AIB releases final reports on three previous incidents

The Accident Investigation Bureau, Nigeria (AIB-N) has again released three (3) final reports on previous serious incidents thus making it a total of 75 aircraft accidents released by the bureau since its establishment in 2007 and a total of 56 reports released by the present administration.

Speaking on the release, the Commissioner of the bureau, Mr Akin Olateru said the reports were essential to the fulfilment of the bureau’s mandate of investigating aircraft accidents and serious incidents with the aim of enhancing safety, through recommendations.

The three final reports released today included 20 Safety Recommendations that were addressed to the regulatory body, the Nigerian Civil Aviation Authority (NCAA), the affected airlines, the Nigerian Airspace Management Agency (NAMA), an aircraft manufacturer, and the Federal Airport Authority of Nigeria, among others.

The Bureau has also released a total of 252 Safety Recommendations since its inception with 171 of the recommendations released by this administration.

The three Final Reports included 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 second final report released involved 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 while the third report was on 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 AIB Commissioner, on the incident involving Max Air Boeing 747-400 marked 5N-DBK, the bureau was notified of the incident by the NCAA on September 6th, 2019.

“On 6th September 2019 at 23:34 hour a Boeing 747-400 aircraft with nationality and registration marks 5N-DBK operated by Max Air Limited as Flight NGL2092 departed King Abdul Aziz International Airport, Jeddah; Kingdom of Saudi Arabia, (OEJN) with returning Hajj pilgrims bound for Minna Airport, Nigeria, (DNMN). There were 18 crew (2 cockpit crew, 14 cabin crew and 2 maintenance engineers) and 560 passengers with 8 hours 13 minutes’ endurance.

Instrument Flight Rules (IFR) flight plan was filed. The Pilot was the Pilot Flying (PF) and the Co-Pilot was the Pilot Monitoring (PM). The take-off, climb, cruise and descent phases of the flight were normal.

“The flight crew briefed for RNAV approach. At 3:31:21 h, NGL2092 established contact with Minna Tower and was cleared to Minna VOR (MNA) for ILS/DME approach Runway (RWY) 05. At 3:50:23 h, NGL2092 further reported to MinnaTower that there was an accumulation of storms on the final approach path. They requested to deviate left and extend the downwind of RWY 05. Minna Tower acknowledged and instructed NGL2092 to report when clear of weather.

“The flight crew stated that at about 2000 ft the autopilot disengaged and then they elected to fly manually. At 03:55 h, NGL2092 landed on RWY 05. The aircraft touched down on the right of the centreline of RWY 05 with the left main wheels first and the number one engine nacelle impacted the runway and was dragged along the runway centreline. Minna Tower passed the landing time and issued taxi instructions.

Among the causal factors responsible for the incident according to AIB’s investigations was the excessive rudder and aileron inputs at the short finals phase of the approach while the contributory factors included: the decision of the pilot to continue the ILS approach runway 05 with erratic localizer signals and an un-stabilized approach with a no go-around decision.

Part of the safety recommendations made by the bureau to the Federal Airports Authority of Nigeria (FAAN) was that it should ensure that the Aerodrome Manuals including Safety Management System (SMS) manuals are updated and submitted to the Nigerian Civil Aviation Authority (NCAA) for approval.

On the incident involving a Nigerian police air wing Cessna Citation 560 XLS- 5N-HAR which crashed on 22nd of October, 2018, AIB declared:
On 3rd October, 2018 at about 07:29 h, a Cessna Citation 560 XLS+ aircraft with nationality and registration marks 5N-HAR operated by the Nigeria Police (NP) was on a flight routing to Nnamdi Azikiwe International Airport, Abuja (DNAA) to Akure Airport, Akure (DNAK) via Sir Abubakar Tafawa Balewa Airport, Bauchi (DNBC) and back to Abuja (DNAA).

Onboard were six persons including three crew members (Pilot, Co-pilot and Cabin Crew (CC)), and three passengers with fuel endurance of 4 hours 20 minutes. The Pilot was the Pilot Flying (PF) and the Co-pilot was the Pilot Monitoring (PM).

“At 08:11 h, the aircraft landed on the runway (RWY) 35 in DNBC. After landing, the aircraft was taxied and parked normally. While taxiing to the apron, the pilot requested a quick turn-around from Air Traffic Control (ATC) and opted to file a flight plan by radio, which the Duty Air Traffic Control Officer (DATCO) granted.

“According to the PF, he set the parking brake and shut down the left engine for the passengers to disembark. Thereafter, PF instructed the cabin crew to put the chocks ON. The PF maintained that he was not aware that a transit walk-around was carried out on ground Bauchi by the PM.

“The crew reported that during the take-off roll on RWY 17 after Rotation speed (Vr) was attained, the aircraft did not get airborne. On the take-off run at Vr, the PF stated that the aircraft would not lift up (rotate) and he commanded for an abort. All persons on board disembarked without injury. The investigation’s causal factors included 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.

Among the contributory factors was the inability of the aircraft to get airborne after attaining the rotation speed (Vr) during take-off roll even with aft elevator pressure and the non-adherence to Standard Operating Procedures (SOPs) as contained in the Cessna Citation 560 XLS+ Airplane Flight Manual by the crew.

The five recommendations made by the AIB included advice to Cessna Aircraft Company (Textron Aviation), USA to 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 was also asked to develop Operations Manuals and Standard Operating Procedures in accordance with the provisions of subpart 8.14 of the Nigeria Civil Aviation Regulations for guidance and ensure crew members adhere to all provisions of Crew Rest Management during flight operations.

Speaking on the Azman Air Boeing 737-500-5N-AIS, the flight which was scheduled flight departed Murtala Mohammed International Airport Ikeja, Lagos (DNMM); Nigeria for Port Harcourt International Airport, Port Harcourt (DNPO); Nigeria on an Instrument Flight Rules (IFR) Flight Plan.

Onboard were 114 persons including of two cockpit crew, three cabin crew and fuel endurance of three hours.

“About six minutes after take-off, the number two engine turbine vibration began to rise and within 40 seconds it reached a peak of 5.26 unit, stayed for about 40 seconds then gradually decreased and settled at 3.0 units within a period of 90 seconds. AZM 2316 levelled off at FL 290 in cruise with both engines operating at N1 of 85% RPM. Two minutes later, the number two engine N1 dropped to 68% and within five seconds it returned to 85%.

“This coincided with the time when the flight crew heard a loud bang from the right side, which caused airframe vibration and yaw to the right. The flight crew concluded that the noise might be a result of cargo shift as the parameters of engines indicated normally.

“AZM 2316 established contact with POT Approach and obtained inbound clearance to POT for ILS/DME Approach RWY 21. About 13 minutes later, the aircraft began the descent, and reported passing FL235 for FL210 and 98 NM on radial 285 inbound.

“AZM2316 configured for landing, gears down, flaps set at 15°, 150 kts both engines stable and symmetrical with N1 at approximately 57%. About a minute later, the number two engine N1 started decreasing and within five seconds it dropped to 47% causing asymmetric engine power while the number two turbine vibration began to increase. At this time, the flight crew reported hearing another loud bang from the right side accompanied by severe vibration and yaw to the right. The number two engine turbine vibration reached 9.90 units.

“The Approach became unstable, the Autopilot disengaged, TO/GA was engaged, accompanied by Autopilot warning.

About 25 seconds later, the number two engine N1 further decreased to 30%, and its fan vibration and Low-pressure compressor vibration increased to 4 units respectively. The flight crew executed a Missed Approach and AZM 2316 was
vectored to fly heading 350⁰ by the ATC.

“The number two engine Oil Filter Bypass Light illuminated during the Go-Around. The flight crew carried out a precautionary shutdown of number two engine in accordance with the ENGINE OIL FILTER BYPASS checklist. The flight crew declared emergency and AZM 2316 was vectored by ATC for the ILS RWY 21.
The flight crew stated that, they got preoccupied by the limitation of 10° bank and map shift, they did not align with the runway centreline passing through 500 ftRADALT while experiencing high vibrations in number one engine.
The aircraft crossed the localizer extremely late at 150 ft AGL and one dot high.

The Approach became unstable again and the flight crew executed a second Missed Approach. The aircraft aligned properly on profile during the third landing attempt before reaching the final approach fix. At 11:35 h, AZM 2316 landed on runway 21.

The causal factor according to the bureau was the failure of number 4 and 5 bearings of engine number 2 leading to loss of power during the approach while the contributory factors included the failure to recognize the abnormal engine conditions (surge) during the cruise phase and hence, not making the appropriate decision. This might have been connected to the insufficient technical knowledge and loss of situational
awareness.

Also discovered was the non-implementation of the Flight Data Monitoring programme in accordance with 2.2.5.1 of the Azman Air Safety Management System Manual and the non-rectification of the number two engine vibration anomalies recorded over a period of 8 months.

In the safety recommendations issued, Azman Airlines was asked to review relevant portions of its Operations Manual, including 5.1.3 of Azman Air Ltd Operations Manual Part A to specify the criteria for determining the experience level required for crew composition and also ensure that all its flight crew possess the requisite qualification as contained in Azman Air Services Operations Manual Part A chapter 6 before they are assigned flight duties/responsibilities.

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