AIB releases final report of maiden int’l aircraft investigation

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Nigeria’s Accident Investigation Bureau (AIB) has released and submitted the final report of the accident involving Cavok Airlines CVK 7087 AN-74TK-100 aircraft registered Ur-CKC, which occurred at Sao Tome International Airport, Sao Tome on July 29, 2017.

It would be recalled that the Banjul Accord Group Accident Investigation Agency (BAGAIA) had invited the bureau to conduct an investigation into this crash, which by the International Civil Aviation Organization (ICAO) Annexe 13 is the responsibility of the state of occurrence.

Speaking at the Nigerian Embassy in Sao Tome and Principe, the commissioner and chief executive officer of AIB, Mr. Akin Olateru said the assignment was “very significant” because it was it was the first time in the history of AIB that accident investigation was handled by the Bureau on behalf of another state or a regional body.

Olateru said the feat was achieved “as a result of effective collaboration and corporation the Bureau has garnered in the last 24 months with the aviation stakeholders and the endless work by the Bureau’s investigators.”

Responding, the charge de affaire, Mrs. Faith Ekwekwuo appreciated the bureau’s job commended the Bureau for the job and maintaining a good relationship with the Sao Tome authorities.

AIB also signed a four-part memorandum of understanding with the Instituto Nacional De Aviaco Civil, Sao Tome & Principe (INAC) that is, the National Civil Aviation Authority of Sao Tome &Principe.

They are cooperation, capacity building, exchange of information on accident investigation and assistance in cases of any air accident within both countries.

The MoU is aimed at strengthening strengthen a good relationship and effective collaboration towards achieving a common goal in the air accident investigation sector in Africa.

Report of the aircraft accident

The bureau reported that the accident involving Antonov aircraft Model AN-74 TK-100, registered UR-CKC, owned by SWIFT SOLUTION FZC and operated by CAVOK Airlines LLC overran runway 29 during a rejected take off at Sao Tome International Airport in July 2017.

It reported that the captain, the first officer, the flight engineer and two maintenance engineers on board were rescued unhurt except the flight navigator who sustained an injury to his left foot and some minor bruises.

The intended non-scheduled return flight to Accra was initiated in accordance with appropriate regulations.

Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed.

The accident investigator attributed the cause of the accident to the presence of birds on the runway adding that the take-off was rejected at a speed above decision speed V1, which was inconsistent with CAVOK’s Standard Operating Procedures (SOP).

The contributory factors include but are not limited to the failure of the crew to deploy interceptors (speed brakes/spoilers), inadequate flight crew training on details of rejected take-off procedure scenarios, the omission of the take-off briefing in CAVOK’s Normal Operations checklist as well as poor Crew Resource Management (CRM), especially in a multi-crew flight operation.

Nine safety recommendations were made in the report with six addressed to    INAC, one to Ukraine Civil Aviation Authority and two to CAVOK AIR, LLC, Ukraine .

It recommended to INAC to improve the habitat management programme (including reduction or elimination of trees, shrubs and other plants which provide food, shelter or roosting sites for birds); enhance its aerodrome grass management appropriate to the prevalent species and the degree of risk that they pose; liaise with local inhabitants to limit the attraction of birds to fields (in the vicinity of the airport); install specialized ground-based radar equipment used for tactical detection of large flocking birds; adopt and extend Runway End Safety Area to conform to ICAO standards and include the information about the ravine at the end of RWY 29 into the AIP and Send it as Notice To Airmen (NOTAM).

To the Ukraine Civil Aviation Authority, AIB recommended that it should enhance its oversight functions by reviewing all safety related items pertinent to operators’ checklists and manuals.

To Cavok Airlines, AIB recommended the review of its (Cavok Airlines’) rejected take off (RTO) training syllabus to incorporate robust RTO training plan for both initial and recurrent aircraft type simulator training and assessment to include unexpected scenarios and stop-and-go decision making.

Besides, it recommended the review of its normal operations checklist in order to include take-off briefing as an item for each flight.

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