Occurrence No.: AIBN-004-2019       Occurrence Type: Accident      Report Created: Jun 3/12
Title: Loss of Engine Power – Collision with Terrain       Flight Phase: Descent      Aircraft Type: MD-83
Carrier/Owner: Dana Airlines Nigeria Limited       A/C Registration: 5N-RAM
Location: Iju-Ishaga Area of Lagos State, Nigeria
Status: Final Last Update: Mar 13/17
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Conclusions

Summary Loss of power of the engines, crew actions and decision making were identified as major contributing factors to the accident.

With respect to engine power loss, the investigation did not lead to a definitive specific mechanical cause of the engine failures on 5N-RAM. Nor did the investigation lead to an explanation as to why both engines lost power on 5N-RAM, unlike similar occurrences where only one engine lost power.

Findings

1.    The flight crew were certified to fly the aircraft.
2.    The two pilots were foreigners.
3.    The Captain was new in the company having been employed on the 14th March, 2012 and was checked out as a line Captain on 1st May, 2012.
4.    The Captain had previous regulatory issues with the U.S.A Federal Aviation Administration (FAA) which led to his suspension at that time.
5.    All the reference letters presented by the Captain to Dana Airlines were neither signed nor authenticated.
6.   The background check on the Captain was inadequate.
7.   The line training given to the Captain was hurriedly carried out.
8.   There was no evidence that the deficiencies observed by the checkout Captain were addressed before the accident Captain was released for line operation.
9. The Co-pilot’s first experience on a commercial jet airplane was with Dana Airlines.
10. The aircraft was airworthy at the time of departure.
11. The aircraft came out from a check and was released to service on 1st June, 2012.
12. All deferred defects were cleared during the last check.
13. The left aileron bus cable was replaced on 1st June, 2012.
14.  A test flight was carried out on 2nd June, 2012 after the replacement of left aileron bus cable.
15.  5N-RAM Engine No.1 was not compliant with SB 6452 while Engine No. 2 was in compliance with the SB.
16.  Both 5N-RAM Engines were overhauled in Millenium Engine Associates Inc. within a time frame of four (4) months.
17. The aircraft departed Abuja with three hours and thirty minutes fuel endurance.
18.  The Engine number 1 lost power seventeen minutes into the flight.
19. There was no evidence that both normal and emergency Checklist were used throughout the duration of the flight before the crash.
20. The aircraft did not make any contact with the Control Tower before the crash.
21. The aircraft crashed five miles on the extended centreline of runway 18R.
22. The aircraft crashed into a residential area.
23. The aircraft first point of impact was an uncompleted building followed by a Mango tree, a Coconut tree, and finally three other buildings.
24. There was fire outbreak.
25. All 147 passengers and six crew were fatally injured.
26. There were other fatalities on ground.
27. The aircraft wreckage was concentrated in a small area.
28.The huge crowd of people at the crash site slowed down rescue efforts and investigation.
29. The Fire Service ran out of water and it was very difficult to replenish supply because of the crowd and poor road network.
30. Flight recorders (black boxes) were recovered but were badly burnt.
31. NCAA revalidation procedures were not followed before the captain’s licence was issued.
32. The validated licence issued by NCAA to the captain was stamped but not signed.
33. There was a related incident involving 5N-SAI, an aircraft in Dana Airlines’ fleet that led to an air return on 6th October, 2013 for which the Airline issued an Engineering Authorization No. MD83-EA-73-001.
34. Millenium Engine Associates Inc. (MRO) has changed its name to Global Engine Maintenance LLC with the same FAA certificate number Y2MR496Y.
35. 5N-SAI Engine No.1 was not compliant with SB 6452 and overhauled in Global Engine Maintenance LLC on 11th April, 2013.

Causes

Probable Causal Factors:

1. Engine number 1 lost power seventeen minutes into the flight, and thereafter on final approach, Engine number 2 lost power and failed to respond to throttle movement on demand for increased power to sustain the aircraft in its flight configuration.

2. The inappropriate omission of the use of the Checklist, and the crew’s inability to appreciate the severity of the power-related problem, and their subsequent failure to land at the nearest suitable airfield.

3. Lack of situation awareness, inappropriate decision making, and poor airmanship.

Other Factors and Concerns

Millenium Engine Associates Inc. (now Global Engine Maintenance LLC) Commonalities between 5N-RAM and 5N-SAI:

  • All three engines (two on 5N-RAM and one on 5N-SAI) were overhauled by the same Repair Station, Millenium Engine Associates Inc.
  • The accident aircraft engines were overhauled within a time frame of four (4) months in the same facility, while the air return aircraft engine was overhauled much later.
  • Out of the three engines in consideration, two were not in compliance with SB 6452 while the third was SB 6452-compliant, with new tube material which has significantly greater fatigue life, reducing the occurrences of fractures.
  • All engines had primary and secondary fuel manifold assemblies fractured, cracked, bent, twisted or pinched which led to fuel leaks, fuel discharge to bypass duct, loss of engine thrust and obvious failure of engine responding to throttle movement.

The work processes, ethics and culture in Global Engine Maintenance LLC formerly known as Millenium Engine Associates Inc. are subject of concern to Nigerian Civil Aviation Authority and AIB. This concern was as a result from the discovery made in the cause of investigation in the Air Return aircraft 5N-SAI, which shows the improper installation of the right hand fuel manifold inlet fairing. Installation of distorted manifolds and incorrect shimming of the manifold which are capable of aggravating the condition as stated in SB 6452. There was lack of engagement of the front and rear sections of the manifold fairings on the inboard side.

The engine suffered thermal stress and fractured secondary manifold feeder line resulting in loss of power and failure to respond to throttle movement.

The Nigerian Regulatory Authority (NCAA) directed on 18th December, 2013 after an audit was carried out on Dana Airlines, that all engines previously overhauled by Millenium Engines Associates Inc. be sent to other NCAA approved Engine Shop(s) for overhaul before they could be re-installed on any Dana Airlines aircraft. This was a clear safety concern by the Regulatory Authority.

Consequently, the loss of thrust and no response to throttle movement were common to failure sequence in all three engines with catastrophic result in 5N-RAM.

 

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More Information?

Nil

Summary: The terrain condition in the landing area consisted of loose, dry dirt. While the aircraft was attempting to land, the interaction of the aircraft with the terrain resulted in a significant brownout and loss of visibility.

During the crash, debris was distributed within the football stadium. A parked car suffered minor damage from flying debris.


Information

Name

Kabba Football Stadium

Description

Unpaved field.

Elevation

1500 ft (457 m) above mean sea level.

Location

About the coordinate 07°50’32”N 06°04’42”E.


More Information?

Nil.


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Recorders

Summary: 34 minutes after departure, in cruise, the Flight Recorder light came ON indicating recorder had stopped recording, and the Crew Alerting System (CAS) displayed FDR and CVR fail. The crew consulted the Caverton Helicopters Quick Reference Manual (QRH) which advised that the flight should continue.

The Flight Recorder was retrieved from the wreckage and taken to the AIB Flight Safety Laboratory in Abuja. The flight recorder voice and data has been downloaded and is awaiting analysis.


Information

Manufacturer

Penny & Giles Aerospace Ltd.

Description

Low weight recorder that has combined Cockpit Voice and Flight Data recording capabilities.

Part Number

D51615-142 Issue 02

Serial Number

A09296-001

Manufacture Date

July 2014

S/W Reference

SW110522

Flight Data Capacity

25 hours.


More Information?

Nil


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Systems

Summary: No Systems issues were identified.

Information:

Nil.


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Nil.


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Flight Controls

Summary: No Flight Control issues were identified.

Information:

Nil.

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Nil.


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Summary: Crew decision making is under investigation. There were no issues with the background of the crew nor the passengers that would have contributed to this accident. There were no fatalities and no injuries. There were no issues that negatively affected the survivability of the accident.


Information

  1. Crew
  2. Passengers
  3. Injuries to Persons
  4. Survival Aspects


More Information?

Nil.


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History of Flight

Click here for a flight reconstruction animation.

Summary: Further investigation is required to determine if there were any crew decision making issues, or adherence to SOP issues, that may have contributed to the accident. With respect to the IVSI and RADALT, further investigation is needed to determine if there were any equipment issues that may have contributed to the accident, or any issues with the crew’s usage of the equipment.


Information

  1. History of the Flight
  2. Police Helicopter (Secondary Aircraft)
  3. IVSI / RADALT

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Nil.


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Transcripts

Summary: Not applicable.

Information:

Nil.

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Nil.


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Structures

Summary: Not applicable.

Information:

Nil.

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Nil.


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Operations

Summary: Not applicable.

Information:

Nil.

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Nil.


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Witnesses

Summary:Interviews with witnesses are ongoing.

Information:

TBA.

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Nil.


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WX

Summary: While the local weather was not a contributing factor to the accident, the interaction of the aircraft with the soil conditions resulted in inadvertent Instrument Meteorological Conditions (IMC).


Information

According to the weather report obtained by the Nigerian Airspace Management Agency (NAMA), the prevailing weather at the stadium was good (CAVOK)

The downwash of NGR002 induced a brownout event, resulting in a significant loss of visibility.


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Nil.


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FOD/Bird/Drone Strike

Summary: Not applicable.

Information:

Nil.

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Nil.


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Fire

Summary: There was no fire – before, during or after the accident.

Information:

Nil.

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Nil.


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ATC

Summary: No issues with ATC were identified.


Information

The helicopter was in radio communication with Abuja Tower and Abuja Radar Approach.

On departure, a squawk code of 1301 was given by the Air Traffic Control (ATC) for radar monitoring.

The helicopter was monitored on Abuja Approach Radar until 55 NM to Kabba, when the helicopter began descent.


More Information?

Nil.


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Conclusions

Initial Findings

Click here to review table of initial findings

Causes – TBD

Contributing Factors – TBD

More Information?

Nil.

 

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Recommendations

1.0 Immediate Safety Recommendation 2019-002

NCAA should issue an Advisory Circular to all helicopter operators flying in Nigeria to be alert of the possibility and the effect of brownout. Appropriate procedures should be put in place to mitigate its effect(s).

2.0 Immediate Safety Recommendation 2019-003

Caverton Helicopters Limited should ensure that flight operations are carried out in accordance with the company’s approved operations manual, vis-a-vis site survey and proper safety risk analysis are done before dispatching any helicopter to unapproved landing pads.


More Information?.

Nil.


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Inadvertent IMC – Hard Landing

Executive Summary

While attempting to land in a football stadium, VIP chartered flight Nigeria 002 (NGR002) encountered brownout conditions and experienced a hard landing on the right main landing gear and rolled over to the right.

There were 12 persons onboard, including the Vice President of the Federal Republic of Nigeria and his entourage, and three crew members (Captain, Co-Pilot and an Engineer). All occupants of the helicopter were evacuated uninjured.

Footnote: Brownout in helicopter operations is an in-flight visibility restriction caused by dust or sand in which the flight crew looses visual contact with nearby objects that provide the outside visual references necessary to control the helicopter near the ground.

More Information?

Nil.


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AW-139

Summary: Further investigation is required to determine if there were any issues with the aircraft (power plant, rotors, control surfaces, instrumentation) that may have contributed to the accident, including any issues related to the aircraft’s interaction with dust or stones from the brownout.


Information

  1. Aircraft Information
  2. Damage to Aircraft
  3. Wreckage and Impact Information


More Information?

Nil.


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Similar Occurrences

Summary: TBA.

Information:

For demonstration and illustration purposes, the following links demonstrate a video and an animation. They could be representative of similar occurrence information.

Video example:

https://www.youtube.com/watch?v=AIQY1O2wXts

https://www.youtube.com/watch?v=MIsV2hCsuAk

Animation example:

https://www.planesciences.com/demo-video

More Information?

Nil.

 

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Standard Operating Procedures (SOPs)

Summary: Further investigation is required to determine if there were any issues related to Standard Operating Procedures (SOPs) that may have contributed to the accident. These issues may be related to the adequacy of the SOPs themselves, or issues related to the crews adherence to the SOPs.

Information:

Nil.

More Information?

Nil.


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Training Aids

Future Contents: The intent of this Training Aids pulldown is to provide training aids information related to a specific occurrence. This would facilitate connecting the safety and training communities, with respect to timeliness in making follow-up training information available for a specific occurrence.

Initially this will involve engaging with the training community to provide training aids that could be referenced, or even added directly to the occurrence Training Aids pulldown. The longer term goal is to develop a database warehouse of training aids and give users the ability to find them using key words. The system could then automatically attach training aids to occurrences using the key words, when the occurrences are posted.

Information:

Nil.

 

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