…Says Pilot Used Inappropriate Landing Technique, Did Not Adherence To Company Procedures
… Asks NCAA To Conduct Safety Management System Audit Of Caverton Helicopters
The Accident Investigation Bureau (AIB), Nigeria has identified a brownout condition encountered by flight crew during the hover to land as the cause of the crash of Agusta Westland AW139 helicopter operated by Caverton Helicopters Limited with registration marks 5N-CML, that was carrying the Vice President, Prof. Yemi Osinbajo, his entourage and three crew members; Pilot, Co-pilot and an Engineer at Kabba, Kogi State on February 2, 2019.
According to the Final Report released today by the Commissioner and Chief Executive Officer of AIB, Engr. Akin Olateru, the causal factor of the crash was that the “flight crew encountered a brownout condition during the hover to land, which led to the loss of external visual references, spatial disorientation and loss of situational awareness resulting in a misjudgement of distance and ground clearance, as the flight crew tried to control the helicopter’s movements for landing.”
This, the report said made the helicopter to land hard and rolled over on its right side.
AIB, Nigeria also said that the contributory factor to the crash was that the pilots did not only used inappropriate landing technique but that he also did not adhere to company procedures for known or anticipated brownout condition during landing.
Other contributory factors according to AIB report includes: lack of risk assessment, limited landing site preparation and planning prior to commencement of the flight.
The final report further stated that 11 days after the accident, AIB issued two Interim Safety Recommendations(ISR), one to the Nigerian Civil Aviation Authority(NCAA) and the other to Caverton Helicopters, the operator of the aircraft and that the required safety actions were initiated and implemented promptly.
One of the safety recommendations issued according to AIB states that NCAA should, “Conduct a Safety Management System (SMS) audit of Caverton Helicopters. The SMS audit by the NCAA should ensure that Caverton Helicopters has implemented the Immediate Safety Recommendation 2019-003, the NCAA All Operators Letter (FSG 002), and the recommendations documented in the Caverton Helicopters internal SMS investigation of this accident. The NCAA audit should also ascertain that the Caverton Helicopters internal SMS processes in the maintenance activities require the establishment of the reasons/causes of equipment failure/malfunction (reference is made to the failures of the Multi-Purpose Flight Recorder (MPFR) and the unavailability of the reasons of the failures),”
The final report also directed The Office of the National Security Adviser (NSA) should, “Consider whether the Presidential Air Fleet (PAF) Unit should be involved in the coordination and preparation of all high profile Executive VIP mission (flights) in order to ensure that all Executive VIP flights are conducted in accordance with the PAF Unit’s Standards and in line with its approved operating procedures.”
Other reports released by the air incidents and accidents investigation body includes:
Serious Incident involving Bombardier DHC-8-Q400 aircraft owned and operated by Aero Contractors with nationality and registration marks 5N-BPU, which occurred at FL240, 80 NM to Lagos on April 18, 2017.
AIB, Nigeria in its report said that flight NIG316 was scheduled from Port Harcourt to Lagos.
According to AIB Final Report causal factor of the serious incident is that the engine oil leaked onto a hot surface of the engine causing fumes, which mixed with the engine bleed air supply to the air conditioning system, resulting in smoke in the aircraft cabin, cockpit and lavatory/ cargo compartments.
The report further stated that two safety recommendations were made ; one to Aero and the other to NCAA.
“Aero Contractors Company of Nigeria Limited should ensure that Cockpit and Cabin Crew are alive to their responsibilities during emergencies vis-à-vis establishing effective two-way communication.
“Nigerian Civil Aviation Authority should ensure that operators utilize the New Oil Analysis Technology made available by Pratt & Whitney Canada in order to identify impending failure of the carbon seals on PW150A engines that are yet to comply with SB 35342R1,” the report said.
Also released is the serious incident involving a Diamond DA-42 aircraft with Nationality and Registration Marks 5N-BNH owned and operated by the International Aviation College(IAC), which occurred on runway 23 Ilorin International Airport on May 1, 2019.
The flight according to AIB’s final report was a Commercial Pilot Licence (CPL) mock test with two persons onboard, a Flight Instructor (FI) and a Student Pilot (SP) with the flight instructor flying while the student pilot was monitoring.
According to AIB in its report, the investigation identified that the causal factor was that the crew carried out the approach and landed with landing gears not extended.
It also identified three contributory factors which are:
* Inadequate crew coordination during the approach to landing phase of flight.
* Lack of situational awareness on the position of the landing gears by the flight crew during approach to land.
* The inappropriate execution of approach and landing check list.
The AIB in its final report made three safety recommendations; one each to NCAA, IAC, Ilorin and the Nigerian Airspace Management Agency(NAMA).
“NCAA should intensify its oversight on International Aviation College (IAC) and ensure that it adheres strictly to the use of Checklists and appropriate procedures during all training sessions and phases of flight.
“International Aviation College (IAC) should improve on its Crew Resource Management training vis-à-vis the need for trainees to be assertive when necessary.
“NAMA should devise means to ensure duty air traffic controllers, DATCOs, maintain continuous watch on all aircraft movements within the vicinity of the aerodrome,” AIB recommended.
Serious Incident involving a Diamond DA-40 aircraft with Nationality and Registration Marks 5N-BRM also owned and operated by IAC, Ilorin, which occurred on runway 23, Ilorin International Airport on March 27, 2014.
It was a training flight with a student pilot and an Instructor on board.
AIB, Nigeria in its final report identified the following causal and contributory factors: loss of directional control after touchdown and subsequent veer of the aircraft off the runway as causal factor while wrong engine power application during landing roll was identified as the contributory factor for the incident.
It added that two safety recommendations were that, “IAC should have in place a stringent flight training policy to discourage disruptions of students’ training during the stipulated period and that IAC should also develop and incorporate in their training manual, procedures to ensure that corrective actions are developed and implemented to prevent observed deficiencies such as “exceeding required minimum hours for solo flight”, duly signed out by Instructors and records kept in the student’s file prior to conducting a solo flight.”
Speaking further Olateru said that the purpose of accident investigation, is not to apportion blame or liability but to prevent future recurrence of similar incidents.
He said these reports are the strong foundation on which safety of the aviation industry is built and timely release of these reports is as critical as Accident Investigation itself.
According to him, “Since the inception of this administration at AIB, we have been able to keep to our promise of ensuring timely release of accident and serious incident reports. We have before now released 27 final accident reports to the public and today, we will be releasing an additional four reports, which will bring the total final report released by this administration from 2017 till date to 31.
These Four Final Reports include a total of 9 safety recommendations, making a total of 51 Final Reports and 187 Safety Recommendations since the inception of AIB.
Safety recommendations in accident reports, Olateru pointed have impacted air safety positively not only in Nigeria, but globally, adding that they are very important towards preventing recurrence of such accidents or serious incidents when safety recommendations are adhered to.
