Home Safety Nigeria/Sao Tomé collaboration pays off as AIB submits São Tomé final Accident...

Nigeria/Sao Tomé collaboration pays off as AIB submits São Tomé final Accident report

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The collaboration between Nigeria and Sao Tome and Principe in the area of Accident Investigation has paid off as Nigeria’s Accident Investigation Bureau, AIB has successfully submitted the final accident report which occurred in that country.

Late last year, the Sao Tome and Principe government sought the assistance of the AIB to investigate its air accident.

The Commissioner AIB, Mr. Akin Olateru who lead a team to submit the final report of the accident report involving Cavok Airlines CVK 7087 AN-74TK-100 Aircraft Registered Ur-CKC, which occurred at Sao Tome International Airport, Sao Tome on 29th July, 2017, said Nigeria had set another standard in the region, as regards releasing timely and accurate air accident report.

According to him, this was as a result of effective collaboration and cooperation the Bureau had garnered in the last 24 months with the aviation stakeholders and the endless work by the Bureau’s investigators.

The Banjul Accord Group Accident Investigation Agency (BAGAIA) had invited AIB Nigeria to conduct an investigation into this crash, which by the International Civil Aviation Organization (ICAO) Annexe 13 is the responsibility of the state of occurrence.

This was very significant as for the first time in the history of Accident Investigation Bureau, accident investigation was handled by the Bureau on behalf of another state or a regional body.

SUMMARY OF AIRCRAFT ACCIDENT REPORT: CVK/201+7/07/29/F

Runway Excursion following a Rejected Take-Off CAVOK Airlines CVK 7087 AN-74TK-100 Aircraft Registered UR-CKC which occurred at Sao Tome International Airport, Sao Tome on 29th July, 2017

On 29th July, 2017 at about 0905hrs Antonov aircraft Model AN-74 TK-100, registered UR-CKC, owned by SWIFT SOLUTION FZC, operated by CAVOK Airlines LLC overrun runway 29 during a rejected take off at Sao Tome International Airport. The Captain, the First Officer, the Flight Engineer and 2 maintenance Engineers on board were rescued unhurt except the Flight Navigator who sustained an injury to his left foot and some minor bruises. The intended non-scheduled return flight to Accra was initiated in accordance with appropriate regulations. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed.

The safety issues discussed in this report focused on rejected take-offs and rejected take-off procedures; compliance with SOP, other related checklists and manuals, flight crew training for RTO scenarios; flight crew performance, including the captain’s action to initiate an RTO after V1, and CRM.

Nine safety recommendations were made in this report and are addressed to:

Institut National de l’Aviation Civile (INAC), Sao Tome,
Ukraine Civil Aviation Authority and
CAVOK AIR, LLC, Ukraine.
Causal Factor

The investigation determines that the cause of this accident was:

Due to the presence of birds on the runway, the take-off was rejected at a speed above decision speed V1, which was inconsistent with CAVOK’s Standard Operating Procedures (SOP).

Contributory factors

The contributory factors to this accident include but are not limited to the following:

Failure of the crew to deploy interceptors (speed brakes/spoilers).
Inadequate flight crew training on details of rejected take-off procedure scenarios.
The omission of the take-off briefing in CAVOK’s Normal Operations checklist.
Poor Crew Resource Management (CRM), especially in a multi-crew flight operation.
Safety Recommendations

Instituto Nacional de Aviacao Civil (National Civil Aviation Authority of STP)

1. Should improve the habitat management programme (including reduction or elimination of trees, shrubs and other plants which provide food, shelter or roosting sites for birds)

2. Should enhance its aerodrome grass management appropriate to the prevalent species and the degree of risk that they pose.

3. Should liaise with local inhabitants to limit the attraction of birds to fields (in the vicinity of the airport).

4. Should install specialized ground-based radar equipment used for tactical detection of large flocking birds.

5. Should adopt and extend Runway End Safety Area to conform to ICAO standards.

6. Should include the information about the ravine at the end of RWY 29 into the AIP and Send it as Notice To Airmen (NOTAM).

Ukraine Civil Aviation Authority

7. Should enhance its oversight functions by reviewing all safety related items pertinent to operators’ checklists and manuals.

CAVOK Airlines

Should review its Rejected Take Off (RTO) training syllabus to incorporate robust RTO training plan for both initial and recurrent aircraft type simulator training and assessment to include unexpected scenarios and stop-and-go decision making.
Should review its Normal Operations checklist in order to include take-off briefing as an item for each flight

Olakangudu Olayinka Yusuf
Public Affairs Officer
Accident Investigation Bureau (AIB)
Nigeria
07031210207
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