Human error, mechanical faults cause Dana Air, Bristow, 2 other aircraft accidents—AIB

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…We’ve implemented safety recommendations–Dana

The Accident Investigation Bureau (AIB), AIB has published the final reports of accidents/incidents involving Dana Air, Bristow Helicopters, OAS Helicopters and the incident involving the Presidential Implementation Committee on Maritime Safety and Security (PICOMSS) Diamond DA-42 aircraft.

Presenting the reports in Lagos, the commissioner of AIB, Mr. Akin Olateru attributed the causal factors for Dana Air accident of June 3, 2012 to the loss of engine power 17 minutes into the flight and on final approach,  inappropriate omission of the use of the Checklist and the crew’s inability to  appreciate  the  severity  of  the  power related  problem, their subsequent failure to land at the nearest suitable airfield as well as lack of situation awareness, inappropriate decision    making, and    poor airmanship.

On OAS Helicopters accident involving Ecuruiel A350B2 Helicopter with Registration 5N-BKA on Oke-Oba Hill, Ikonifin, Osun State July 29, 2011, the AIB commissioner said non-adherence  of  the  pilot  to  visual  flight  rules  of  clear-of  cloud  and  obstacles while  maintaining  ground  contact  at  all  times  led  to  controlled  flight  into  terrain was the major causal factor.

The other factors were that the pilot was not instrument rated besides that he was not familiar with the route

On the serious incident that involved Presidential Implementation Committee on Maritime Safety and Security (PICOMSS) Diamond DA-42 aircraft marked 5N-BKA at Benin Airport on July 5, 2012, Olateru the casual factor had to do with “the decision  of  the  crew  to  continue  the  glide  approach  despite  repeated  landing gear  warnings  with  the  power  lever  below  25 per cent  rather  than  initiating  a  co-around” .

He also said “the failure  of  the  crew  to  recognize  the  landing  gear  warnings; no standard  operating  procedure/training  policy  in  place; the  crew  low  hours  and  experience,  coupled  with  the  rostering  of  two  pilots with  same  capability  on  a  training  flight and lack  of  crew  resource  management  training” contributed to the incident.

On the incident involving Bristow’s Sikorsky S-92 helicopter marked 5N-BKA at the Murtala Muhammed Airport in Lagos on February 27,  2013, the commissioner  attributed it to the fact that “115v  cable  loom  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 factor were that “the  effectivity  of  the  aircraft  was  excluded  in  the  alert  service  bulletin  ASB No.  92-20-002A  issued  by  the  manufacturer” as well as the fact that “the  Technical  Directive  TD-S92A-29-99  did  not  include  check/inspection  of the  right  hand  side  of  the  upper  deck.”

AIB further gave recommendations on each of the accidents and incidents. In the case of Dana Air, eight safety recommendations were made.

Olateru said the  safety  recommendations  previously  made  in  the  preliminary  report published  on  September 5,  2012  were four  in  numbers  wherein  three were targeted  to  Dana  Air  and  all  were  accepted  and  closed while one was to NCAA,  accepted  and  closed.

There were four safety recommendations made in the published reports;   1.1. 1.2. 1.3. 1.4. 2; one  of  which  is  to  Federal Aviation Administration (FAA)  targeting  Pratt  &  Whitney  the  engine manufacturer; one  to  Dana  Air; one  to  the Nigerian Civil Aviation Authority (NCAA)  (with  3  safety  recommendations  in  one);  and   one  to  the Nigerian Airspace Management Agency (NAMA)  on  quality  assurance  management.

In the case of OAS, safety recommendations made in the published reports were 5;   1.1. 1.2. 1.3, three  of  which  were  targeted  at  NCAA; one    to  NAMA;  and   one  to  Nigeria Police Force.

On PICOMSS incident, there were two safety recommendations made in the published report 1.1. 1.2. 4, one to    NCAA; and   One was targeted to the Nigerian Police Force.

There were  two  safety  recommendations  made  in  this  published report  and  both  targeted  to  Bristow  Helicopters.

However, Bristow  Helicopters  issued  a  Technical  Directive,  TD-S92A-29-104 following  the  incident with the subject: “Inspect  LH  and  RH  MGB,  and  Upper  Deck  Heat  Exchanger  Area,  All  1, 2,  and  3  system  Hydraulic  lines,  Clamping  all  Components,  and  wiring Looms  for  any  damage,  chafing,  or  wear”.

Reacting to the report, Dana Air assured its clients of “our total commitment to their safety and comfort onboard our flights.”

The airline said in a statement shortly after AIB had released the final report that it started the implementation of the recommendations since 2013.

“Following the release of the final report of the June 3, 2012 Accident, we wish to state that Dana Air swung into action immediately the interim safety recommendations were released in 2013 and as an airline strictly committed to the safety and comfort of its guests, we  implemented all the recommendations same year, as released by  AIB.

“We did not stop at just implementing the recommendations; we also successfully passed an operational audit conducted by the NCAA’s Flight Safety Group and its foreign partners.

“In 2016, after another rigorous operational audit, Dana Air was admitted into the IOSA register to underscore its strict adherence to global management and safety standards and procedures required of global carriers. Also went further to win two awards from two reputable organizations for the redefining role it played in the aviation industry same year.

“While we acknowledge the full report, and will continue to review it, we are glad that the report confirmed that the aircraft was airworthy at the time of departure, flight crew was certified and that we have cleared all defects during their last check.

“The safety and comfort of our guests remains a top priority to us and may the beautiful souls of the crew and guests we lost at the unfortunate accident continue to rest in peace

“They remain forever in our hearts and our prayers and thoughts will continue to be with their friends and loved ones,” said the airline.

 

 

 

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