…seeks prompt implementation of safety recommendations
… six more reports ready 1st quarter 2018
By Sade Williams
The Accident Investigation Bureau (AIB), on Wednesday, released final reports of serious incident involving a Boeing 737-500 with registration 5N-BLE belonging to Aero Contractors Company of Nigeria Ltd, which occurred at FL330 en route Kaduna Airport on 5th June, 2015; serious incident to Nigerian College of Aviation Technology (NCAT) Socata TBM 850 aircraft with registration 5N-BZA which occurred Near Kaduna Airport, Kaduna, Nigeria on the 21st of May, 2013; the Accident involving Gitto Construczioni Generali Nigeria Limited Bell 407 helicopter with registration 5N-BIC at Uyo Airport, Akwa Ibom State, Nigeria on the 21st of October, 2009 and that of serious incident involving International Aviation College (IAC) Diamond DA42 Aircraft with registration 5N-BNH, on Runway 23 of Ilorin International Airport, which occurred on 18th August, 2014, calling for prompt complete implementation of safety recommendations in the reports.
Engr. Akin Olateru, Commissioner, AIB, who read the reports at a press conference at the Murtala Muhammed Airport office of the bureau, said eventhough AIB does not have the power to implement recommendations, it has set up a team to work with the Nigerian Civil Aviation Authority (NCAA) on the implementation.
He said the Bureau inherited 27 unpublished reports from the administration early this year, adding that a total of 10 and a safety bulletin has been released since then.
“Early this year, when this management came onboard, we made a pledge to clear the backlog of outstanding accident investigation reports we inherited, which were about 27 as at the time we took over. I am happy to announce to you today that we have kept our promise.
“This management embarked on a relentless pursuit of releasing accident reports in order to achieve the main purpose of accident investigation, which is accident prevention. Accident Investigation plays a vital role in enthroning and sustaining a robust air safety regime. This cannot, however be achieved when outcomes of accident investigations are not timely released.
“In January 2017, 27 Final Reports were Pending, in March 2017, 4 accidents and serious incident final reports were released, in August 2017 , 2 final Reports were published including one Safety Bulletin.
“Today, we have released four reports to bring a total this year to 10 published final reports. AIB was established in 2006 by the Civil Aviation Act and since commencing operations in 2007, we have published117 safety recommendations .This year from the 10 published reports, 35 safety recommendations have been made. Our statutory obligation is to investigate air accidents and serious incidents: and by our safety recommendations, mitigate them in order to forestall reoccurrence he said.
He disclosed that AIB is being repositioned to be the leader in accident investigation in Africa, adding that countries such as Sao Tome, Benin Republic and Cape Verde have all indicated interest to partner it.
“Recently, I had had some sessions with the Chief accident investigation of National Transportation Safety (NTSB) just to study the systems and procedures and tap from their experience, this is to help place AIB on a pedestal that will attract other countries. You can be a leader without getting equipment, infrastructure and human capital right, we currently have three investigators in United States on On The Job Training with NTSB, before the end of the year, another four will be in Singapore”, he added.
On funding, Olateru expressed gratitude to the National Assembly and Minister of State, Aviation, Hadi Sirika, for ensuring that the bureau gets some funds.
He added however, that it is yet to receive anything from the Federal Airports Authority of Nigerian (FAAN) as part of the 5 percent fund approved for the AIB.
Meanwhile, the Agency has launched a mobile application for seamless accident reporting, which is now available on ios and Google play store.
Olateru said the need to launch such for the agency was borne out of the fact that technology is now essential in every spheres of life.
“Today one of the result of the simplification is presented to you;- the AIB Mobile Application. In the information age we find ourselves, having a smart phone is no longer luxury but essential.
“Tapping into this, the development of a mobile application is essential to our processes as it extends our relationship with users by providing better access to news and updates, convenience, live reporting by eye witnesses in the event of accidents or incidents. Pictures can be uploaded on the app. This can assist greatly in investigations”, he said.
He added that it also makes information circulation faster and it an easier alternative to web browsing, adding that it provides instant updates and notifications.
“AIB Mobile App as it is called, gives us a new and more convenient way to receive Aircraft Accident Report in real time, thus increasing promotional opportunities with push notifications and more which depicts its core objectives of Accident and Incidence investigation reports.
“This app would improve engagement with Nigerians by providing easy and open access to the Bureau and its activities. The Application is now available for free download on the Apple, Android and Google play stores. Details of which are now available on our website.
THE REPORTS AND RECOMMENDATIONS
- Report on theserious incident involving a Boeing 737-500 with registration 5N-BLE belonging to Aero Contractors Company of Nigeria Ltd, which occurred at FL330 en route Kaduna Airport on 5th June, 2015;
Aircraft Accident Report No.: AERO/2015/06/05/D
Registered Owner and Operator: Aero Contractors Company of Nigeria Ltd.
Aircraft Type and Model: Boeing 737-500
Manufacturer: Boeing Aircraft Company, USA
Date of Manufacture: 7th August, 1992
Registration number: 5N-BLE
Serial No.: 26672
Location: Flight Level 330 en-route Kaduna
Date and Time: 5th June, 2015 at 1857hrs
(All the times in this report are local time, equivalent to UTC+1 unless otherwise stated)
SYNOPSIS
The Accident Investigation Bureau (AIB) was not officially notified but got to know of the serious incident the following day, 6th June, 2015 through the media. Relevant authorities and stake holders were appropriately notified thereafter.
On 5th June, 2015, Aero Contractors Company of Nigeria Ltd. scheduled commercial flight NIG181, a Boeing 737-500 aircraft with registration number 5N-BLE from Lagos to Kaduna, took off at 1828hrs with 108 passengers and 5 crew on board. The First Officer was the pilot flying. The flight operated on an Instrument Flight Rules (IFR).
The Air Traffic Control (ATC) cleared the aircraft for takeoff and to climb and maintain Flight Level (FL) 350. Normal cabin rate of climb (300ft/min) was observed during the initial climb. During climb at approximately 23 minutes, the cabin altitude warning horn sounded and the cabin altitude warning light came ON.
The Captain took control of the aircraft, passenger announcement was made and emergency descent initiated to an altitude of 10,000ft.
The flight diverted to Abuja with a distance of about 120nm to go. The aircraft made a safe landing in Abuja at 1932hrs and all passengers and crew disembarked normally and without injuries.
The incident occurred at night.
The investigation identified the following causal and contributory factors:
Causal Factor
The inadvertent failure to discover that the PRSOV was in the LOCKED CLOSED position after the engine change.
Contributory Factor
Failure to recognise that the number 2 bleed pressure was zero after engine start and subsequent failure to monitor the pressurisation system during climb.
One Safety Recommendation was made.
4.1 Safety Recommendation 2017-019
NCAA should ensure that the activities of flight operations and maintenance departments of Aero Contractors Company of Nigeria Limited are carried out in compliance with the Nig.CARs.
SAFETY ACTIONS
NCAA response to the investigation, Ref. No. NCAA/DG/AIB/9/16/31
FREQUENT ENGINE CHANGES
Due to the frequent engine changes detailed in Table 1, the Authority is considering issuing an All Operators’ Letter (AOL), requiring operators of aircraft to mandatorily inform it of any engine changes prior to accomplishment. This will enable the Authority to monitor the processes.
- Report on the Serious Incident to Nigerian College of Aviation Technology (NCAT) Socata TBM 850 aircraft with registration 5N-BZA which occurred Near Kaduna Airport, Kaduna, Nigeria on the 21st of May, 2013;
Aircraft Accident Report No.: NCAT/2013/05/21/F
Registered Owner and Operator: Nigerian College of Aviation Technology (NCAT)
Aircraft Type and Model: TBM 850
Manufacturer: Daher-Socata
Year of Manufacture: 2010
Registration Number: 5N-BZA
Serial Number: 534
Location: 3NM Southeast of KU (VOR), between 13000ft and 9000ft Above Mean Sea Level (AMSL)
Date and Time: 21st May 2013 at about 1745hrs
All times in this report are local time (UTC +1) unless otherwise stated
SYNOPSIS
Accident Investigation Bureau (AIB) was notified of the occurrence on the 16th of June 2013. Investigators were dispatched to carry out a preliminary investigation on the occurrence.
At about 1705hrs, on 21st May, 2013, TBM-850 (turbo prop aircraft certified for 1-pilot operation) with registration 5N-BZA, operated by Nigerian College of Aviation Technology (NCAT), Zaria as admin-flight, departed NnamdiAzikiwe International
Airport, Abuja (NAIA) to Zaria Aerodrome, with two persons on board (pilot and an observer).
Shortly after it commenced descent and while passing FL130, the aircraft entered an intense area of hail associated with a CB cloud. The encounter caused damage to the aircraft’s radome, landing lights and other parts of the engine but the flight continued to its destination, Zaria Aerodrome and landed safely.
The occupants of the aircraft sustained minor injuries. Instrument Meteorological Conditions (IMC) prevailed at the time of the occurrence and the flight was operating on an Instrument Flight Rules (IFR) flight plan.
The following causal and contributory factors were identified:
Causal Factor
The decision of the crew to depart NAIA with the knowledge of weather forecast, and failure to follow the guidance provided by the weather radar advisory to avoid the impending adverse weather.
Contributory Factors
- Late recognition of the icing/hailstorm encountered by the pilot during the flight.
- Failure of the pilot to adequately follow aircraft certification standards (procedures/limitations) for turbulent air, storms and icing conditions penetration.
The safety issues in this report focused on TBM-850 procedures for the use of ice protection systems, radar system, turbulence and icing penetration, airspeed limitations and information, stall warning/protection system capabilities, operation of the autopilot in icing conditions, aircraft icing certification requirements, and icing-related research asper NCAT’s Approved Operations Manual (AOM) and Airplane Flight Manual (AFM), duty and rest period compliance.
Six Safety Recommendations were made.
4.1 Safety Recommendation 2017-005
NCAT should classify all kind of storms as hazardous considering the types of airplanes it operates (light weight) and the nature of operations it conducts (training), thereby delaying or cancelling any intended flight with warning for storm or any adverse weather phenomena.
4.2 Safety Recommendation 2017-006
NCAT should develop and incorporate TBM 850 in its Flying School Training Manual (FSTM) and also basic training on weather radar, its systems and operations procedures and adverse weather recognition and avoidance techniques. These topics would enhance the technical and operational knowledge of weather radar equipment for both the instructors and students.
4.3 Safety Recommendation 2017-007
NCAT should ensure that Instructors and students of turbo propeller-driven airplanes review the guidance contained in their manuals and training programs to include updated icing information and to emphasize that leading edge anti icing/de-icing systems are activated as soon as the airplane encounters icing conditions or when icing condition is anticipated, as per AFM.
4.4 Safety Recommendation 2017-008
NCAT should ensure that before the commencement of any admin flight, all necessary documentation is completed including flight plan and retrieval of weather information especially where such information is readily accessible.
4.5 Safety Recommendation 2017-009
NCAT should ensure that observers neither perform active crew duty nor log any flight time to that effect, in order to add value to his/her personal flying log book.
4.6 Safety Recommendation 2017-010
NCAA should enhance its oversight on all operators of special and private category aircraft to ensure strict compliance with all provisions of Nig.CARs as related to personnel licencing and other operational activities.
RESPONSES TO SAFETY RECOMMENDATIONS
NCAA Response on AIB Safety Recommendations
The NCAA responded to Safety Recommendation 4.6 (2017-010) as follows:
“The NCAA exercises oversight on all Nigerian and foreign registered aircraft operating in the private and special categories in Nigeria. These aircraft and the Approved Maintenance Organizations (AMO)/personnel that release them to service are subject to continuous surveillance and oversight as required by the Nig. CARs and detailed in the approved Technical Guidance Materials;”
NCAT Responses on AIB Safety Recommendations
NCAT responded to Safety Recommendation 4.1 (2017-006) as follows:
“The safety unit will carry out hazard identification and Safety Risk assessment to reduce or mitigate to an acceptable level the safety risks associated with operations during rainy season.”
NCAT responded to Safety Recommendation 4.3 (2017-008) as follows:
“Instructors and students for the operations of the TBM 850 aircraft use the AFM and checklists. The Flying School will issue circular to re-emphasize the use of AFM in icing conditions.”
NCAT responded to Safety Recommendation 4.4 (2017-009) as follows:
“NCAT would ensure that all necessary documentation is completed before the conduct of admin flights.”
NCAT responded to Safety Recommendation 4.5 (2017-010) as follows:
“NCAT will ensure that no observers perform active crew duty nor log any flight time to that effect. NCAT flight operations will review the logbooks of All pilots not rated on the TBM 850 aircraft that acted as observers on the aircraft. Where the observers logged any flight time, the flight time will be expunged from their logbooks.”
- Report on the Accident involving Gitto Construczioni Generali Nigeria Limited Bell 407 helicopter with registration 5N-BIC at Uyo Airport, Akwa Ibom State, Nigeria on the 21st of October, 2009;
Aircraft Accident Report No.: GITTO/2009/10/21/F
Registered Owner and Operator: GittoConstruczioni Generali Nigeria Limited
Aircraft Type and Model: Bell 407 Helicopter
Manufacturer: Bell Helicopter Textron, Canada
Date of Manufacture: January, 1999
Registration Number: 5N–BIC
Serial No.: 53340
Location: GittoConstruczioni site located within Uyo Airport.
Date and Time: 21st October, 2009 at 1330hrs
All times in this report are local time (equivalent to UTC+1) unless otherwise stated.
SYNOPSIS
The Accident Investigation Bureau (AIB) was notified by the Nigerian Civil Aviation Authority (NCAA) of the accident on 22nd October, 2009 at about 1200hrs. The Bureau investigators were dispatched to the site same day. All other stakeholders were notified accordingly.
The Bell 407 helicopter registered 5N-BIC operated from Abuja to Calabar on the 20th of October 2009. On the 21st of October 2009, 5N-BIC departed Calabar to Port Harcourt at about 1230hrs on a Visual Flight Rules (VFR) positioning flight with the Pilot and an Engineer on board. According to the Pilot, a few minutes after departing Calabar for Port Harcourt, the transmission chip detector indication was noticed at a location close to GittoUyo Site. The pilot made a radio call to Eket of the intention to divert to Uyo due technical. On landing at Gitto site, Uyo, the Maintenance Engineer reported that maintenance inspection was carried out on the transmission oil system; the three chip detector plugs on the transmission were checked and found satisfactory. Furthermore, an engine ground run was carried out and all indications were found normal.
The Pilot decided to continue the flight from Uyo to Port Harcourt. Less than five minutes after take-off, the engine chip detector indication came on and about thirty seconds after, the engine oil pressure showed zero. The Pilot decided to make an air return but could not make it to the Helipad as there was a ‘bang’ from the engine and the aircraft dropped uncontrolled to the ground and crashed. There was post-crash fire.
The Engineer sustained minor injury and was treated and discharged from the same hospital in Port Harcourt.
The investigation identified the following causal and contributory factors:
Causal Factors
- Improper maintenance of the oil system which led to oil starvation resulting in the failure of the No. 6, 7, and 8 bearings in the power turbine section of the engine, leading to power loss.
- Improper identification by the pilot of the transmission chip light illumination during flight instead of the engine chip light.
Contributory Factors
- The decision of the pilot to continue with the flight from Uyo to Port Harcourt International Airport without identifying the cause of the transmission chip detector indication.
- The non-replacement of the stage 1 & 2 turbine wheels due to limited life remaining.
One Safety Recommendation was made.
4.1 Safety Recommendation 2017-004
NCAA should intensify its surveillance and monitoring on all privately-owned aircraft to ensure that operational and maintenance procedures are strictly adhered to in accordance with the relevant sections of the Nigerian Civil Aviation Regulations (Nig. CARs).
RESPONSES TO SAFETY RECOMMENDATIONS
NCAA Response on AIB Safety Recommendations
The NCAA responded to Safety Recommendation 4.1 (2017-004) as follows:
“The NCAA exercises oversight on all Nigerian and foreign registered aircraft operating in the private categories in Nigeria. These aircraft and the Approved Maintenance Organizations (AMO)/personnel that release them to service are subject to continuous surveillance and oversight as required by the Nig. CARs and detailed in the approved Technical Guidance Materials;”
- Report on the serious incident involving International Aviation College (IAC) Diamond DA42 Aircraft with registration 5N-BNH, on Runway 23 of Ilorin International Airport, which occurred on 18th August, 2014.
Aircraft Accident Report No: IAC/2014/08/18/F
Registered Owner and Operator: International Aviation College (IAC), Ilorin
Aircraft Type and Model: Diamond DA42
Manufacturer: Diamond Aircraft Industry, Austria
Date of Manufacture: 2006
Serial No.: 42.010
Registration Number: 5N-BNH
Location: Runway 23 of Ilorin International Airport
Date and Time: 18th August, 2014 at about 1610hrs.
(All times in this report are local time, equivalent to UTC + 1) unless otherwise stated
SYNOPSIS
Accident Investigation Bureau (AIB) was notified by International Aviation College (IAC), Ilorin at about 1730hrs on 18th of August 2014, of a serious incident involving a Diamond DA42 aircraft with registration number 5N-BNH owned and operated by the College, which occurred on Runway 23 at Ilorin International Airport. Investigators were dispatched to the crash site the following day. All relevant stakeholders were also notified.
On 18th August, 2014 at 1220hrs, the aircraft 5N–BNH took off from Runway 23 of Ilorin International Airport for a training flight with fuel endurance of four hours. There were two persons on board; a Flight Instructor and a Student Pilot. At the training area, the Flight Instructor requested the Student Pilot to perform some manoeuvres; which involved stall simulation in landing configuration. After landing gear extension, the Flight Instructor noticed that the right main gear did not extend. He then took control of the aircraft and performed the emergency gear extension procedure in accordance with the Airplane Flight Manual (AFM); the right main gear still did not extend.
At 1430hrs, the crew informed the Control Tower about the situation and subsequently, the airport safety and emergency services/procedures were activated and put on standby.
At 1535hrs, the Tower in liaison with the owners of the aircraft decided to approve the belly-landing of the aircraft on a foamed runway in accordance with the manufacturer’s specifications.
At 1610hrs, the aircraft 5N-BNH belly-landed at the Touch Down Zone (TDZ) on the centre line of Runway 23 after it had been airborne for three hours and fifty minutes.
The aircraft was substantially damaged and there was no fire outbreak. Also, no injuries were sustained by the crew.
The investigation identified the following causal and contributory factors:
Causal Factor
The failure to adhere to the main wheel installation procedure as contained in the AMM, Section 32-40-00, bordering on:
- Minimum clearance check between the MLG tire and the lower wing shell/wheel bay cut-out.
- Test of correct operation of the landing gear retraction and extension system.
Contributory Factor
Inadequate oversight by the Quality Assurance department.
Four Safety Recommendations were made.
4.1 Safety Recommendations 2017-015
NCAA should intensify its safety oversight responsibilities on the operator to ensure that it adheres strictly to procedures in the AMM and that maintenance records are properly kept.
4.2 Safety Recommendations 2017-016
IAC should restructure its Quality System to provide adequate safety oversight on the maintenance department thereby enhancing airworthy aircraft and safe operations.
4.3 Safety Recommendations 2017-017
IAC should ensure that medical, pathological or toxicological examinations are conducted immediately after an occurrence.
4.4 Safety Recommendations 2017-018
Diamond Aircraft Industries should incorporate the following procedures in the AFM:
- Landing with partial gear.
- Resetting emergency extension lever after manual extension.
SAFETY ACTION
NCAA agrees with the Conclusion in Section 3.1.9 and is presently amending the subject Noise Certificates to reflect the type of engine installed.
