NSIB releases 4 incidents/ accident reports, charges NCAA to ensure Dana complies with timely use of checklist
The Nigerian Safety Investigation Bureau, NSIB, has called on the Nigeria Civil Aviation Authority, NCAA, to ensure Dana Air Limited complies with timely use of
Checklist / Quick Reference Handbook particularly at critical phases of flight when dealing with
abnormal and emergency situations in line with standard company operating procedures.
The NSIB also urged the NCAA to ensure that Dana Air Limited adheres to standard
phraseology in communicating malfunctions during Abnormal or Emergency
operations.
Some of these recommendations are contained in the major safety reports issued by the Nigeria accident / incident investigating Agency to the Aviation Regulatory Agency in Abuja on Friday May 23rd during the release of aviation incidents and marine report involving Dana Air, Air Peace, Max Air and late Nollywood actor fatal boat accident in Anam River in Anambra State.
Speaking during the official release of the reports, the Director General of NSIB, Mr. Alex Badeh Junior also tasked the NCAA to review Dana Air Limited training program and
Standard Operating Procedures with a view to highlighting Crew Resource Management (CRM) , Threat and Error Management (TEM) as tools in management of abnormal or emergency
operations.
Badeh Junior tasked the Nigeria Airspace Management Agency to ensure that Air Traffic Controllers always insist on communication of specific malfunction with standard phraseology, in this instance, the use of “indicated system malfunction…” rather than “GEAR DISAGREE”.
On the serious
Incident involving Air Peace Embraer, EMB – 145 LR aircraft which occurred at Kaduna Airport on 14 January, 2021 with nationality and registration marks 5N BVD, operated by Air Peace Limited, which was a scheduled passenger flight (four sectors); Lagos Owerri-Lagos and Lagos-Kaduna-Lagos, with the same flight crew, Badeh noted that the operating aircraft has an unserviceable hydraulic system which led to a high speed rejected takeoff.
He pointed out that there was a leakage of Hydraulic System 1 due to a loose coupling on the hydraulic line servicing the Brake
Control Valve.
Badeh stated that the non adherence on Air Peace guidelines on diagnosis and reporting of faults, including the non-detection of a hydraulic leakage and non-indication of hydraulic system failure message on the Engine Indicator and Crew Alerting System (EICAS) reinforced the flight crew decision (confirmation bias) to continue with the flight.
The NSIB recommended in the report that Air Peace Limited should ensure that its personnel adhere to the company’s approved
instruction, guidelines and procedures, including the requirements of Operations Manual
Part A Chapter 8.1.11.2.5 with regards to handling defects/damage to aircraft making appropriate entries of technical faults encountered in flights in the aircraft Technical
Logbook and inspected by authorized personnel.
Badeh ordered Air Peace Limited to ensure that flight crew adhere to requirements of Operations
Manual Part A Chapter 8.1.11.2.5 (c) requiring coordination between the flight crew and the Air Peace Ltd Operations Control Centre in the decision-making process to resolve any malfunctions or damage encountered at an airport where authorized Air Peace Limited maintenance personnel is not available.
The Bureau also recommended that
Air Peace Limited should improve its internal oversight over its aircraft maintenance activities to ensure procedures are appropriately followed to promptly identify and
remedy trends of deviation from the established standards, including the identification and rectification of excessive hydraulic fluid depletion.
The Bureau called on the Nigeria Civil Aviation Authority to ensure that Air Peace Limited and other operators adhere to the provisions of Nig. CARs 7.8.1.3(b), 8.14.10.3 (a) and 8.5.1.24 (b) and (c) and
other Instructions issued by the Authority relating to preservation of the contents of Cockpit Voice Recorders following incidences of reportable occurrences, including full compliance with the Authority’s ALL OPERATORS LETTER (FSG 003).
It also called on the NCAA to enhance its oversight of Kaduna airport to ensure operations are conducted in compliance with the relevant provisions of the Nigeria Civil
Aviation Regulations, including compliance with Part 12.6.16.10 regarding regular testing of response time to evaluate effectiveness of the Fire-fighting service of the airport.
The Bureau recommended that the Nigerian Airspace Management Agency (NAMA) should ensure a functional Air Traffic Control Tower that provides an unobstructed view of both ends of the Runway 05/23 provided at Kaduna airport.
The NSIB also recommended that the Federal Airports Authority of Nigeria (FAAN) should ensure that Kaduna airport has an approved Airport Emergency Plan and carries out testing of the Emergency Plan as required by Part 12.6.15 of the Nigeria Civil Aviation Regulations.
While the Federal Airport Authority of Nigeria should ensure that its staff adhere strictly to the Provisions of Civil Aviation (Investigation of Air Accidents and Incidents) Regulations, 2019
Part 3 (General) Regulation 19 (Protection of evidence, custody, and removal of damaged
aircraft) which is now section 3.5 of the Civil Aviation (Investigation of Air Accidents and
Incidents) Regulations, 2023.
The report explained that at 10:27 h, Air Peace 5N-BVD departed
Murtala Muhammed International Airport Lagos (DNMM) for Kaduna airport (DNKA) for the third
sector of the day as flight APK7376 on an Instrument Flight Rules (IFR) Flight Plan with 53 persons
on board (49 passengers and four crew) and fuel endurance of three hours.
According to the report, the First Officer was the Pilot Flying (PF), while the Captain was the Pilot Monitoring (PM).
During Climb Out of Lagos, on the third Sector, an Advisory Light HYD1 LO QTY on the Engine
Indicating and Crew Alert System (EICAS) came ON and the Quick Reference Handbook (QRH)
Section 107 (HYDRAULIC SYSTEM LOW QUANTITY) was accomplished.
The hydraulic fluid level indication was monitored until landing in Kaduna. While preparing for the fourth Sector, in
Kaduna, the Electric Motor Driven Pump (EMDP) was used to power the Hydraulic System. During
Taxi, the Lead Cabin Crew informed the flight crew that there was an unusual sound from the
over-wing to the aft of the aircraft. The flight crew concluded that the sound emanated from the
EMDP and continued with pre-fight activities. The aircraft lined up for take-off and as it
accelerated towards 119 kt, the take-off was aborted, thus initiating a sequence of events that
eventually led to the failure of Number 1 and Number 2 Wheel Assemblies and additional damage
to the aircraft. The incident occurred at 12:09:20 h, daytime in Visual Meteorological Conditions
(VMC).
On the ground collision incident involving a Lavatory service truck operated by Skyway Aviation Handling Company PLC, SAHCO and a parked Boeing 737-300 aircraft with registration number 5N- DAB operated by Max Air, which occurred at Nnamdi Azikiwe International Airport Abuja on 21st November 2021, NSIB recommended that SAHCO Plc should ensure adherence to the provision of section 19 (1) of the Civil Aviation
(Investigation of Air Accidents and Incidents) Regulations 2019 regarding tampering with evidence which is now section 3.5 of the Civil Aviation (Investigation of Air Accidents and
Incidents) Regulations, 2023.
It recommended that
SAHCO Plc should ensure adherence to its Standard Operating Procedures and provisions
in its manuals including sections section 3.3.4 and 3.5.2 and section 7.1.3.5 and 7.1.3.6 of
its Ground Operations Manual.
NSIB other recommendations include: That SAHCO should ensure availability of adequate manpower at the ramp to cater for different operations occurring simultaneously.
That SAHCO plc should ensure that its operations are well coordinated and adequately supervised.
The Max Aircraft was scheduled to operate eight sectors on the day. After the third sector, 5NDAB was
parked at Stand D8. While boarding passengers for the fourth sector (Abuja to Maiduguri), the
Pilot requested Ground Service for the aircraft Lavatory. According to the Ground Support
Equipment (GSE) driver, he was attending to another aircraft when he was called upon to service
the Max Air aircraft. After positioning the truck with the aid of a SAHCO GSE marshaller; it was
put on chocks. When the driver realised his hands could not reach the aircraft Lavatory Drain
Valve, he requested the GSE marshaller to guide him to reposition the truck closer to the aircraft.
The GSE driver further stated that to move the truck by reversing, he stepped on the Throttle
Pedal instead of the Brake Pedal, and the truck impacted the aircraft’s Tail section.
Causal factor: Abrupt stepping on the Throttle Pedal instead of the Brake Pedal, causing the truck to impact the parked aircraft’s tail section.
It was observed that less than adequate ramp supervision/coordination of SAHCO’s GSE operations contributed to the incident.
Other contributory factors include Inadequate workforce in the operation of SAHCO’s ramp activities in handling more than
one aircraft simultaneously.
Non-compliance with various sections of SAHCO’s Operational and Ground Operation Manuals.
Lack of standard procedure for changing duties from one unfinished task to another.
The GSE Truck was not accurately marshalled the first time while positioning to service
Max Air aircraft.
The GSE Truck did not wait to be marshalled after requesting to reposition
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