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AIB final report on air crashes fingers human error, laxity by NCAA

BusinessDay
4 Min Read
Final report of the Accident Investigation Bureau (AIB) on air crashes that occurred within seven years points to human error by the crew and laxity on the part of the Nigeria Civil Aviation Authority (NCAA).
Speaking at a conference yesterday, Akin Olatero, commissioner, AIB, disclosed that report on Dana crash showed that the MD 83 aircraft first engine lost power 17 minutes into the flight.
Olatero said on final approach to landing in Lagos, the second engine lost power and failed  to  respond  to  throttle movement  on  demand  for  increased  power  to  sustain  the  aircraft  in  its  flight configuration.
According to the report, the  inappropriate  omission  of  the  use  of  the  Checklist,  and  the  crew’s inability to  appreciate  the  severity  of  the  power-related  problem,   their  subsequent failure to land at the nearest suitable airfield, lack  of  situation  awareness,  inappropriate  decision  making,  and  poor airmanship were identified as major causes of the accident.
Four  safety   recommendations were  made to Federal Aviation Administration (FAA),  targeting  Pratt  and Whitney,  the  engine manufacturer, Dana Airline and  to Nigerian Airspace Management Agency (NAMA) on Quality Assurance management.
It would be recalled at that on June 3rd 2012, Dana Air had a major accident that claimed the lives  153  persons  onboard  the airplane,  including  six  crew  were  fatally  injured.  There  were  also  six confirmed  ground  fatalities.  The  airplane  was  destroyed.  There  was  post impact  fire.
The  flight  originated  from  Abuja  (ABV)  and  the  destination was Lagos (LOS). AIB  published  a preliminary  report  on  5th  September,  2012  and  four  interim statements have been published. Four Interim  Safety  Recommendations  were  made  and  have  been  implemented  by the Operator and the Regulatory Authority.
On AOS helicopter, the Accident  Investigation  Bureau  identified causes to be non-adherence  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).
In addition to this, the report showed that the Pilot was not Instrument Rated and lacked route familiarisation.
Five safety recommendations have been made, three  of  which  were  targeted  at  NCAA; one    to  NAMA;  and   one to Nigerian Police Force.
On the Presidential Committee Implementation On  Maritime  Safety  and  Security (PICOMSS), the report showed that the decision  of  the  crew  to  continue  the  glide  approach  despite  repeated  landing gear  warnings  with  the  power  lever  below  25 per cent   rather  than  initiating  a  Go-around was the cause of the accident.
Contributory  factors include the failure  of  the  crew  to  recognize  the  landing  gear  warnings, 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, Lack of Crew Resource Management (CRM) training.
Two safety recommendations were made to NCAA and  to the Nigerian Police Force.
On Bristow Helicopters, the causes were identified as 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.
 
Contributory factors  include effectivity  of  the  aircraft  excluded  in  the  Alert  Service  Bulletin  ASB No. 92-20-002A issued by the manufacturer and the  Technical  Directive  TD-S92A-29-99  did  not  include  Check/Inspection  of the right hand side of the Upper Deck.
Two safety recommendations made  in  the  published report and both targeted to Bristow Helicopters.
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