Dana Air Crash Report: Human Negligence Not Human Error By Group Capt.(rtd) John Ojikutu
Within a couple of weeks of his assumption into office, the new AIB Commissioner surprised many stakeholders by releasing the long awaited Report on the Dana airline crash that had occurred in June 3rd 2012, nearly five years ago. Like many other air accidents before it, the Dana crash was one accident that its investigation had been unnecessarily delayed even when there were sufficient evidence in the Preliminary Report for determining the direct cause of the accident. Unfortunately, the AIB that was parading less than 10 technical staff, lacked the necessary staff skill, effective supervision and the capacity to sufficiently analyse most aircraft accident investigation correctly and therefore, has not always been successful in establishing the direct and indirect causes of many accidents in good time.
Before the release of the Final Report on the Dana accident on March 13,2017, the AIB had released a Preliminary Report on September 5,2012; Second Interim Statement on June 3, 2014; Third and a Final Interim Statement on June 3,2015. However, after the Final Interim of June3, 2015, AIB still went and released a Fourth Interim Statement on June 3, 2016. None of the Interim Statements and the Preliminary Report showed what many had known from the ATC communication transcripts as the direct cause of the accident. But for the new management, the AIB old management would have again probably released a 5th Interim Statement on June 3, 2017.
Few days following the crash, the Air Traffic Control(ATC) communication transcripts that was released, alongside the Preliminary Report had revealed even to the discerning public minds that the failure of the pilot to take necessary action following the flameout of one of the two aircraft engines 17 minutes after takeoff from Abuja was a direct cause of the crash. Unfortunately, the Preliminary Report and the subsequent Interim Statements did not contain this obvious evidence and fact and to show that the pilot had violated essential regulation of the national civil aviation aircraft operating standards and the emergency management procedures in the Airline Operating Manual approved by the NCAA for such emergency situation.
An immediate interim safety recommendation was expected to have been released with the Preliminary Report and the Second Interim Statement so that other airlines that could find themselves in such situation would not repeat what the pilot of the Dana aircraft did on 3rd June, 2012. Of course less than 2 years after, precisely in June 2015, an Aero aircraft flying from Lagos to Kaduna had similar emergency situation 25 minutes after its departure from Lagos. Like the Dana aircraft pilot did, Aero aircraft pilot pressed on and still flew more than 30 minutes to divert its flight to Abuja rather than land in Ilorin or Minna; but thank God the situation never resulted into accident.
The failure of the Dana pilot to take necessary actions in accordance with the Standard Emergency Procedures following the flameout of one of the aircraft engine 17 minutes after its takeoff from Abuja was an act of negligence and not an act exercised in error. Action such as: to return to Abuja or to land at the nearest airport like Minna or Ilorin are the Standard Operating Procedure for such emergency situation. None of these actions were known to have been attempted or taken by the pilot; rather the pilot pressed on and continued flying the aircraft with one engine yet for another 38 minutes until the second engine too flamed out and the aircraft crashed 8 kilometers to Lagos Airport, killing the 153 passengers on board and 6 persons on ground.
By the conventional flight operation Standard, the pilot’s action was not an error of procedures in the Checklist as the AIB reported; his action was culpable negligence. Advanced Oxford Dictionary defines Negligence as a failure to act or not taking necessary care of something under ones’ care especially when something goes wrong, or a breach of duty of care which results in damage or loss of lives. Whereas, Error is an act of doing wrong in conduct or in judgment, in this case, no reasonable action was seen, known or recorded to have been taken by the pilot within the statutory regulations and standard operating procedures at the loss of the first engine. That was exactly an act of inaction that even characterized the mode of his employment by Dana Airline.
Here was a captain who was employed by Dana on March 14,2012. He had been earlier suspended in 2009 by the United State FAA for some misdemeanors on one of his flights which he did not record in the aircraft logbook nor reported – a negligent act. A revalidated license claimed to have been issued to him by NCAA though stamped, but was not signed by any NCAA official – fraudulent act. Most of the letters of recommendation submitted by the captain to his employer Dana and to NCAA were not signed. Above all, the line trainings that preceded his captain checkout with Dana airlines had a lot of adverse remarks made by his training captain. You wonder how he got qualified for the job with Dana over many Nigerian pilots in the labour market with all these misdemeanors. How could he have been cleared by the NCAA and the Airline Operator to fly within 2 days as a checkout captain on May 2nd 2012 after his final check on May 1, 2012? Within four weeks of the final checkout, with the adverse report and all the misdemeanors in his credentials, this pilot was detailed to fly as a captain on June 3, 2012 and eventually crashed the flight with 153 persons on board – an act of culpable negligence by the operator. One wonders if all the information of his background were made available to the NCAA Personnel and Licensing Department. These misdemeanors by the Dana Air too must be seriously investigated by the NCAA and the National Assembly.
We cannot continue to hide certain criminal acts of culpable negligence inappropriately under Pilot Error or Human Error as had been done in many previous aircraft Accident Reports. How would one conclude or classify a report of two pilots, who fought themselves in the cockpits and crashed a chartered UN aircraft in 2007 at a Mali airport; Pilot Error or Human Negligence? Compared these with a Controller, who controlled two aircraft into conflicting headings through error of judgment that was jailed in Poland more than three decades ago?
While the crew of the Dana aircraft was seen to have negligently handled the emergency situation abinitio, the Air Traffic Controller at MMIA was not too different in the way and manner he had handled the subsequent situation till the aircraft eventually crashed 8 kilometer to landing. When the aircraft declared emergency and pronounced Mayday and reported ‘dual engine failure’, the approach/radar controller, cleverly feign ignorance of the pilot transmission wordings using wrong phraseology in response to ask ‘How do you read’. To which the captain replied ‘I read you fine (clearly) and repeated the nature of his emergency again in more details viz ‘dual engine failure; negative response from throttle’.
Rather than holding on to controlling the emergency aircraft as the senior controller and as the watch supervisor as demanded by the ATC services emergency management procedures, he asked the aircraft to transfer itself to the control tower radio frequency. The aircraft never got in touch with the control tower before it crashed and there was also no evidence that the Radar/Approach controller procedurally handed the aircraft to the tower controller. He never in any moment during the control showed concern that he was handling emergency
Thirdly, the Lagos State Corona inquest had before the AIB Report threw more light into the mismanagement of the accident at the crash site. The Corona reported that most of the Persons On Board (POB) the crashed aircraft were suffocated to death by smoke inside the aircraft and not burnt to death. How could that have happened? It happened because rescue help did not come on time? Why did help not come on time? Because the aeronautical emergency management plan did not include the services of the LGAs especially those along the airports established departure and approach routes where 80% of aircraft accidents usually occur.
Aircraft emergency management plans and programmes are planned primarily for saving lives not to recover dead bodies. Therefore, we cannot always depend on the States and Federal Emergency Services that reside mainly at the states and federal capitals. Government needs to start planning now on how to build the capacity and resources of the LGAs around the airports as the First Responders for the management of any aircraft emergency outside the airport and within their areas, the same way the airports emergency services would act to accidents within the airports. The states and national emergency services should only be the Second and Third Responders when the resources of the First Responder become inadequate.
Fourthly, the Cockpit Voice Recorders (CVR) and the Cockpit Data Recorders (CDR) on the crashed aircraft were reported to have been completely burnt by fire in the accident and the contents could not be redeemed for data analysis. That was the same fire that over 100 persons on board were reported to have died of suffocation from smoke not burnt to death. How or where the fire that burnt the blackbox beyond the state that made data in it irrecoverable is still questionable.
The report of aircraft blackbox missing became very common after the EAS Aircraft Accident Report in 2003, which revealed damming practices by domestic airline operators. (See Vanguard newspaper report on EAS accident, May 5 & 6, 2003). Following that Report, experiences and knowledge from most accident reports showed that the blackbox containing the CVR and CDR were either reported missing, like those of the ADC that crashed in 1996 in Ejinrin, Lagos and the Bellview crash in 2005 at Lisa, Ogun State. There were those that were reported to be badly damaged or completely burnt like those of the Sossoliso crash in 2005 at Port-Harcourt and the ADC crash in 2007 at Abuja.
The EAS report had revealed that some airlines aircraft were not even carrying any blackbox and when or if they did, the registration numbers on them were not those that were registered with the NCAA for the aircraft licensing and registration. The report on the Dana blackbox could not therefore be too different from others before it, so also was the history of the captain that seemed to share some semblance with that of the pilot of EAS aircraft that crashed in 2002. (Again, read Vanguard, May 5 & 6, 2003). The report revealed how the blackbox readings, when analysed, gave conflicting data on runways headings in Europe as against readings for runways headings of airports in Nigeria where the aircraft was operating. The EAS Accident Report also revealed how one of the pilots of the flight had to provide the NCAA a court affidavit as an alternative to justify the correctness of the records of his pilot’s logbook that he had reported ‘missing’; the records that NCAA could easily have obtained from his previous employers.
In spite of the international standards and national regulation for civil aviation safe operation and emergency management procedures, it is certain that accidents would still happen and people would die and others get injured due to factors associated with negligence, errors of judgment (either excusable or culpable) on the part of the personnel; inefficacy of aeronautical facilities, natural causes like inclement weather or a combination of some or all of these factors. Government has always been concerned with the causes or reasons of aircraft crashes but not always concerned with the manners of death of the persons on board the aircraft or the causes of their death. The manner of death of persons on board always not mattered to the government as if the deaths of persons on board an aircraft have been prescribed by the national laws and regulations.
A Ministerial Committee on the Implementation of Safety Recommendations on accidents from 2000 to 2014 had reported in December 2014 that none of more than 150 recommendations that were made within the period 2000 & 2014 were implemented. It is very doubtful if the NCAA and AIB are taken any lessons from previous accidents reports. The Report also stated that between 2000 and 2014 there had been 21 fatal accidents with 638; fatalities, 325 of these fatalities or about 50% happened in 2 years from only 3 aircraft fatal accidents. How many of these fatalities did the government or the NCAA ensured that they have adequate compensations? Does the NCAA ever ensure that ‘airlines included in their tickets and statement to the effect that liabilities arising from death or bodily injuries to passenger in the course of carriage by air within or out of Nigeria’ are governed by the provision of the NCAR or CAA NCAR Part 18.12.3. Does the NCAA ensure that the ‘airlines and other aircraft operators in public air transportation have valid insurance’ to enable them sufficiently comply with NCAR Part 18.11.2 and 18.11.4.
It is trite that Nigerian constitution provides for the rights of every citizen to his own life and that right is also entrenched in the UN Charter on human right. It is therefore not an accident that ICAO as an organ of the UN responsible for civil aviation prescribed in 18 Annexes, the way and manner which air transportation is to preserve passages life or their right to life.
Pilot errors appear to be only the causes of accident known to the Nigerian AIB in almost all the Accident Reports. In most Reports of serious accident that had occurred between 2005 and now there seems to be some cover up of laxity and negligence and not acts of error called Human or Pilot’s Error in most Accident Reports and none has been referred to as Negligence. How I wish the present management of AIB will revisit the causes of the Bellview crash (2005) at Lisa and that of ADC (1996) crash at Ejinrin.
Group Capt. John Ojikutu,(rtd)is the Secretary General of Aviation Safety Round Table Initiative(ASRTI), the Managing Director of Centurion Securities, Aviation Security Expert and an Aviation Analyst . He is based in Lagos