Dana Airline Crash: Human Negligence Not Human Error Part 2 By John Ojikutu
The technical manpower of the AIB for aircraft accidents investigation has been described in the first part of this paper as inadequate and ineffective by a ministerial committee set up in 2014 to look into the implementation of Safety Recommendations arising from the various reports of previous accidents that had occurred between 2000 to 2014; the Dana plane crash was one of the accidents in these reports. The committee observed that the AIB had only fourteen (14) technical staff, who were aircraft accidents investigators out of a total of sixty eight (68) staff strength; eight (8) of the fourteen (14) technical staff were on contract; effectively, the AIB had just six (6) Accident Investigators; the rest were supporting staff and they included administrative and account staff, drivers, security men, cleaners, etc.
With only six permanent technical staff and eight contract technical staff, the AIB lacked the capacity that was required to do thorough analysis of the various serious accidents in the AIB library inventory like the Bellview crash of October 2005; the Sossoliso crash of December 2005 and of course the Dana crash of June 2012. These accidents had their reports among the sixty three (63) aircraft accidents and serious incidents reports in the AIB library inventory. However, the ministerial committee found only thirty four (34) reports but twenty nine (29) of the reports were not available and were presumed to be missing. The committee could therefore review the one hundred and fifty eight (158) Safety Recommendations that were recorded from the thirty four (34) accidents reports that were available.
With all these platitudes of settings and inadequacies at the AIB, not much could be expected from the six permanent technical staff to do efficient investigation and produce accurate reports on the sixty three accidents, twenty one of which were fatal. There was no way they could produce timely reports too without the assistance of external local technical bodies as does the NTSB of the US. Without accurate reports, there can be no lessons for the operator of the accident aircraft and other stakeholders to learn from the cause or causes of these accidents especially where there were Safety Recommendations that could or should be shared in good time to avert reoccurrence.
The report of the Dana plane crash was an example of lack of due diligence and inaccurate or insufficient investigation into the possible causes of the accident. The causes of the plane crash as enumerated in the AIB final report were not convincing to many of the stakeholders and discerning public as there were gaps in the report that were not sufficiently addressed which made the whole essence of the report questionable.
Firstly, after the first engine flameout seventeen (17) minutes after the aircraft takeoff from Abuja, did the AIB conduct sufficient analysis on the aircraft Mayday report of “dual engine failure, negative response from the throttle”? Were the investigators aware or didn’t they take cognisance that the aircraft APU Fuel Valve Electrical Plug was worked on a day before the 3rd of June 2012 flight? Did the investigators at any time during the investigation refer to this immediate past repairs on the Fuel Valve and therefore suspected fuel starvation or fuel contamination? Was the AIB aware that there had been three (3) previous accidents reports in its library that were cases of fuel contaminations and that these included Network Aviation Services 5N-ATE, June 2001; Executive Airline Services (EAS) 5N-ESF, May 2002 and Nigerian Police Aircraft 5N-POL, November 2012? The analysis of previous maintenance records, previous accidents reports and flight information reports from the CVR and ATC communication are the basis that could or should have been the AIB starting point. These could have given the investigators some reasons to suspect fuel starvation or contamination, unfortunately, the report of the investigators never gave significant considerations to any of these. This is professional negligence.
At the Aviation Safety Round Table (ART) Q3 Business Breakfast Meeting (BBM) in September 2015, Captain Nogie Meggison, President of the Airline Operators of Nigeria (AON) told guests and participants that some fuel marketers were selling raw kerosene as Jet-A1; not many marketers nor even the airlines operators reacted publicly to deny this allegation except Mr Femi Otedola, who collaborated Captain Meggison allegation and responded by admonishing his fellow fuel marketers who according to him “were spoiling the market by selling adulterated fuel”.
NCAA too responded that it had a letter back in July 2015 from an EU aviation safety organisation that some European carriers had reported to it that there were some kind of adulterations in the fuel they were being supplied by fuel marketers in Nigeria. Unfortunately, there had been no evidence that these serious allegations were investigated by the responsible safety authorities or that the NCAA in particular had shown safety concern to these allegations and had released safety directives or bulletins to the marketers to address these serious allegations. Another form of negligence.
Secondly, the investigators had seen the engines at the crash site and had recorded that “the physical inspection of the engines showed little or no damage to the fan blades, which was consistent with low thrust from the engine. This collaborated the fact that the engines were not fully powered”. How this type of physical inspection could have been significant and sufficient in analysing the cause of the accident were not stated and the investigators did not go beyond that in their local investigation. Without an established due process or the conduct of further analysing possible causes of the accident and probably believing what they were told by the fuel marketers at Abuja Airport that the fuel was not contaminated, the AIB decided to send the engines of the aircraft to the NTSB laboratory for analysis. Moreover, after the inspection, both engines were removed from the crash site, and were stored outdoor exposed to environment weather for many days, weeks and probably days before they were shipped or flown to the US for examination. Negligence.
At the NTSB laboratory, the engine examiners noted in their report and findings that the engines were transported and arrived the laboratory uncrated with some parts missing and others dismembered or damaged while some others were covered in rust. Some of the missing parts included; Fan and Exhaust Ducting from ‘D’ Flange; Front Fan Case of the Engines; five (5) Bolts from the ‘D’ Flange, etc. Add these to the missing FDR and many more still missing and damaged through improper storage and handling, it was clear that the NTSB could not have been able to produce any meaningful report with mechanical or aeronautical reasoning as the cause or causes of the accident.
How the AIB arrived at its conclusion that the non application of the aircraft emergency checklist by the pilots was the Human Error that led to the accident must beat the imagination of many stakeholders. To conclude that there was human error, there must have been an action or intent to act rightly that ended wrongly especially in an emergency situation as there was with the Dana plane. Unfortunately, there was no intent on the part of the pilots to act or react to the first engine flameout, which occurred seventeen (17) minutes after the takeoff from Abuja. The only action of Mayday from the pilots came just a few seconds before the crash and that was more than thirty eight (38) minutes after the loss of the first engine. Pure Culpable Negligence.
There were a number of aircraft accidents similar to the Dana aircraft accident and whose reports in the AIB library remained illogically concluded and very inaccurate. Among such reports was that on the Bellview airline aircraft crash in October 2005, which concluded that a weather of just two octas of cumulonimbus cloud (Cb) was the cause of the accident over Lisa village. The investigators of that accident did not evaluate why the aircraft was given a departure clearance different from the standard departure route to Abuja from Lagos; they did not evaluate the location of Lisa village relative to the Lagos airport traffic Holding Area; they also did not evaluate how many aircraft that could have been conflicting traffic were in the Holding Pattern or the holding area at the time the aircraft was given right turnout instead of left turnout. In other words, at the time the Bellview aircraft was given a rights turnout did the controller take procedural precautions to avoid conflicting traffic over the holding area knowing fully well that the radar was not in use at that time? Did the investigators take cognisance of all these before they concluded on weather as the cause of the accident? It was a similar fate that had earlier befell arriving ADC flight that crashed at Ejinrin in 1996, which had a similar conflicting traffic profile with a departing Triax airline aircraft.
Human negligence is becoming too common and too many with most of the Nigerian aircraft accident reports and often, we prefer to call even culpable negligence human error to shield the guilts away from appropriate punishment or sanctions. Government in particular that has the responsibility to protect the lives of air travellers under the constitution, the Chicago Convention and the UN Charter, is doing nothing about the loss of lives in many accidents that were traceable operational and administrative negligence. Most were found to have resulted from inexperienced and insufficient manpower or lack of appropriate skills and inefficient ground operational facilities. Mindful of the fact that the main objective of governance is to protect and save lives and mindful that the personnel of the aviation operative systems were issued licences by its responsible agency, it is high time government reviewed the laws on accident reports that is protecting culpable negligent operators or operatives especially when lives are lost, and that should include government agencies and officials.
Finally, while the public is still worried about the emergency management services that are put in place within and outside the airports for aircraft accidents, government should also have concerns for the families of the victims particularly the traumatised ones. The NCAR truly provides for the establishment of Family Assistance Programmes which “shall provide succour for families of victims of aircraft accidents in Nigeria”. Unfortunately, this provision does not go beyond that vague statement in the NCAR. It has not designated responsibility for the development, management or funding of the Programmes to any agency, department, office or officials. In the same vein, government must address the regulations on airlines insurance livability, its implementation and compensation to accident victims and their defendants as most airline operators have failed to adequately compensate victims and dependants of past accidents. Most, if not all the airlines are not complying with the provisions of the NCAR that requires all airlines to ” include in their ticket coupon a statement to the effect that liability arising from death and bodily injuries to passengers in the course of carriage by air within or from Nigeria shall be governed by the provisions of the Civil Aviation Act 2006 and the NCAR “.
The problems of the government agencies and the AIB in particular is not necessarily the lack of funds to support aircraft accident investigation; the problems generally is the lack of adequate professionally inclined manpower that could conduct accurate and timely investigation. Lack of effective supervision that would ensure due analytical process in the investigation and produce unbiased reports. There should be no conflict in the AIB responsibility as distinct from that of the NCAA. Suffices to state that while the AIB is responsible for aircraft accident with power to apportion blames to any operator, agencies or anyone, the NCAA is the only authority on civil aviation that is responsible for safety oversight of the industry as well as prevention of accidents. That explains why the AIB must timely send to NCAA every Safety Recommendations from all it investigation for implementation.
Group Capt. J.O 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