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AIB fingers NCAA in Agagu’s plane crash, urges NCAT to address deficiencies of student pilots

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…..advices Westlink and Bristow helicopters

The Accident Investigation Bureau, AIB has urged the Nigeria Civil Aviation Authority NCAA to intensify it safety oversight functions as it’s poor safety oversight is fingered to be responsible for the crash of the Associated Airline in Lagos on the 3rd October, 2013.

The aircraft an Embraer 120 ER with registration 5N-BJY, carrying the corpse of the late former Minister of Aviation, Chief Olusegun Agagu crashed into the Joint Users Hydrant Installation facility at the the Murtala Mohammed International airport Lagos few minutes after take off.

The Commissioner, AIB, Akin Olateru during the release of the final investigation report into the Associated Airline crash and 5 others, listed the causes and contributory factors to include the decision of the crew to continue the take-off despite the abnormal No. 2 Propeller rpm indication, Low altitude stall as a result of low thrust at start of roll for take-off from No. 2 Engine caused by an undetermined malfunction of the propeller control unit.

Others are the rotation of the aircraftbefore attaining V1and the decision to continue the take-off with flap configuration warning and auto- feather warning at low speed.

“Poor professional conduct of the flight crew, Inadequate application of Crew Resource Management (CRM) principles, Poor company culture and Inadequate regulatory oversight”.

Olateru said the pilots of the aircraft did not help to savage the situation as both pilots did not agree on what to do due to poor proper coordination resulting in the death of 16 and 4 serious injuries of the 20 on board.

The AIB therefore advice the NCAA in its 4 safety recommendations, to enhance the enforcement of the regulations with regards to the implementation of operators approved personnel training program and intensify its safety oversight function on the Airline to ensure that flight operations are carried out in accordance with approved operations manuals in line with the provisions of Nig. CARs.

Others are to intensify its safety oversight on Associated Aviation Limited to ensure staff welfare issues, and remunerations are settled promptly and to ensure that State Confidential Voluntary Reporting System was established and implemented in line with state safety program.

Another accident report released was that of Westlink Airlines Limited Piper Aztec 23-250 aircraft with the 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, Nigeria on 12th November, 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 the 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.

On the two Bristow Helicopters serious incidents at the Addax Base Helipad, Calabar in Cross River State 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) are 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,
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.

He noted, “today we have release 27 Safety Recommendations and a total of 147 safety recommendations since the inception of AIB. We believe that these has impacted air safety, not only in Nigeria but globally”.

“With 66 safety recommendations out of 147 and 16 reports out of 35 recorded from January 2017 to date, we have achieved 45 percent on our Safety Recommendation and 46 percent on publication of the accident and serious incident report”, he added.

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