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Reports chide Air Peace over poor safety procedure, CVR recordings overwritten
…AIB to criminalise over-writing of CVR
….Releases three preliminary findings
The Accident Investigation Bureau (AIB) today released three preliminary reports on serious incidents involving three aircraft owned and operated by Air Peace Limited.
More worrisome is report that recordings of the occurrence on the Cockpit Voice Recorder were found overwritten, an offence the AIB said would be put in the law as criminal offence.
Over-writing of CVR amounts to alterations of information in the data storage facility by airlines to conceal information that could be indicting to the airline under investigation.
In its safety recommendations, AIB said Peace Limited should ensure that flight crew adheres to strict compliance with Company Operations Manual (OM Part A) Chapter 11 (11.4.3) on Preservation of Recordings.
The report also advised NCAA to ensure that Air Peace Limited complies with Immediate Safety Recommendations 2019-005 in accordance with Nig.CARs 8.5.1.24 (b)(c); IS: 9.2.2.5.
For immediate safety recommendation 2019-008, AIB charged the airline to ensure that its crew adheres strictly to the Company’s Standard Operating Practices (SOP) in carrying out a missed approach/go-around promptly, below 1000 ft AGL in an unstabilized approach.
The first of the three incidents according to the accident investigative body occurred on May 15, 2019 on the Runway 18R, Murtala Muhammed International Airport, Lagos with B737-300 with registration 5N-BUK causing substantial damage to the airplane.
Findings revealed evidence of significant damage to the aircraft structure and its No. 2 engine as the airplane had been declared unserviceable and grounded by the operator since the date of the incident, for further maintenance evaluation.
Scrapes and dents were visible on the No. 2 engine cowling, scrapes and dents were also seen on the No. 2 thrust reverser cowling, just as some fan blades were bent on No. 2 engine.
The report also noted that both main landing gears Oleo struts collapsed while scuffing of the sidewall of the No. 4 main wheel tyre also occurred.
The Bureau on the basis of these findings disclosed that it commenced investigation into the circumstances of the occurrence under the provisions of Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 2016 and Annex 13 of International Civil Aviation Organization (ICAO).
It stated that the purpose of this preliminary report is to provide details of initial facts, discussions and findings surrounding the occurrence; it includes information gathered from witness statements and a preliminary inspection of the aircraft.
According to AIB, “On May 15th, 2019 at about 17:43 h, a Boeing 737-300 aircraft with nationality and registration marks 5N-BUK, owned and operated by Air Peace Limited departed Port Harcourt International Airport (DNPO) for Murtala Muhammed International Airport, Lagos; as a scheduled flight APK7091, operating on an Instrument Flight Rules (IFR) flight plan”.
The Instrument Landing System (ILS) according to the AIB was available and serviceable at the time of the incident, stressing that the VOR/DME were as well serviceable.
Communications was said to be effective between the crew and air traffic control.
The second serious incident involving the airline’s B737-500 geriatric airplane or what is generally called classics on June 23rd, 2019 at the Port-Harcourt International Airport.
AIB said it was notified of the occurrence by Nigerian Airspace Management Agency (NAMA) on July 22, 2019, stressing that investigators arrived the site the next day and commenced post incident assessments under the provisions of Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 2016 and Annex 13 of International Civil Aviation Organization (ICAO).
The report stated that during the Voice Recorder playback, below 1,000 ft, sound similar to that of wipers movement was heard continuously till the end of the flight. Shortly before 500 ft, PF announced “autopilot disengaged”. At about 300 ft, the crew called, “minimums, checked landing”. At this point, the captain (PM) announced “I have controls”.
The crew stated that, on short finals after obtaining landing clearance, it started drizzling but the runway lights were visible, the runway markings were identifiable and the ILS was functional.
According to the report, after touchdown on runway 21, the intensity of rain increased in strong winds, visibility reduced causing them to experience loss of directional control of the aircraft.
The crew also stated that, due to wet runway, the aircraft skidded to the left of the runway centerline uncontrollably even with the application of brakes, rudder and ailerons. The aircraft subsequently veered to the left of the runway into the grass area.
The third incident which is more serious occurred on runway 18R Murtala Muhammed International Airport on July 23, 2019.
The B737-300 according to report departed Port Harcourt International Airport (DNPO), Port Harcourt as flight APK7191 for Murtala Muhammed International Airport (DNMM) Lagos.
It was a scheduled flight, operating on an Instrument Flight Rules (IFR) flight plan with six crew members and one hundred and thirty-three (133) passengers.
The First Officer was the Pilot Flying (PF) while the Captain was the Pilot Monitoring (PM).
The aircraft landed on the nose gear causing the nose wheel to break off on landing runway 18R, at Murtala Muhammed Airport, Ikeja, Lagos.
According to the Captain, during the callouts: 50, 30, the PM noticed that the aircraft was not aligned with the centre line of the runway, and took control, after announcing “I have controls” and “corrected back on the centreline”.
“The crew stated that, “…the right wheels touched down, simultaneously, we lost visibility and nose wheel touched down… We heard a loud screeching noise and metals grinding, we also saw a lot of debris flying around”.
The aircraft was substantially damaged. The asphalt and concrete runway was damaged due to impact forces, with deep holes made by the nose wheel shock strut. Also, electrical lines and light on runway were damaged.
In its safety recommendations, AIB Air said Peace Limited should ensure that flight crew adheres to strict compliance with Company Operations Manual (OM Part A) Chapter 11 (11.4.3) on Preservation of Recordings.
The report also advised NCAA to ensure that Air Peace Limited complies with Immediate Safety Recommendations 2019-005 in accordance with Nig.CARs 8.5.1.24 (b)(c); IS: 9.2.2.5.
For immediate safety recommendation 2019-008, AIB charged the airline to ensure that its crew adheres strictly to the Company’s SOP in carrying out a missed approach/go-around promptly, below 1000 ft AGL in an unstabilized approach.
According to AIB, the preliminary reports are not the final reports as they contain details of the initial facts, discussions and findings surrounding the occurrences; which include information gathered from witness statements, flight recorders, Health and Usage Monitoring System (HUMS) Data, Flight Data Monitoring (FDM) data, and preliminary inspection of the accident sites and the wreckages.
Air Peace damage 2 Air Peace damage Air Peace damaged plane 3
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