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AIB final accident reports identify human error, poor regulation
Final reports on six accidents and incidents released by the Accident Investigation Bureau (AIB) that occurred in the Nigeria aviation industry between 2009 and 2014 have identified human error and poor regulation as causal factors.
Among the six reports released were two accidents and four serious incidents. One of the accidents was the one involving Associated Aircraft crash of October 3, 2013, with the registration number, 5N-BJY.
Another accident report released was that of Westlink Airlines Limited Piper Aztec 23-250 aircraft with registration number 5N-BGZ, which occurred at Matseri village, Bunza Local Government Area of Kebbi State, on August 11, 2014.
The serious incidents were Aero Contractor’s DHC-8-400 aircraft incident with registration 5N-BPT, with the Nigerian Aviation Handling Company (NAHCO) baggage loader on April 29, 2014, and another incident involving two Bristow Helicopters aircraft, Bell 412 helicopters with registration numbers 5N-BGS, and 5N-BDD, at the Addax Base Helipad, Calabar, Cross River State, on November 12, 2009.
Also covered were the serious incidents involving two aircraft belonging to Nigerian College of Aviation Technology (NCAT). They were the Tampico Club TB9 with registration number 5N-CBE, which serious incident occurred at Zaria Aerodrome, Kaduna State, on October 4, 2012, and another serious incident involving Tampico TB–9 Aircraft with registration number 5N-CBI that occurred at the same Zaria Aerodrome on May 23, 2012.
Accident involving the Associated Aviation Limited, which led to a post impact fire resulting in 16 fatalities and four serious injuries identified several causal factors, some of which include the decision of the crew to continue the take-off despite the propeller rpm indicator.
The bureau also identified low altitude stall as a result of low thrust at the start of roll for take-off from engine caused by an undetermined malfunction of the propeller control unit.
Akin Olateru, commissioner of AIB, while reading out the results Wednesday in Lagos, said the bureau’s four safety recommendations on the crash were all directed at the Nigeria Civil Aviation Authority (NCAA).
Olateru called on NCAA to enhance the enforcement of the regulations with regards to the implementation of operators approved personnel training programme and intensification of its safety oversight function on the airline to ensure that flight operations were carried out in accordance with approved operations manuals in line with the provisions of Nigeria Civil Aviation Regulations (NCARs).
Others were improved safety oversight on the affected carrier to ensure staff welfare issues, and that remunerations were settled promptly and the establishment of Confidential Voluntary Reporting System, which must be implemented in line with the State Safety Programme.
On the two Bristow Helicopters serious incidents at the Addax Base Helipad, Calabar on November 12, 2009, like Associated Airways, the bureau also made four safety recommendations.
AIB recommended that the regulatory agency should ensure that Calabar Base Helipad Manual of APDNL be reviewed to comply with Nigeria Civil Aviation Regulations (NCARs), APDNL should ensure that helicopters are properly parked in designated locations, APDNL should ensure that Helicopter Landing Officers (HLOs) were always present during aircraft operations and the agency should ensure that helicopter flight operations at the Helipad were done in accordance with Nig. CARs.
AIB in the report, however, stated that NCAA responded to the safety recommendations of the bureau and implemented them.
On the Aero Contractors incident with NAHCO aviance baggage loader vehicle fleet L3-23 and a parked Bombardier DHC-8-400 aircraft of Aero Contractors, the AIB in its report said the NAHCO personnel who operated the baggage loader vehicle was neither employed to operate the vehicle, nor was he authorised to do so.
The report observed that the rostered driver of the baggage loader vehicle was not available at the time of the occurrence and cited the non-adherence to NAHCO Safe Operating Procedures by the Ramp manager as one of the contributory factors to the incident.
It also made four safety recommendations to NCAA, which included ‘strict adherence to NAHCO’s Standard Operating Procedures’ and ‘Air Operators’ Certificate (AOC) holders should determine the minimum number of personnel for airline ground handling operations to be deployed for each aircraft type.’
On the Westlink Airlines’ Piper Aztec 23-250 aircraft accident, AIB identified inadequate visual lookout and failure to avoid the obstacle by the pilots as the only causal factor responsible for the accident.
The contributory factors included less than adequate planning and preparation for the flight, inadequate pilot training and experience on agricultural aerial work and limited regulatory guidance and oversight on agricultural operations.
It also made four safety recommendations to NCAA in its report.
The report also included two NCAT serious incidents that occurred on May 23, 2012 and October 4, 2012 in Kaduna State, which generated eight safety recommendations.
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