The Accident Investigation Bureau-Nigeria(AIB-N) has released three Final Reports on the serious air incidents and 20 Safety Recommendations .
The three final reports include:
The serious incident involving a Boeing 747-400 aircraft with nationality and registration marks 5N-DBK operated by Max Air Limited, which occurred at the Minna Airport, Nigeria on 7th September, 2019, the Final Report on the serious incident involving Cessna Citation 560 XLS aircraft with nationality and registration marks 5N-HAR operated by the Nigerian Police Airwing which occurred at Sir Abubakar Tafawa Balewa Airport, Bauchi, Nigeria on 3rd October, 2018, and the serious incident involving a Boeing 737-500 aircraft with nationality and registration marks 5N-AIS operated by Azman Air service Limited, which occurred at Port Harcourt, Nigeria on 3rd January, 2019.
According to the Chief Executive Officer of AIB-N, Engr. Akin Olateru, who released the reports said that they are essential to the fulfilment of the Bureau’s mandate of investigating aircraft accidents and serious incidents with the aim of enhancing safety, through safety recommendations issued, thereby assuring safe skies in Nigeria and globally.
He disclosed that in the reports are 20 Safety Recommendations, which were addressed to the Nigerian Civil Aviation Authority (NCAA), the affected airlines, the Nigerian Airspace Management Agency (NAMA), an aircraft manufacturer, the Federal Airport Authority of Nigeria(FAAN) among others.
He explained that the newly released reports bring the total of 75 aircraft accident reports released by the Bureau since its establishment in 2007 and a total of 56 reports released by the current administration from 2017 till date.
He added that this year alone, seven reports have been released.
The Bureau, he informed, also released a total of 252 Safety Recommendations since inception with 171 of the recommendations released by this administration.
On the causal factor, the AIB-N attributed it to excessive rudder and aileron inputs at the short final phase of the approach.
While the contributory factors include the decision to continue the ILS approach runway 05 with erratic localizer signals and an un-stabilized approach with a no go-around decision.
The Bureau made seven safety recommendations, which include :
- That FAAN should ensure that the Aerodrome Manuals including Safety Management System (SMS) manuals are updated and submitted to Nigerian Civil Aviation Authority (NCAA) for approval.
- That FAAN should ensure that all airfield lightings are properly maintained and kept serviceable.
- That FAAN should ensure that Aerodrome Emergency Plan (AEP) is operational and test run as required by the Nig.CARs 12.6.15.1.
That FAAN should ensure that Aerodrome Rescue and Fire Fighting Service (ARFFS) equipment are of the appropriate standard and minimum requirements for the category of aircraft expected to land at Minna airport.
That the Nigerian Airspace Management Agency (NAMA) should ensure that all navigational aids are maintained and calibrated in accordance with the standards prescribed in Nig. CARs 14.1.49.3.
The Nigerian Civil Aviation Authority (NCAA) should ensure that all relevant programs and their attendant manuals for Minna airport are reviewed and subjected to the approval procedures and that Max Air Limited should ensure that its flight crew are encouraged to consider executing go-around procedures when not stabilized on final approach.
On the Nigerian Police Airwing Cessna Citation 560 XLS -5N-HAR,AIB-N investigation identified the uncoordinated flight as a result of inadequate Crew Resource Management (CRM) that led to the partial release of the parking brake, which resulted in rejected take-off.
While investigation also revealed the contributory factors as the inability of the aircraft to get airborne after attaining the rotation speed(Vr)
during take-off roll even with aft elevator pressure and non-adherence to Standard Operating Procedures (SOPs) as contained in the Cessna Citation 560 XLS+ Airplane Flight Manual.
The contributory factors are inability of the aircraft to get airborne after attaining the rotation speed (Vr) during take-off roll even with aft elevator pressure and non-adherence to Standard Operating Procedures (SOPs) as contained in the Cessna Citation 560 XLS+ Airplane Flight Manual.
One of the Safety Recommendations is that Cessna Aircraft Company (Textron Aviation), USA should consider redesigning the parking brake system of Cessna Citation XLS+ to incorporate take-off protection, visual and aural warnings and also make the position visible to both occupants of the cockpit.
The Nigeria Police Airwing should develop Operations Manuals and Standard Operating Procedures in accordance with the provisions of sub-part 8.14 of the Nigeria Civil Aviation Regulations for guidance.
Other Safety recommendations are that the Nigeria Police Airwing should ensure that flight crew adhere to all provisions of CRM during flight operations, and the NCAA should ensure that NPAW flight operations are carried out in accordance with relevant provisions of Nig. CARs 2015 and that NCAA (Principal Maintenance Inspector (PMI)/Principal Operations Inspector (POI)) attached to Nigeria Police Airwing should intensify oversight function on Nigeria Police Airwing’s operations.
On Azman Air Service Limited Boeing 737-500-5N-AIS, the Bureau’s investigation revealed that the causal factor was the failure of number 4 and 5 bearings of engine number 2 leading to loss of power during approach.
While the contributory factors according to AIB-N are the failure to recognise the abnormal engine conditions (surge) during cruise phase and hence, not making appropriate decisions, adding that this might have been connected to the insufficient technical knowledge and loss of situational
awareness.
Other contributing factors according to the agency is the non-implementation of the Flight Data Monitoring programme in accordance with 2.2.5.1 of Azman Air Safety Management System Manual, non-rectification of the number two engine vibration anomalies recorded over a period of 8 months and the inadequate regulatory oversight of the Azman Air Safety Management
System.
The Bureau said that it issued one immediate safety recommendation to the NCAA in the preliminary report on February 4,2019, which is that NCAA should ensure Azman Air Services Limited immediately takes further necessary step to ensure that it reviews the training of the incident flight crew in order to be able to understand and recognise engine failure/malfunctions and its effect (s) at every phase of flight before they are allowed to resume flight duties and that no action was taken by the regulatory body.
