Home Safety Dana crash: AIB final report identify ‘Human error’ as cause of crash

Dana crash: AIB final report identify ‘Human error’ as cause of crash

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Pix from left Captain Dayyabu Raka, Director of Operations; Eng Akin Olateru, Commissioner/CEO and Eng Mohammed Wali, Director of Engineering, all of Accident Investigations Bureau during the press conference on the presentation of reports of the 2012 Dana Air crash and other air accidents held at AIB office, Murtala Muhammed Airport, Ikeja, Lagos

…….OAS, PICOMSS and Bristow helicopters also released

…….NCAA, NAMA, FAAN, FAA , NPF and others urged to implement safety recommendations

The final report into the Dana air crash in Lagos on the 3rd of June, 2012 revealed that the crash was as a result of failure of the pilot to land at the nearest suitable airfield when it was noticed that the first engine of the aircraft failed 17 minutes after take off from Abuja.

The cause of the accident and three others as released by the Accident Investigation Bureau, AIB today in Lagos fingered human error as responsible for all the air crashes and serious incidence.
The crash which occurred in the densely populated area of iju ishaga of Agege area in Lagos killed 153 onboard and 6 people on the ground heading to Lagos from Abuja.

Commissioner, AIB, Mr. Akin Olateru said the investigation identified as the
Probable Causal Factors to include “Engine number 1 lost power seventeen 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”.

Others are, 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 and Lack of situation awareness, inappropriate decision making, and poor airmanship.

Speaking further, Mr. Olateru said the investigation conducted on OAS helicopter crash which occurred at Oke-Oba Hill, Ikonifin, Osun State, Nigeria on 29th July, 2011 killing all 3 people on board was as a result of pilot’s lack of route familiarization and Pilot not Instrument Rated.

He said, “The accident occurred at about 1000hrs in daylight with 3 fatalities. The damage on both the main and the tail Rotor blades was consistent with engine on power”
The investigation identified the following, “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)”.

Other accident investigations report released were serious incidence involving the
Presidential Implementation Committee on Maritime Safety and Security (PICOMSS) with Registration 5N-BKS at Benin Airport Edo State Nigeria on 5th July, 2012 and the Bristow Helicopters Ltd. Sikorsky S-92 with Registration 5N-BOA at MMA Lagos, Nigeria on 27th February 2013 with no fatalities recorded.

The AIB boss explained that the two serious incidence were due to, “the decision of the crew to continue the glide approach despite repeated landing gear warnings with the power lever below 25% rather than initiating a Go-around”.
While the Contributory Factors were, the failure of the crew to recognize the landing gear warnings.
He added,” 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 and Lack of Crew Resource Management (CRM) training”.

Mr. Olateru stressed that all safety recommendations relating to the different accidents and serious incidences have been sent to the appropriate agencies and security agencies involved, namely, the NCAA, NAMA, FAAN, the Nigerian police force, aircraft manufacturer, U.S FAA among others.

“There were four (4) Safety Recommendations made in the published reports; One of which is to FAA targeting Pratt & Whitney the engine manufacturer; One to Dana Airlines; One to NCAA (with 3 safety recommendations in one); and One to NAMA on Quality Assurance Management”.

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