AIB releases DANA 5N-RAM accident report, Three others

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The Accident Investigation Bureau (AIB) has issued a comprehensive report on air crashes involving Dana Airlines, OAS Helicopters, Bristol Helicopters and Federal Government’s Diamond DA-42 jet, which crashed with a Presidential Implementation Committee on Maritime Safety and Security (PIMCOMSS) on 12th July, 2012.

According to the report presented to aviation correspondents on Monday by Commissioner of the Bureau, Akin Olateru, Dana’s flight 0992 with registration number 5N-RAM lost power in one of its engines 17 minutes into flight before it finally crashed on a building in the densely populated Iju-Ishaga suburb of Lagos on 3rd of June, 2012.

“On 3rd June 2012 at about 1545:00hrs, 5N-RAM, a Boeing MD-83, a domestic scheduled commercial flight, operated by Dana Airlines Nigeria Limited as flight 0992 (DANACO 0992), crashed into a densely populated area. Engine number 1 lost power seventeen minutes into the flight with a further loss of power on number 2 engine on final approach to 4 runway 18R at Murtala Muhammed Airport, Lagos, Nigeria,” the report read.

Other causal factors that contributed to the crash included inappropriate omission of the use of the Checklist, the crew’s inability to appreciate the severity of the power-related problem, subsequent failure to land at the nearest suitable airfield and lack of situation awareness, inappropriate decision making, and poor airmanship

Over 160 fatalities were recorded, both onboard the airplane and on ground; 153 passengers, 6 crew members and six other persons on ground perished on the spot. The airplane was destroyed and there was post impact fire which affected other buildings around the crash scene.

It added that Visual Meteorological Conditions (VMC) prevailed at the time and the airplane was on an Instrument Flight Rules (IFR), which suggests that the cause of the crash was not an external factor.

The AIB confirmed that in the course of investigation, the National Transportation Safety Board (NTSB) of the United States of America (USA), representing the State of Design and Manufacture of the aircraft, appointed an Accredited Representative along with a team of experts from Federal Aviation Administration (FAA), the Boeing Company and Pratt & Whitney USA to help the investigation with valid information and forensic support in accordance with the provisions of the International Civil Aviation Organization (ICAO) Annex 13.

The bureau also said the operator of the airline, Dana Airlines Limited, co-operated with the investigation and provided assistance as required, adding that the Nigerian Civil Aviation Authority (NCAA) was kept informed of developments to a conclusive stage.

On the Accident involving OAS Helicopters’ Ecuruiel A 350 B2 Helicopter with registration number 5NBKA at Oke-Oba Hill, Ikonifin, Osun State, Nigeria on 29th July, 2011, the bureau said:“The chopper departed OAS helipad Maryland, Lagos at 0925hrs for Ilorin and had its initial contact with Ibadan at 0939hrs. The Pilot checked abeam Ibadan (west) at 0950hrs and requested to climb to 1,500ft on QNH 1014hPa, which was granted.

It added, however, that at 1001hrs, Ibadan Control Tower called the pilot to confirm if he had two-way contact with Ilorin Control Tower but there was no reply. It was later confirmed that the chopper had crashed.

“The wreckage was later sighted at about 2250hrs same day at Ikonifin near IfeOdan in a hilly terrain between Iwo and Ogbomoso. The accident occurred at about 1000hrs in daylight with 3 fatalities. The damage on both the main and the tail Rotor blades was consistent with engine on power,” the report said.

The report blamed the crash on non-adherence of the Pilot to Visual Flight Rules of clear-of cloud and obstacles while maintaining ground contact at all times, a situation that led to Controlled Flight into Terrain (CFIT).

Other contributory factors identified showed that the Pilot was not Instrument Rated and lacked good knowledge of the route he wasn’t familiar with.

On Bristol Helicopters, the bureau said it was notified of the Incident at about 0815hrs on 27th of February, 2013 and investigators were dispatched immediately to the incident site. All relevant authorities were also notified.

“At about 0715hrs, 5N-BOA, S-92 Helicopter with eight passengers onboard was about to request for taxi clearance, when the crew perceived a burning smell in the cockpit. A ground personnel on the ramp was also seen waving his hands in an urgent manner, indicative of a problem. The co-pilot saw a bit of smoke from his top left window, even though there was no indication of engine or any other fire in the cockpit, but the crew agreed that there was fire.

“The crew carried out an emergency engine shutdown and waited for the rotor to come to a stop before evacuating the passengers. The standby fire extinguisher was used to put off the fire by ground personnel, the fire only lasted few seconds. Both crew members deplaned without any injuries to them or to the passengers,” the report said.

It identified a fault with the chopper’s 115v cable loom which was chafed and arced with hydraulic pipeline, puncturing it and causing a high pressure leak which ignited on contact with hot surface of the Right Hand heat exchanger, resulting in fire on the Upper Deck.

Other causal factors pointed to the fact that the effectivity of the aircraft was excluded in the Alert Service Bulletin ASB No. 92-20-002A issued by the manufacturer. And, that the Technical Directive TD-S92A-29-99 did not include Check/Inspection of the right hand side of the Upper Deck.

On FG’s Diamond DA-42, which crashed on 5th of July, 2012, the bureau reported that the aircraft departed Benin airport for a low-level range navigation south of the airfield with two crew members on board and was airborne at 1002hrs with endurance of 04hrs.

However, at about 10NM, the crew was asked to confirm whether they wanted to maintain Benin frequency or go to Osubi frequency to which the crew replied that they will remain with Benin and was advised to report ‘ops normal’ at 1020hrs.

“The crew reported ‘ops normal’ and requested rejoining for some touch and go. After the fourth touch and go at 1054hrs, the crew called Benin at 1058hrs for a full stop landing. The crew stated that during the final approach for a full stop landing in a glide approach exercise, they were preoccupied with the procedures and failed to recognize and heed landing gear warning.

“However, as they made last minute attempt to select the gear down it was too late for the gear to lock down before the aircraft touched down. The aircraft touched down with the gears in transit and the gears collapsed under the weight of the aircraft. The aircraft first point of touchdown was at about 3,609ft (1,100m) from the threshold of runway 05. The aircraft belly rolled for another 656ft (200m) before veering-off the runway into the grass area,” the reported stated.

Causal factors reveal that the decision of the crew to continue the glide approach despite repeated landing gear warnings with the power lever below 25% rather than initiating a Go-around was a major cause of the crash.

Contributory factors include: “failure of the crew to recognize the landing gear warnings, no Standard Operating Procedure/Training Policy in place, the crew’s low hours and experience, coupled with the rostering of two pilots with same capability on a training flight and lack of Crew Resource Management (CRM) training.

Commissioner of the Bureau, Akin Olateru, disclosed that the reports reflect every bit of information gathered in the course of investigations, adding that safety recommendations were also made to the authorities concerned and operators of the airlines to avoid future occurrences.

The AIB boss stated further that more reports on other such incidences will be released before the end of 2017.

What is missing, however, is whether victims of the crash were insured or not, and whether families of the deceased were promptly compensated in line with civil aviation laws.


By Oketunbi at 14 Mar 2017, 12:09 PM
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