AIB Blames Human Error, Poor Regulation for Dana Crash
By Chinedu Eze
The failure of the pilot in command to take a strategic decision to return to base when the first engine of the ill-fated Dana Air Flight 992 failed 17 minutes into the flight led to its crash.
The aircraft, with registration number 5N-RAM, crashed on June 3, 2012, killing 163 people on board and on ground.
This was disclosed by the Commissioner of Accident Investigation Bureau (AIB), Akin Olateru, who indicted the Nigerian Civil Aviation Authority (NCAA) which is accused of laxity and poor regulation, which enabled a pilot who was not instrumented on an aircraft to operate it.
Olateru, who addressed journalists on the detailed report of the Dana Air flight crash, OAS and two Bristow helicopter accidents yesterday in Lagos, said the report on Dana crash showed that the MD 83 aircraft first engine lost power 17 minutes into the flight.
He 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 the Federal Aviation Administration (FAA) targeting Pratt and Whitney, the engine manufacturer; Dana Air and to Nigerian Airspace Management Agency, (NAMA) on Quality Assurance Management.
Olateru said the flight originated from Abuja (ABV) and the destination was Lagos (LOS). AIB published a preliminary report on September 5, 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.
AIB said contributory factors to the accident included the failure of the crew to recognise the landing gear warnings, no standard operating orocedure/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, AIB 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.
Contributory factors included 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 targeted Bristow Helicopters.
Meanwhile, reacting to the AIB report, Dana said since the accident, it has continued to adhere strictly to safety operation and recommendations of the regulatory body.
“Following the release of the final report of the June 3, 2012 accident, we wish to reassure our passangers of our total commitment to their safety and comfort onboard our flights.
“We wish to also state that Dana Air swung into action immediately the Interim Safety Recommendations were released in 2013, and as an airline strictly committed to the safety and comfort of its passangers, we implemented all the recommendations same year, as released by AIB. We did not stop at just implementing the recommendations; we also successfully passed an operational audit conducted by the Nigerian Civil Aviation Authority’s Flight Safety Group and its foreign partners”, the airline said.