuja lost power 17 minutes into the flight, and thereafter on final approach, the second engine lost power and failed to respond to throttle movement.
Other factors identified were the inappropriate omission of the use of the Checklist, and the crew’s inability to appreciate the severity of the powerrelated problem, and their subsequent failure to land at the nearest suitable airfield.
According to him, lack of situation awareness, inappropriate decision making, and poor airmanship were also responsible for the accident.
He said eight Safety Recommendations were made in the published reports which were directed at Federal Aviation Administration (FAA) of the United States targeting Pratt & Whitney the engine manufacturer; Dana Airlines; the Nigeria Civil Aviation Authority (NCAA) the Nigerian Airspace Management Agency (NAMA) on Quality Assurance Management.
Other reports released were OAS Helicopters (Nig.) Limited Ecuruiel A 350 B2 Helicopter with Registration 5N-BKA which occurred at Oke-Oba Hill, Ikonifin, Osun State, on 29th July, 2011; serious incident involving Bristow Helicopters Ltd Sikorsky S-92 with Registration 5N-BOA at Murtala Mohammed Airport (MMA), Lagos on 27th February, 2013 and the serious incident involving Presidential Implementation Committee on Maritime Safety and Security (PICOMSS) aircraft with Registration 5N-BKS which happened at Benin Airport Edo State on 5th July, 2012.
While the OAS crash claimed three lives, the remaining two did not record any casualty.
The cause of the OAS crash, according to Olateru was identified to be nonadherence of the Pilot to Visual Flight Rules of clear-of cloud and obstacles while maintaining ground contact at all times led to Controlled Flight into Terrain (CFIT).
Besides the Pilot, he said, was not qualified to fly that helicopter type just as he lacked route familiarization.
Five safety recommendations were made with three targeted at NCAA; one to NAMA; and the other one to Nigerian Police Force, he said.
On the PICOMSS crash, the AIB boss explained the investigation identified the decision not to respond to engine warning as the causal factor.
Other factors include no Standard Operating Procedure/Training Policy in place; the crew low hours and experience, coupled with the rostering of two pilots with same capability on a training flight, as well as lack of Crew Resource Management (CRM) training.
Two safety recommendations were made; one each to NCAA and the Nigerian Police Force.
On the Bristow incident, he said 115v cable loom chafed and arced with hydraulic pipeline, puncturing it and causing a high pressure leak which ignited on contact with hot surface of the Right Hand heat exchanger, resulting in fire on the Upper Deck.
Olateru who said accident investigation is very expensive lamented that only N16m was budgeted for investigation in the bureau’s 2017 budget, adding the essence of investigation was to prevent a reoccurrence and not to punish anybody.
An aviation veteran, Capt. Dele Ore lauded the AIB for releasing the reports, saying the most important issue is for those concerned to implement the safety recommendations contained in the reports.
He said, “I congratulate AIB and its new management for coming up with these reports less than a month after the new Commissioner took over? But I ask, what have we learnt? How have we been able to implement all the safety commendations contained in the reports in order to have accident-free operations”.
On the issue of the Dana report “This is basic in flying school. When there is an emergency like that, you bring down the aircraft and resolve the problem before continuing with the journey. Our young pilots should take note of this.
Ore also urged the regulatory authority, the Nigeria Civil Aviation Authority (NCAA) to ensure that all the safety recommendations contained in the report are implemented to the letter so that “we can have accidentfree operations”.