Captain Ore peeps at the Ministrial panel report on Dana crash

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ECHOES OF THE PAST
ACCIDENT TO DANA AIRCRAFT
A LOOK AT MINISTERIAL PANEL REPORT

BY CAPT. DELE ORE

The panel is titled ‘Technical and Administrative Review Panel of Domestic Airlines’.

The panel was premature in setup and in conflict with Accident Investigation Bureau Mandate. When an accident occurs the Accident Investigation body does not just focus on the accident but examines the aviation system within which the accident occurred including all the matters in the Terms of this Reference of panel. No accident investigation body completes its task without critically examing all the issues in the Terms of Reference of the Panel.

Hence to a great extent this Panel is an aberration of the AIB and undermines the authority and responsibility of AIB Let us now examine the Panel report itself in its technical contents and presentation.

3.1.3 Maintenance Practices of DANA Airlines

The Review Panel portrayed sheer lack of knowledge of maintenance control and engineering analysis and displayed a deliberate attempt to misinterpret and even hide facts, as if a predetermination had been made to fault Dana as our Airline and NCAA as a regulatory body.

Compressor wash was already established by DANA as an Engineering Authorisation and had become part of their maintenance programme. The reasons for establishing this programme were specifically discussed and agreed upon. This was a proactive preventive maintenance activity rather than reaction to any problem encountered by DANA.

DANA performs a regular engine health programmed through engine performance monitoring which would reveal any incipient performance deterioration that would reveal engine internal engine problem.

Despite the records provided by DANA as to the genesis of engine wash, the panel, which was determined to rubbish DANA and NCAA, ignored these records and were not convinced that engine compressor wash had become a routine maintenance activity.

In 3.1.7. which dealt with engine change due to high EGT, despite the records of troubleshooting provided by DANA to the panel, the panel chose to ignore this having made up its mind to rubbish DANA and NCAA. It is on record that proper troubleshooting was carried out by DANA before engine removal. Confirmation of defect and associated rectification action was beyond the competence of DANA which appropriately sent the engine to an approved facility overseas which confirmed the defect.

The Panel turned a blind eye to the engine shop disassembly report. I want to confirm that DANA made a very correct judgment and action in respect of the engine change.

The Panel demonstrated abject lack of understanding on use of Technical Log.

Routine maintenance actions like engine compressor wash are not required to be recorded in Tech. Log – only such actions by authorized maintenance personnel emanating from response to flight crew recorded observations are required to be recorded.

I want to emphasize that compressor wash was not a corrective action to mitigate identified hazards, but rather a maintenance action programmed to be performed at identified and stipulated intervals.

The report indicated that the flight crew did not record some observations requiring maintenance action in the Tech. Log. Unfortunately for the panel, owing to their predetermined posture to find fault, failed to properly scrutinize copies of the Tech. Log presented to them. There was proper documentation in the Tech. Logs by the flight crew concerning this particular aircraft which the Panel decided not to see.
The Panel jumped to conclusion of oversight function of the Regulatory Authority over DANA as one would expect a catalogue of oversight deficiencies by NCAA to be presented by the Panel. But this was not so.

The areas referred to in its report, rather than being oversight deficiency, clearly portrayed the technical incompetence of the Panel.

The Panel failed to mention specific maintenance practices shortcomings of domestic operators, rather it made a general all-encompassing statement which was not substantiated.

NCAA TRAINING.
The recommendations arrived at by the Panel (3.2.1 & 3.2.2) in Terms of Reference leave much to be desired and are technically and factually unsound, and deserve some attention.

Closer surveillance has never been an answer to safe practices, particularly when the trend in developed countries is towards devolution and continuous monitoring by (ref ICAO) NCAA is required to lay the foundation for real time regulatory practices.

That NCAA inspectors are not well trained is arrant nonsense and creates the impression that FAA Team that carried out a progressive inspection of NCAA system over a prolonged period was incompetent.

MANAGEMENT OF AIRWORTHINESS
Also the panel has not shown enough understanding that emphasis should be placed on management of airworthiness rather than the inspection of aircraft and that the operating organization takes primary responsibility for the product under its control. This cannot be shifted to the Regulatory Authority.

Safety oversight principles enshrined in ICAO documents put the ultimate responsibility for safety on the operator

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