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Full text of final accident reports as presented by AIB

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ACCIDENT INVESTIGATION BUREAU (AIB)
Publication and Release of Aircraft Serious Incident and Accident Reports

1. Report of the Accident involving Dana Airlines
2. Report on the Serious Incident Involving Bristow Helicopters Limited
4. Report on the Serious Incident involving Presidential Implementation Committee on Maritime Safety and Security (PICOMSS)

13 MARCH 2017

PREAMBLE
I want to thank everyone one for coming. First, I will like to express my deep appreciation to the management and members of staff in AIB for the sleepless nights in the past two (2) months in ensuring the publication of these reports.
As a preliminary point, Accident Investigation Bureau (AIB) was established by the Civil Aviation Act of 2006 and in compliance with section 29(9)(10) follows and adhere to the Nigeria Civil Aviation Accident Investigation Regulation made and approved by the Minister in the execution of its functions under this Act.
Its mandate is to investigate aircraft accidents and serious incidents, the aim of which is prevention of reoccurrence and not punitive. It is a fact-finding proceeding and are not conducted for the purpose of determining the rights or liability of any person(s).
It should also be noted that the cost of investigating an accident or serious incident is very huge – for example . Transport Safety Board of Canada (TSB) spent over US$50million for investgating the MD 11 Swiss SR111 of 1998 and over US$110million was spent for the Malaysia MH 370 on search alone. AIB’s budget on accident investigation for 2017 is 16million which is around about USD$47,000.
Whilst we must thank the past and present administration for establishment and continual support of the Bureau, we use this opportunity to plead for our Minister to use his good office to see the possibility of creating a special fund for accident investigation.
The Bureau needs funds for the purpose of exploring preventive measures for accident or serious incident and for its readiness in cases where an accident or serious incident occurs. My prayer is that the government will come to the aid of AIB and support the bureau so that we can deliver on our targets.
As at today and after this release, the summary of accident and serious incident reports is as follows;

• Final Report published – 21
• Final Report yet to be published – 23
Final Accident Report Published Today
1. Report On the Accident involving Dana Airlines Nigeria Limited Boeing MD-83 Aircraft with Registration 5N-RAM at Iju- Ishaga, Lagos State Nigeria – 03 June 2012
Aircraft Accident Report No: DANA/2012/06/03/F
Registered Owner and Operator: Dana Airlines (Nig.) Ltd.
Manufacturer: Boeing Company, USA
Model:MD-83
Nationality: Nigerian
Registration: 5N-RAM
Place of Accident: Iju-Ishaga Area Of Lagos State
Date And Time: 3rd June 2012 at about 1545:00hrs.
All times in this report are local times (equivalent to UTC+1) unless otherwise stated
Location: N 06o 40.310’ E 003o 18.837′ Elevation 177ft

SYNOPSIS:
Accident Investigation Bureau (AIB) was notified by the Federal Airport Authority of Nigeria (FAAN) Fire Service section at about 1605:00hrs on 3rd June 2012, of an accident involving a Dana Airlines Boeing MD-83 aircraft with registration 5N-RAM at Iju-Ishaga area of Lagos.
Air Safety Investigators were dispatched to the scene of the accident and investigation commenced immediately. All appropriate stakeholders were notified accordingly.
In accordance with International Civil Aviation Organization (ICAO) Annex 13, the National Transportation Safety Board (NTSB) of the United States of America (USA), representing the State of Design and Manufacture of the aircraft, appointed an Accredited Representative along with a team of experts from Federal Aviation Administration (FAA), the Boeing Company and Pratt & Whitney USA.
The operator co-operated with the investigation and provided assistance as required. The Nigerian Civil Aviation Authority (NCAA) was kept informed of developments.
On 3rd June 2012 at about 1545:00hrs, 5N-RAM, a Boeing MD-83, a domestic scheduled commercial flight, operated by Dana Airlines Nigeria Limited as flight 0992 (DANACO 0992), crashed into a densely populated area. Engine number 1 lost power seventeen minutes into the flight with a further loss of power on number 2 engine on final approach to runway 18R at Murtala Muhammed Airport, Lagos, Nigeria. Visual Meteorological Conditions (VMC) prevailed at the time and the airplane was on an Instrument Flight Rules (IFR). All 153 persons onboard the airplane, including six crew were fatally injured. There were also six confirmed ground fatalities. The airplane was destroyed. There was post impact fire. The flight originated from Abuja (ABV) and the destination was Lagos (LOS).
AIB published a preliminary report on 5th September, 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.

The investigation identified the following:
Probable Causal Factors:
1. 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.
2. 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.
3. Lack of situation awareness, inappropriate decision making, and poor airmanship.

Eight Safety Recommendations were made.
The Safety Recommendations previously made in the Preliminary Report published on 5th September 2012 were, 4 in numbers wherein 3 was targeted to Dana Airlines and all were accepted and closed. 1 was to NCAA, accepted and closed.
There were four (4) Safety Recommendations made in the published reports;

1.1. One of which is to FAA targeting Pratt & Whitney the engine manufacturer;
1.2. One to Dana Airlines;
1.3. One to NCAA (with 3 safety recommendations in one); and
1.4. One to NAMA on Quality Assurance Management.

Report on the Accident involving OAS Helicopters (Nig.) Limited Ecuruiel A 350 B2 Helicopter with Registration 5N- BKA at Oke-Oba Hill, Ikonifin, Osun State, Nigeria on 29th July, 2011
Aircraft Accident Report No: OAS 2011/07/29/F
Registered Owner Operator: OAS Helicopter Limited
Aircraft Type and Model: Ecureuil A 350 B2 Helicopter
Nationality:Nigerian
Registration:5N-BKA
Location:Oke-Oba Hill, Ikonifin
Date and Time:29th July 2011 at 1000hrs
(All the times in this report are local time, equivalent to UTC+1 unless otherwise stated)

SYNOPSIS

Accident Investigation Bureau was notified of the accident in the evening of 29th July 2011. Investigators were dispatched to the crash site the following morning. The international stake holders were notified of the accident, but no accredited representative participated in the investigation.
5N-BKA departed OAS helipad Maryland, Lagos at 0925hrs for Ilorin and had its initial contact with Ibadan at 0939hrs. The Pilot checked abeam Ibadan (west) at 0950hrs and requested to climb to 1,500ft on QNH 1014hPa, which was granted.
At 1001hrs, Ibadan Control Tower called the pilot to confirm if he had two-way contact with Ilorin Control Tower. There was no reply from the aircraft.
The Controller reported to the Airspace Manager that somebody called the Airport Fire Service that she heard a ‘bang’ somewhere around Ife Odan. The caller confirmed the bang and the likelihood of an accident when she was called back, consequent upon which the Air Space Manager directed the Controller to get in touch with Ilorin, Lagos and other neighboring states and subsequently initiated a search and rescue operation.
The wreckage was later sighted at about 2250hrs same day at Ikonifin near Ife- Odan in a hilly terrain between Iwo and Ogbomoso. 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,

Causal Factor:

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).

Contributory Factors:
i. The Pilot was not Instrument Rated.

ii. The pilot’s lack of route familiarization. Five safety recommendations have been made.
The Safety Recommendations made in the published report were 5;
1.1. Three of which were targeted at NCAA;
1.2. One to NAMA; and
1.3. One to Nigerian Police Force.

3. Report on the Serious Incident involving Presidential Implementation Committee on Maritime Safety and Security (PICOMSS) with Registration 5N-BKS at Benin Airport Edo State Nigeria on 5th July, 2012.
Aircraft Accident Report No. PICOMSS/07/05/2012/F
Name of Operator:Federal Government of Nigeria. Presidential Implementation Committee
On Maritime Safety and Security (PICOMSS)
Aircraft Type and Model:Diamond DA-42
Registration:5N-BKS
Location: Benin airport, Edo State. N 06o.19′.0; E 005o.37′.0 Elevation 258ft
Date and Time: 5th July, 2012 @ about 1059hrs.
All times in this report are local time (Equivalent to UTC+1) unless otherwise stated.

SYNOPSIS

The Accident Investigation Bureau (AIB) was notified of the serious incident at about 1200hrs on 5th July, 2012. Investigators were dispatched to the crash site same day. All relevant authorities were notified.
The aircraft departed Benin airport for a low-level range navigation south of the airfield with two crew members on board and was airborne at 1002hrs with endurance of 04hrs. At about 10NM the crew was asked to confirm whether they wanted to maintain Benin frequency or go to Osubi frequency, the crew replied that they will remain with Benin and was advised to report ‘ops normal’ at 1020hrs. The crew reported ‘ops normal’ and requested rejoining for some touch and go. After the fourth touch and go at 1054hrs, the crew called Benin at 1058hrs for a full stop landing.
The crew stated that during the final approach for a full stop landing in a glide approach exercise, they were preoccupied with the procedures and failed to recognize and heed landing gear warning. However, as they made last minute attempt to select the gear down it was too late for the gear to lock down before the aircraft touched down. The aircraft touched down with the gears in transit and the gears collapsed under the weight of the aircraft.
The aircraft first point of touchdown was at about 3,609ft (1,100m) from the threshold of runway 05. The aircraft belly rolled for another 656ft (200m) before veering-off the runway into the grass area.
The Federal Airports Authority of Nigeria (FAAN) and the Nigerian Air Force (NAF) Fire Services responded immediately by sending their Rapid Response Vehicles to the crash site, in readiness to combat any fire outbreak.
The investigation identified the following:

Causal Factor:
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.
Contributory Factors:
• The failure of the crew to recognize 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.
There were two (2) Safety Recommendations made in the published report

1.1. One to NCAA; and
1.2. One was targeted to the Nigerian Police Force.
4. Report on the Serious Incident involving Bristow Helicopters Ltd. Sikorsky S-92 with Registration 5N-BOA at MMA Lagos, Nigeria on 27th February 2013.
Aircraft Accident Report No: BH/2013/02/27/F
Registered Owner and Operator: Bristow Helicopters Ltd.
Aircraft Type and Model: Sikorsky S-92
Registration:5N-BOA
Location:Murtala Muhammed Airport, Lagos
Date and Time:27th of February, 2013 at about 0715hrs
(All times in this report are local time, equivalent to UTC+1, unless otherwise stated)
SYNOPSIS

Accident Investigation Bureau (AIB) was notified of the Incident at about 0815hrs on 27th of February, 2013 and Investigators were dispatched immediately to the Incident site and thus investigation into the incident began same day. All relevant authorities were notified.
At about 0715hrs, 5N-BOA, S-92 Helicopter with eight passengers onboard was about to request for taxi clearance, when the crew perceived a burning smell in the cockpit. A ground personnel on the ramp was also seen waving his hands in an urgent manner, indicative of a problem. The co-pilot saw a bit of smoke from his top left window, even though there was no indication of engine or any other fire in the cockpit, but the crew agreed that there was fire. The crew carried out an emergency engine shutdown and waited for the rotor to come to a stop before evacuating the passengers. The standby fire extinguisher was used to put off the fire by ground personnel, the fire only lasted few seconds. Both crew members deplaned without any injuries to them or to the passengers.
The Investigation identified the following causal and contributory factor:

Causal Factor

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
1 The effectivity of the aircraft was excluded in the Alert Service Bulletin ASB No. 92-20-002A issued by the manufacturer.
2 The Technical Directive TD-S92A-29-99 did not include Check/Inspection of the right hand side of the Upper Deck.
Two safety recommendations were made.
The were two (2) Safety Recommendations made in this published report and both targeted to Bristow Helicopters.
Bristow Helicopters Nigeria Limited issued a Technical Directive, TD-S92A-29-104 following the incident.
Subject: Inspect LH and RH MGB, and Upper Deck Heat Exchanger Area, All 1, 2, and 3 system Hydraulic lines, Clamping all Components, and wiring Looms for any damage, chafing, or wear.
Effectivity: All Bristow S92As
Date: 27th February 2013

Our Plan
We look to publish more reports before the end of the year.
Our statutory obligation is to investigate air accident and serious incident: and by our safety recommendations, mitigate them inorder to forestall reoccurrence.

Food for Thought
I want to leave the following questions to my colleagues in the industry, the regulators, investors and Nigerians in general.
1. What is the cost of an accident?
2. How do we measure the valve of people’s lives?
3. Can we ever calculate/quantify the investment worth of damage?
4. 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/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.

Before I close, I would like to thank the Honourable Minister for Transportation and the Honourable Minister for State (Aviation) for the continual support by ensuring that we stay focus.
To everyone, I thank you for your time and kind attention.

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