The Nigerian Safety Investigation Bureau (NSIB) has released the preliminary report on the serious incident involving a Boeing 737-400 aircraft operated by Max Air with nationality and registration marks 5N-MBD, which occurred between take off at Yola, Airport Adamawa State and on landing at Nnamdi Azikiwe International Airport, Abuja Nigeria on May 7th, 2023.
According to the findings of the accident bureau, the quality control department of the airline failed to supervise the maintenance action of the brake unit and wheel change on the 5N-MBD aircraft conducted on 5th May 2023 while the crew did not take adequate measures to confirm the information about the missing wheel assembly.
“There was severe fire damage on the No. 2 main wheel assembly. After the replacement of the wheel brake on the 5th May 2023, an aircraft mechanic crosschecked the work performed by the engineer.The Yola ATC Voice Recording System (VRS) did not record any communication between the Pilot and the duty controller on the day of the occurrence.
While the findings of the bureau also revealed that the CVR recording on the plane was found to be overwritten, the report further declared:
“Max Air Limited stated that they were unaware of the NCAA All Operators Letter (AOL) (NCAA/FSG/AOL/19/03) in respect of continuous overwriting of Cockpit Voice Recorder (CVR) Information.
There was wrong tech log entry of the serial number of the incident aircraft.The quality control department did not supervise the maintenance action of the brake unit and wheel change on 5N-MBD conducted on 5th May 2023.The crew did not take adequate measures to confirm the information about the missing wheel assembly.
There was severe fire damage on the No. 2 main wheel assembly. After the replacement of the wheel brake on the 5th May 2023, an aircraft mechanic cross-checked the work performed by the engineer.
The Yola ATC Voice Recording System (VRS) did not record any communication between the pilot and the duty controller on the day of the occurrence.
Addressing the media on the incident, the Director General of the Bureau, Mr Akin Olateru however stated that in the findings of the Bureau, the flight crew of the aircraft were licensed and qualified to conduct the flight and that the aircraft had a valid Certificate of Airworthiness.
“At 12:10 h 5N-MBD departed Nnamdi Azikiwe International Airport (DNAA) for Yola (DNYO) as NGL1648 and arrived Yola at 13:25 h.The aircraft was on ground Yola for about 30 minutes before the turn around for Abuja.
According to the flight crew, after takeoff the landing gear was left extended for 3 minutes to allow cooling due to high temperature on ground Yola.At 14:08 h, Nigerian Air Force personnel from the Air Force Hangar close to runway 35, reported to Yola Control Tower that an object appearing like a tyre fell off from the departing NGL1649. Yola DATCO promptly informed the Pilot of NGL1649 as well as Kano Area Control (ACC) and Abuja Tower.
“The flight purser (L1) and another cabin crew (L2) informed the Pilot that a passenger at seat row 24 informed them about seeing a wheel fall off from the airplane.The Pilot mentioned that instruments and landing gear indications were normal.At 14:51 h Yola ATC informed Abuja Tower and NGL1649 that nothing was found after the runway inspection.
According to the Pilot, the landing was normal but after the airplane started decelerating he noticed the port side wing was dropping lower than normal, he applied full aileron control to keep the wing from dropping until the lift decayed. Thrust reverser and minimal braking was used to stop the aircraft on the runway.
“At 14:57 h, Abuja ATC informed NGL1649 “be advised, it appears you have smoke around your aircraft. We have called fire watch room”, the Aerodrome Rescue and Fire Fighting Services (ARFF) and emergency services were alerted. The aircraft came to a stop between Link A5 and A6 about 2900 m from the threshold of runway 22.
The port wheel assembly was located by personnel of the Federal Airports Authority of Nigeria (FAAN) about 1000 m from threshold of Runway 35 Yola airport on 08th May, 2023.The roller bearings on the wheel assembly of No. 1 main wheel had discoloration and was burnt out.
The bureau in its recommendations to the airline called for immediate Safety Recommendations adding that Max Air Limited Quality Assurance should ensure maintenance activities are supervised and monitored in accordance with Maintenance Control Manual.
The bureau tasked the Nigeria Civil Aviation Authority (NCAA) to among others; “(a)Conduct regular safety management system (SMS) assessments to evaluate the capability of Max Air limited to effectively manage safety.(b)Ensure that the PMI and POI of Max Air Limited increase surveillance and oversight to ensure maintenance and flight operations are carried out in accordance with NCAA Technical Guidance Material (TGM) Volume IV (Airworthiness Inspector’s Handbook) Chapter 23 (Continuing Surveillance) and TGM Volume III Flight Operations Inspector’s Handbook Chapter 30 (Continuing Surveillance).
“MAir Limited should ensure that flight crew display good situational awareness and airmanship at all times during conduct of flight operations in accordance with Max Air ops manual.NCAA should invoke the relevant sections of Nig.CARs 2015 in accordance with IS 1.3.3 Legal Enforcement Actions to non-compliant operators with the AOL (NCAA/FSG/AOL/19/03) on continuous overwriting of Cockpit Voice Recorder (CVR) Information.”