•Bureau says aircraft lost first engine 17 minutes into the flight
•’Pilots should have diverted aircraft to alternate airport’
THE Accident Investigation Bureau ( AIB) has released the final report of the June 3, 2012 DANA Air MD 83 crash at Iju Ishaga, Lagos, where 153 passengers including six crew members were killed.
AIB Commissioner Akin Olateru, who spoke on the release of four accident reports, attributed the cause of the DANA plane crash to pilots’ failure to divert the aircraft to an alternate airport when the aircraft lost its first engine 17 minutes after take-off from Abuja.
Olateru, who also spoke on OAS and Bristow helicopters’ crashes, said the DANA pilots also lacked ‘situational awareness’ of their flight terrain during the flight, because they headed for a densely populated area after the second aircraft engine failed on approach to Lagos Airport.
On the AOS Helicopter crash of July 29, 2011, where three persons died, AIB indicted the pilot for not being instrument-rated, in addition to lack of familiarisation of the route by crew and non-adherence of the pilot to visual flight rules.
Olateru said AIB engaged stakeholders, including the affected operators and the NCAA for their input 60 days before it was reviewed for final publication.
He said the AIB, in accordance with prescribed regulations by the global civil aviation regulation, International Civil Aviation Organisation (ICAO) annex 13, was not bound to accept the contributions of the affected operators.
The report on DANA Air reads: “Engine number 1 lost power 17 minutes into the flight, and thereafter on final approach, engine number 2 lost power and failed to respond to throttle movement on demand for increased power to sustain the aircraft in its flight configuration.
“The inappropriate omission of the use of the checklist and the crew’s inability to appreciate the severity of the power-related problem and their subsequent failure to land at the nearest suitable airfield.
“Lack of situation awareness, inappropriate decision-making and poor airman ship.”
He said some safety recommendations have been made for implementation by the operators and the NCAA.
On the crash involving OAS Helicopters on July, 29, 2011, at Oke – Oba Hill , Ikonifin, Osun State, the AIB indicted the NCAA, saying one of the pilots was not rated on the instrument.
The AIB report reads: “The 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). The pilot was not instrument-rated. The pilot lacked route familiarisation.”
The AIB said three safety recommendations were made and implemented.
It reads: “The three recommendations were targeted at NCAA, one to NAMA and one to Nigeria Police.”
On the crash of Bristow Helicopters, the AIB report said 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.
He said two safety recommendations were made to Bristow Helicopters.
On the report of the Serious Incident involving Presidential Implementation Committee on Maritime Safety and Security (PICOMSS) aircraft with Registration 5N-BKS at Benin Airport on July 5, 2012,the AIB attributed human error as a contributory cause for the accident.
The report reads : “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 are contributory cause of the crash.
Others include: The failure of the crew to recognise 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 – one to NCAA and the other to police.
Olateru, however, advised operators in the industry .
He said : “I want to leave the following questions to my colleagues in the industry, the regulators, investors and Nigerians. What is the cost of an accident? How do we measure the value of people’s lives?
“Can we ever calculate/quantify the investment worth of damage? How do we calculate the cost and set it against the inevitable commercial cost of the investment necessary to avoid the tragedy in the first place?
“My advice is for the stakeholders to come up with a seminar that will involve the entire members to discuss these issues.
“In the last couple of weeks, AIB has been engaging with different agencies and stakeholders to see how we can collaborate and cooperate for the benefit of the flying public and we were assured that we can
all together achieve the desired objectives when all hands are on deck.”
