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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Similar Occurrences

Summary: Approximately 16 months after the 5N-RAM accident, it was determined that loss of power of an engine was also experienced on 5N-SAI, an aircraft in Dana Airlines’ fleet. 5N-SAI MD-83, operating flight 0348 Port Harcourt to Lagos, suffered loss of power on No.1 Engine during climb out at 14,000ft. The Engine failed to respond to throttle movement and remained at idle power 1.03 EPR. That incident led to an air return on 6th October, 2013 for which the Airline issued an Engineering Authorization No. MD83-EA-73-001.
Description of Dana MD-83 5N-SAI Air Return Incident On the other aircraft 5N-SAI that made an air return on 6th October, 2013, the shop and teardown investigation showed the same characteristics as the engines on DANACO 0992 which had a fatal crash in Lagos.

In the course of the internal investigation carried out by the airline, the captain of the air return asserted emphatically that there were other aircraft in the Operator’s fleet that exhibited slow acceleration as in 5N-SAI.

NCAA Audit of Dana Airlines of between 9th and 12th December, 2013 highlighted the need for Dana to propose corrective action on the directive that all the previously overhauled engines by Millennium MRO should be re-certified by an NCAA approved engine shop(s) before re-installation on Dana aircraft.

The summary of the two problems is that they are common occurrences on the JT8D- 217C and 219 engines as acknowledged by Pratt & Whitney. As a result, the manufacturer in October, 2003 issued a Service Bulletin (SB) 6452 on the JT8D engines.

Reason:

1. Problem: There have been several instances reported of secondary fuel manifold assembly fractures, causing fuel leaks, which resulted in 94 Unscheduled Engine Removals (UERs), one In-flight Shut Down (IFSD) and two Air Turn Backs (ATBs). There was also one contained fire in 2001 and the extent of the damage was confined to a dark streak of coked fuel on the Combustion Chamber Outer Case (CCOC), and fan duct damage.

2. Cause: Thermal expansion results in high stresses on the tubes, which do not have adequate fatigue life for those stresses. Also, installation of distorted manifolds and incorrect shimming of the manifold during installation can aggravate the condition.

3. Solution: Provide new secondary fuel manifold assemblies, incorporating tubes fabricated from new material which has a fatigue life that is approximately 2 times greater than the current tube material to improve the durability of the manifold assemblies.

Description:

Replace or modify the left and right secondary fuel manifold assemblies.

The incident which led to the issuing of Engineering Authorization No. MD83-EA-73-001 dated 28/01/2013 is one in so many incidents that brought to the fore, failure of engine to respond to throttle movement. The following were the reasons and shop findings:

Reasons:

Following a recent incident involving an air return for an engine failing to respond to throttle movement, the engine was subsequently removed for shop investigation after inspection and troubleshooting revealed un-burnt fuel escaping in the fan duct section of the engine during ground run.

Shop findings indicate that one of the two fuel manifolds enclosing primary and secondary fuel supply lines in the fan air discharge section located approximately at 5 o’clock position was found not to be of standard configuration, with the secondary supply line severed. The investigation revealed that the improper installation of the manifold assembly resulted in high velocity bypass fan air stressing of the assembly due to its not being aerodynamically sealed.

The engine manufacturer knew that the problem existed and thus issued SB 6452 with compliance code ‘6’ to take care of the problems. An Alert Service Bulletin would have been more appropriate since it makes the modification urgent and timely with higher level compliance category. Making the installation to fit only in one direction will eliminate the issue of incorrect shimming of the manifold during installation, which the manufacturer opined aggravates the condition.

 

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

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

  •  1.6 Aircraft Information
  • 1.18.2 Related Incident – MD-83, 5N-SAI (Air return due to No.1 Engine Power Loss and Not Responding to throttle movement) ESN P725851D
  • 2.4 Similarities in Engine Inspection Reports of the Accident Aircraft 5NRAM and the Air Return Aircraft 5N-SAI
  • 2.5 The Dana Airlines Air Return (Related Incident)

 

 

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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.

More Information?

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.

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.

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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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