Publication and Release of Aircraft Serious Incident and Accident Reports

 

1. Report on the Accident involving Nigeria Police Force (NPF) Bell 427 helicopter with registration 5N-POL at Kabong, Jos South LGA, Plateau State, Nigeria on the 14th of March, 2012;

 

2. Report on the Serious Incident to Nigerian College of Aviation Technology (NCAT) Tampico TB9 aircraft with registration 5N-CBC which occurred at Zaria Aerodrome, Kaduna, Nigeria on the 6th of October, 2008; and

 

3. AIB Bulletin on the Ground Collision incident involving two aircraft belonging to Air Peace Airlines Limited: Boeing 737-500 with registration 5N-BQR and Boeing 737-300 with registration 5N-BQP, which occurred close to Bay 4 of the Domestic Terminal 1 of the Murtala Muhammed Airport, Ikeja, Lagos, Nigeria on the 20th of April, 2017.

 

30 August 2017

 

PREAMBLE

 

I want to thank everyone one for coming.

 

In March this year, after two (2) months in office and upon the release of four accidents/serious incidents, I promised that before the end of the year, we will work hard to release more accident reports. Today, we are releasing three (3) reports. I will like to express my deep appreciation to the management and members of staff in AIB for the continuous effort in ensuring that we fulfill our mandate.

 

 

As a preliminary point and for the first time in history of the Bureau we are releasing what we call AIB Bulletin on the Ground Collision incident involving two aircraft belonging to Air Peace Airlines Limited: Boeing 737-500 with registration 5N-BQR and Boeing 737-300 with registration 5N-BQP, which occurred close to Bay 4 of the Domestic Terminal 1 of the Murtala Muhammed Airport, Ikeja, Lagos, Nigeria on the 20th of April, 2017.

 

This is not an accident or serious incident in accordance with Annex 13 ICAO, but in accordance to the Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 2016 of the Bureau, but being a safety house we are, we decided to investigate this incident because of the safety lessons to be learnt. As a way of moving forward on this initiative, we plan on increasing our safety awareness through stakeholders interactive sessions and the media houses.

 

As at today and after this release, the summary of accident and serious incident reports is as follows;

• Final Report published –22 & 1 AIB Bulletin
• Final Report yet to be published – 22

 

Final Accident Report Published Today

 

1. Report on the Accident involving Nigeria Police Force (NPF) Bell 427 helicopter with registration 5N-POL at Kabong, Jos South LGA, Plateau State, Nigeria on the 14th of March, 2012;

 

Aircraft Accident Report No.:              NPF/2012/03/14/F

Registered Owner and Operator:       Nigeria Police Force (NPF)

Aircraft Type and Model:                   Bell 427 Helicopter

Manufacturer:                                  Bell Helicopter Textron, Canada

Date of Manufacture:                        August 2002

Registration Number:                        5N–POL

Serial No.:                                       56035

Location:                                         Landir Village in Kabong Jos

North L.G.A, Plateau State, at

coordinates N09°55.229,

E008°51.853

Date and Time:                                14th March, 2012 @ 1155hrs

All times in this report are local

times (equivalent to UTC+1)

unless otherwise stated

 

 

 

Synopsis: 

 

Accident Investigation Bureau (AIB) was notified by the Nigerian Civil Aviation Authority (NCAA) at about 1400hrs on 14th March 2012, of an accident involving a Nigeria Police Force (NPF) Bell 427 helicopter with registration number 5N-POL at Landir Village in Kabong, Jos. Investigators were dispatched to the crash site the same day.

The helicopter 5N-POL was operated by the NPF and was registered under the private category with the NCAA. All relevant stakeholders were notified.

 

On Tuesday 13th March, 2012, the flight originated from Abuja airport to Jos Prison Service football field as a ferry flight. The purpose of the flight was to convey the Deputy Inspector General of Police (DIG) Operations from Jos to Abuja. The aircraft had initial contact with Jos Control Tower at 1350hrs en-route and reported ETA to be 1400hrs.

 

The following day, 14th March 2012 at 0930hrs, a police fuel bowser that had arrived Jos from Abuja the previous day, fuelled the aircraft which had been parked overnight at the Jos Prison football field.

At 0958hrs, two-way communication was established between the helicopter and ATC.

 

The pilot reported endurance of two hours, five persons on board, maintaining an altitude of 4000ft, and that it was a patrol flight around Jos city. The pilot also reported that he would be landing at the Police Headquarters, Jos and would call the Control Tower when re-joining for another patrol. The helicopter landed at the Nigeria Prisons Service football field, Jos (customarily used as a landing site for the Police Headquarters, Jos) at 1058hrs.

 

At about 1150hrs, the helicopter lifted up with four persons on board including the DIG. The Control Tower was notified at about 1155hrs of the helicopter’s crash at Landir village, Kabong area near Jos metropolis and that all four persons on board were fatally injured.

The accident occurred in daylight at a coordinate of N09°55.229, E008°51.853.

 

The investigation identified the following probable causal factors:

 

Probable Causal Factors:

The cause of the accident cannot be conclusively decided but the investigation discovered series of discrepancies and non-compliance with Nig.CARs which includes:

 

Pilot:

1. The pilot’s medical had expired as at the time of accident,
2. Simulator recurrency had expired as at the time of accident.

 

Co-pilot:

1. The co-pilot was not type rated on the helicopter (Bell 427).

 

Engineer:

1. The engineer that released the aircraft prior to the flight had no type training and type rating on the aircraft type.

Three Safety Recommendations were made:

4.1 Safety Recommendation 2017-001

NPF Air-Wing should provide the proper funding, conducive working environment, develop and implement a robust training programme for its technical/operational personnel, with adequate supervision and approved equipment to enhance safety.

 

4.2 Safety Recommendation 2017-002

NCAA should ensure that NPF Air-Wing complies with its AMO requirements.

 

4.3 Safety Recommendation 2017-003

NCAA and Department of Petroleum Resources (DPR) should launch an independent inquiry into Aviation fuel quality in Nigeria. The resulting report should focus on the vulnerability and risk of each step in the distribution process.

This should yield firmer regulatory oversight mechanism that ensures international quality of aviation fuels used in Nigeria.

 

RESPONSES TO SAFETY RECOMMENDATIONS

NPF Responses on AIB Safety Recommendations

 

The Police Air-Wing accepts Safety Recommendation 4.1 (2017-001)

 

 

Training:

“The Police pilots and engineers have been type-rated on the police fleet despite the inadequate funding from the government appropriation while many are still on the waiting list to be type-rated.”

 

The Police Air-Wing accepts Safety Recommendation 4.2 (2017-002)

Approved Maintenance Organization (AMO):

“The Police Air-Wing had been able to obtain from the NCAA a valid AMO in compliance with the regulation.”

 

NCAA Response on AIB Safety Recommendations

 

NCAA accepts Safety Recommendation 4.2 (2017-002)

 

“a. The Nigerian Civil Aviation Authority (NCAA) recertified the Nigerian Police Air-Wing in accordance with the Part 6 of the Nigerian Civil Aviation Regulations (Nig. CARs) in 2014 as an Approved Maintenance Organization (AMO), certificate number AMO/5N/NPF. This certificate was subsequently renewed in July, 2016 and is presently valid till the 26th of May, 2018…”

 

“b. The NCAA also accomplishes its surveillance on the certified entity to ensure their continuous compliance with the regulatory requirements.”

 

 

 

 

 

 

 

 

 

2. Report on the Serious Incident to Nigerian College of Aviation Technology (NCAT) Tampico TB9 aircraft with registration 5N-CBC which occurred at Zaria Aerodrome, Kaduna, Nigeria on the 6th of October, 2008

 

Aircraft Accident Report No:                   NCAT/2008/10/06/F

Registered Owner Operator:           Nigerian College of Aviation Technology (NCAT)

Aircraft Type and Model:                  Tampico TB 9

Nationality:                                      Nigerian

Registration:                                    5N-CBC

Location:                                          Zaria Aerodrome

Date and Time:                                6th October, 2008 at 1342hrs

All times in this report are local time (equivalent to UTC+1) unless otherwise stated.

 

SYNOPSIS

The Accident Investigation Bureau (AIB) received notification of the serious incident on the same day from the Nigerian Civil Aviation Authority (NCAA). Investigation into the circumstances surrounding this occurrence commenced the following day. All relevant stakeholders were notified. At 1335hrs, the student pilot was cleared for departure for a second solo flight by the Control Tower. The take-off was normal and he continued with the upwind, crosswind, downwind and the final legs. On final approach, he had good attitude and airspeed control. The aircraft touched down around the first intersection about 600m from the runway 24 threshold, skidded, and veered off the centre line of the runway to the right.

 

Aircraft Accident Report

The aircraft travelled a further 200m from touchdown point before coming to a final stop by a ditch at approximately 31.6m from the edge of the runway. The student pilot disembarked without any injury but the aircraft was substantially damaged. The investigation identified the following causal and contributory factors:

Causal Factor:

The inability of the student pilot to maintain directional control of the aircraft after touchdown.

Contributory Factors:

1. The student pilot lost concentration while retracting the flap and trimming the aircraft during the landing roll preparatory to the next take-off.
2. The student was fatigued as he had done six landings with the instructor and four solo landings.

iii. The increased workload due to the “un-gated” flap control knob assembly.

Three Safety Recommendations were made

4.1 Safety Recommendation 2014-011

BEA (Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile) should propose to the Aircraft Manufacturer – SOCATA of France to incorporate a “gate detent” position in the flap control knob assembly. This will make proper flap selections easier during aircraft operations.

4.2 Safety Recommendation 2014-012

NCAT should ensure that Flying Instructors checking out students on solo flight must at all times be at the Control Tower to monitor the progress of the flight.

4.3 Safety Recommendation 2014-013

NCAT should procure equipment and train relevant personnel to conduct toxicological examination in its Aero Medical facility.

RESPONSES TO SAFETY RECOMMENDATIONS

NCAA Responses to AIB Safety Recommendations

NCAA accepts Safety Recommendation 4.1 (2014-011)

“The NCAA agrees with this recommendation and would ensure compliance of the aircraft type in the Nigerian Registry to incorporate a ‘gate and detent’ position in the flap control knob assembly, when the Type Certificate Holder/Manufacturer (SOCATA) issues a Service Bulletin or the State of Design issues an Airworthiness Directive with respect to this subject matter.”

NCAA partially accepts Safety Recommendation 4.2 (2014-012)

“a. The NCAA is currently reviewing the amendments to NCAT’s Flying School Procedures Manual (NCAT/FSPM/001), Issue 001, June 2012 and has required that the College develops and incorporates into sections 1.5.3 and 1.5.4….”

“b. The 180o Glide approaches and landing is an advanced maneuver and does not require the flying instructor’s presence at the Control Tower;”

NCAA accepts Safety Recommendation 4.3 (2014-013)

“Within the scope of the accomplishment of its safety oversight obligations, the Authority has established that NCAT has procured Breathalyzer, Cup and Strip Equipment and has trained its personnel on the utilization of these equipment for Toxicological screening test…”

 

 

 

 

3. AIB Bulletin on the Ground Collision incident involving two aircraft belonging to Air Peace Airlines Limited: Boeing 737-500 with registration 5N-BQR and Boeing 737-300 with registration 5N-BQP, which occurred close to Bay 4 of the Domestic Terminal 1 of the Murtala Muhammed Airport, Ikeja, Lagos, Nigeria on the 20th of April, 2017.

 

 

AIB BULLETIN                         AIRPEACE/2017/04/20-001  

 

Aircraft Type and Registration:     i) Boeing 737-500, 5N-BQR

1. ii) Boeing 737-300, 5N-BQP

No & Type of Engines:                i) 2 CFM 56-3C-1 Turbofan engines

1. ii) 2 CFM 56-3C-1 Turbofan engines

 

Year of Manufacture:                  i) 1993

1. ii) 1997

 

Registered Owners and Operators: Air Peace Airlines Nigeria Limited

 

Place of Incident:                       Close to Bay 4 of the Apron

 

Date and Time:                          20th of April, 2017 at 0633hrs

 

Location:                                   General Aviation Terminal,

Murtala Muhammed Airport, Ikeja,

Lagos.

 

 

 

Synopsis

The ground collision incident occurred between two aircraft belonging to Air Peace Airlines: a Boeing 737-500 with registration 5N-BQR and a stationary Boeing 737-300 with registration 5N-BQP. 5N-BQR was attempting to taxi between 5N-BQPand a Boeing 737-700 aircraft with registration 5N-MJJ belonging to Arik Airlines Nigeria Limited, which was boarding passengers at Bay 5 of the “Domestic Terminal 1 (DT1)” apron at the time of the incident.

Various factors contributed to the incident: the decision of the Captain to reposition the aircraft without requesting for a push-back, maneuvering the aircraft without the aid of Marshallers and instead relying on the company’s engineers who are inexperienced wing walkers; the decision of the crew to taxi the aircraft without properly assessing the maneuverability of the aircraft at the parking bay; the non-availability of proper apron markings and Marshallers; the presence of cautionary cones at strategic areas where repair work on the apron was awaiting cure. The limited maneuvering space between 5N-BQP and 5N-MJJalso contributed to the incident.

Four Safety Recommendations were made.

Safety Recommendation 2017-011

FAAN should engage more Marshallers, and ensure adequate training and retraining.

Safety Recommendation 2017-012

FAAN should establish a quasi Apron Control Room at the Domestic Terminal.

Safety Recommendation 2017-013

FAAN should provide all necessary Personal Protective Equipment and spares for Marshallers and other relevant personnel.

Safety Recommendation 2017-014

NCAA should ensure that proper regulatory oversight is carried out on operators using the GAT.

 

OUR PLAN

 

As I have promised in the past, we look to publish more reports before the end of the year. I can confirm to you today that two (2) of our reports have gone for sixty (60) days stakeholders comments.

 

Our statutory obligation is to investigate air accidents and serious incidents: and by our safety recommendations, mitigate them in order to forestall reoccurrence.

 

Before I close, I would like to thank the Honourable Minister for Transportation and the Honourable Minister for State (Aviation) for the continual support by ensuring that we stay focus.

 

To everyone, I thank you for your time and kind attention.

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