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AIB Makes 187 Safety Recommendations Since Inception

by timenews
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The Accident Investigation Bureau (AIB) Nigeria has issued 187 safety
recommendations to the Aviation Industry since its establishment in
2007.

Commissioner, AIB, Engr. Akin Olateru, who made this disclosure while
releasing four accident reports at the Agency’s Headquarters in Abuja,
recently, detailed that since his assumption of office in 2017 AIB has
issued 106 safety recommendations accounting for 56.7 per cent of the
total 187 issued since inception.
He added that a total of 31 Final Reports have been released since
January 2017, which makes up 62.7 per cent of AIB’s total of 51 Final
Reports released since inception (2007) stating that before the end of
the year, AIB should be able to release an additional six Final
Reports to the public.

Olateru appreciated the relentless efforts of AIB staff in achieving
this milestone by turning out these reports in a timely manner. “In
order to ensure timely release of reports, we have simplified our
investigation process by encouraging team work. Investigations are now
done in groups and they all work together to ensure investigations are
done efficiently and timely.

“Like I always say, a simple, not complex investigation, should not
last more than 18 months.
One of the reports that is being released today is the accident of an
Agusta Westland (AW139) helicopter with nationality and registration
marks 5N-CML owned and operated by Caverton Helicopters Limited which
occurred on the 2nd of February 2019, in Kabba, Kogi State, Nigeria.
The helicopter had 12 persons on-board, including the Vice President
of the Federal Republic of Nigeria, his entourage and three crew
members which included the Captain, Co-Pilot and an Engineer.

“In all, we have established a system in AIB that is working; we are
committed to swift response to accident and serious incident
occurrences through our well-equipped Command and Control Centre.
Accident reporting has also been simplified through our Mobile
Application which was introduced to interface with the public and make
it easy for them to communicate with AIB digitally,” he explained.

He also appreciated the continuous support of the supervisory
Ministry, particularly the Honourable Minister of Aviation, Capt. Hadi
Sirika.

The four reports released:

The first report was on the Serious Incident involving Bombardier
DHC-8-Q400 aircraft owned and operated by Aero Contractors Company of
Nigeria Limited with nationality and registration marks as 5N-BPU,
which occurred at FL240, 80 NM to Lagos on 18th April 2017.

The AIB identified the causal factor as engine oil that leaked onto a
hot surface of the engine causing fumes which mixed with the engine
bleed air supply to the air conditioning system, resulting in smoke in
the aircraft cabin, cockpit and lavatory/ cargo compartments.
It made two Safety Recommendations; 2019-024 issued to Aero
Contractors Company of Nigeria Limited to ensure that Cockpit and
Cabin Crew are alive to their responsibilities during emergencies
vis-à-vis establishing effective two-way communication.
The second Safety Recommendation 2019-025 was issued to the Nigerian
Civil Aviation Authority (NCAA) to ensure that operators utilise the
New Oil Analysis Technology made available by Pratt & Whitney Canada
in order to identify impending failure of the carbon seals on PW150A
engines that are yet to comply with SB 35342R1.

The second report was on the Serious Incident involving a Diamond
DA-42 aircraft with nationality and registration marks as 5N-BNH,
owned and operated by the International Aviation College, which
occurred on Runway 23 Ilorin International Airport on 1st of May,
2019.
AIB identified casual factors as inadequate crew coordination during
the approach to landing phase of flight; lack of situational awareness
on the position of the landing gears by the flight crew during
approach to land and the inappropriate execution of approach and
landing check list.
It made three safety recommendations to the NCAA, the College and to
the Nigeria Airspace Management Agency (NAMA).
“NCAA should intensify its oversight on IAC and ensure that it adheres
strictly to the use of Checklists and appropriate procedures during
sessions and phases of flight.
“IAC should improve on its Crew Resource Management training
viv-a-vis the need for trainees to be assertive when necessary.
“NAMA should devise means to ensure duty air traffic controllers
(DATCOs) maintain continuous watch on all aircraft movements within
the vicinity of the aerodrome,” it recommended.

The third Report was on the Serious Incident involving a Diamond DA-40
aircraft with Nationality and Registration Marks 5N-BRM owned and
operated by International Aviation College, which occurred on Runway
23, Ilorin International Airport On 27th of March, 2014.
The Agency identified the causal factor as loss of directional control
after touchdown and subsequent veer of the aircraft off the runway. It
also identified wrong engine power application during landing roll as
a contributory factor.

It recommended that the International Aviation College (IAC) should
have in place a stringent flight training policy to discourage
disruptions of students’ training during the stipulated period.
It also recommended that the College should develop and incorporate in
their training manual, procedures to ensure that corrective actions
are developed and implemented to prevent observed deficiencies such as
“exceeding required minimum hours for solo flight,” duly signed out by
instructors and records kept in the student’s file prior in the
direction of conducting a solo flight.

The fourth Report was on the Accident involving an Agusta-Westland
AW139 Helicopter operated by Caverton Helicopters Limited with
nationality and registration Marks as 5N-CML, which occurred at Kabba
Stadium, Kogi State on 2nd February, 2019.
The causal factor was identified as a brownout condition encountered
by the flight crew during the hover to land, which led to the loss of
external visual references, spatial disorientation and loss of
situational awareness resulting in a misjudgment of distance and
ground clearance, as the flight crew tried to control the helicopter’s
movements for landing. The helicopter landed hard and rolled over on
its right side.
Also identified as the contributory factor was the inappropriate
landing technique used, non-adherence to company procedures for known
or anticipated brownout condition during landing and lack of risk
assessment, limited landing site preparation and planning prior to
commencement of the flight.
According to the Commissioner, 11days after the accident, the AIB
issued two Interim Safety Recommendations, one to the NCAA and one to
Caverton Helicopters. “The required safety actions were initiated and
implemented promptly,” he said.
The Agency in the Final Report issued two Safety Recommendations were
issued that the NCAA should Ccnduct a Safety Management System (SMS)
audit of Caverton Helicopters. “The SMS audit by the NCAA should
ensure that Caverton Helicopters has implemented the Immediate Safety
Recommendation 2019-003, the NCAA All Operators Letter (FSG 002), and
the recommendations documented in the Caverton Helicopters internal
SMS investigation of this accident,” it said.
It added that the NCAA audit should also ascertain that the Caverton
Helicopters internal SMS processes in the maintenance activities
require the establishment of the reasons/causes of equipment
failure/malfunction (reference is made to the failures of the
Multi-Purpose Flight Recorder (MPFR) and the unavailability of the
reasons of the failures).
The second Safety Recommendation was that the Office of the National
Security Adviser (NSA) should consider whether the Presidential Air
Fleet (PAF) Unit should be involved in the coordination and
preparation of all high profile Executive VIP mission (flights) in
order to ensure that all Executive VIP flights are conducted in
accordance with the PAF Unit’s Standards and in line with its approved
operating procedures

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