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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Crew / Passenger / Survivability

Summary Second to the loss of power of the engines, crew actions and decision making were major contributing factors to the accident.

Crew Decision Making

Synopsis – Crew Actions and Crew Decision Making As mentioned in the Executive Summary, two of the three Probable Causal Factors in this accident were:

  1. 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.
  2. Lack of situation awareness, inappropriate decision making, and poor airmanship.

The CVR transcripts provide a number of examples of poor crew decision making. The crew did not follow the dictates of the Operations Manual as approved by NCAA. Checklists were not used. Occasionally, the call out for completion of checklist was made without checklist being read. The Crew Resource Management (CRM) between the technical crew was poor as evident in the CVR transcript. Swear words were frequently used. Inappropriate decision making was observed as deviation from regulatory and company procedures in considering diversion option to the officially filed alternate airport which was Ilorin. The crew also exhibited a lack of situation awareness which compounded their problem.

The recruitment procedures and training record of the captain indicate that he was hurriedly hired. The performance assessment by all the training captains (on the accident captain) had always called for improvement which bordered on: inadequate cockpit discipline, non-standard ICAO phraseology and inadequate radio communications technique. Others included non-adherence to company/ICAO procedures, limited crew experience and inadequate line training on MD-83 aircraft type. The training was hurriedly performed.

 

Details Details of the Crew Actions and Crew Decision making are contained in the following document, and specific sections:

http://www.aib.gov.ng/media/1117/dana-airlines-md83-5n-ram.pdf

  • 1.1  History of the Flight
  • 1.5 Personnel Information
  • 1.10 Aerodrome Information
  • 2.1 Conduct of the Flight
  • 2.2 Dana Airlines Policy/Procedures
  • 2.2.1 Captain Recruitment/Training Records

Crew Details

Details are contained in in the following document, and specific sections:

http://www.aib.gov.ng/media/1117/dana-airlines-md83-5n-ram.pdf

  • 1.5 Personnel Information

Injuries to Person

Details are contained in in the following document, and specific sections:

http://www.aib.gov.ng/media/1117/dana-airlines-md83-5n-ram.pdf

  • 1.2 Injuries to Persons

Survival Aspects

The nature of the crash greatly reduced the chances of survival due to massive post crash fire. There was no liveable volume within the forward section of the aircraft. The ground impact, with over eighteen thousand pounds (18,000lbs) of fuel onboard the aircraft, and a printing press with a warehouse of printed books and paper materials turned the whole area into a huge fire ball.

The pathology report showed that some passengers died of smoke inhalation, that is, of carbon monoxide poisoning. “This suggests that the victims were alive for some time in the fire that probably followed the crash, that is, they did not die immediately after the impact.” Though the response of the search and rescue team was prompt, the operation of the fire services was hampered by inaccessibility to the crash site as a result of a bad road network. The massive crowd at the scene did not help the situation; crowd control became a big problem to the fire services and the National Emergency Management Agency (NEMA).

 

Details are contained in in the following document, and specific sections:

http://www.aib.gov.ng/media/1117/dana-airlines-md83-5n-ram.pdf

  • 1.15 Survival Aspects

 

Gallery / Videos

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.


More Information?

Nil.


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Flight Controls

Summary: No Flight Control issues were identified.

Information:

Nil.

More Information?

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

More Information?

Nil.


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Transcripts

Summary: Not applicable.

Information:

Nil.

More Information?

Nil.


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Structures

Summary: Not applicable.

Information:

Nil.

More Information?

Nil.


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Operations

Summary: Not applicable.

Information:

Nil.

More Information?

Nil.


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Witnesses

Summary:Interviews with witnesses are ongoing.

Information:

TBA.

More Information?

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.


More Information?

Nil.


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FOD/Bird/Drone Strike

Summary: Not applicable.

Information:

Nil.

More Information?

Nil.


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Fire

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

Information:

Nil.

More Information?

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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