Accident report indicts pilots, airline, NCAA in Associated’s 2013 crash
The final probe report into the 2013 crash of a plane belonging to Associated Aviation Limited has indicted its pilots and the airline of poor handling of the ill-fated aircraft, leading to the fatal accident in Lagos.
The report, among five others released by the Accident Investigation Bureau (AIB) on Wednesday, found the flight crew of unprofessional conduct, while the airline, now defunct, was charged of “poor company culture”, amid “inadequate regulatory oversight” on the part of the Nigerian Civil Aviation Authority (NCAA).The Associated airlines’ Embraer 120ER chartered flight, with registration 5N-BJ, on October 3, 2013 crashed very close to the Murtala Muhammed International Airport, Lagos, shortly after take-off. On board were the remains of former Ondo State governor, Olusegun Agagu, and 16 souls, travelling to Akure, Ondo State for burial. No fewer than 12 died, while four survivors were seriously injured.
Last month, a Federal High Court in Lagos ordered the Associated Aviation Nigeria Limited to pay the sum of N246 million as compensation for the death of a former Commissioner for Culture and Tourism in Ondo State, Deji Falae, who was among the 12 that died in the crash. Commissioner of the AIB, Akin Olateru, observed from findings that the aircraft departed with number one engine torque indicator stuck at 76 per cent. A crew-derived non-standard procedure was used to set the number one engine take-off power, as the torque indicator is the primary gauge for setting power.
“After take-off power was set, a take-off flap configuration aural warning came on indicating that the flap position did not agree with the selection. This was followed by auto-feather aural warning.
“The number two Propeller RPM was low. The Pilot Monitoring (First Officer) was concerned that in addition to the warnings the aircraft was slow and advised the Pilot Flying (Captain) to abort the take-off. The aircraft got airborne, climbed to 118ft AGL, stalled and crashed into the Joint Users Hydrant Installation (JUHI), close to the airport, with the landing gears in the down position.”
The investigation identified causal and contributory factors. “Causal factor are the decision of the crew to continue the take-off despite the abnormal number two Propeller rpm indication. Low altitude stall as a result of low thrust at start of roll for take-off from number two Engine caused by an undetermined malfunction of the propeller control unit.
“Contributory factors are the aircraft was rotated before attaining V1 (speed attained before take-off). The decision to continue the take-off with flap configuration warning and auto- feather warning at low speed. Poor professional conduct of the flight crew. Inadequate application of Crew Resource Management (CRM) principles. Poor company culture and inadequate regulatory oversight,” the report read in part.
In line with the tradition of conducting accident investigation to prevent reoccurrence, the AIB has issued four safety recommendations.The first directs the NCAA to enhance the enforcement of the regulations with regards to the implementation of operators approved personnel training programme. NCAA should intensify its safety oversight function on the Airline to ensure that flight operations are carried out in accordance with approved operations manuals in line with the provisions of Nigeria Civil Aviation Regulations (Nig. CARs.)
NCAA should also intensify its safety oversight on Associated Aviation Ltd to ensure staff welfare issues, and remunerations are settled promptly. In addition, NCAA should ensure that State Confidential Voluntary Reporting System is established and implemented in line with the State Safety Program.
Citing that the airline in question is now out of business, Olateru, on behalf of the bureau, apologised to Nigerians for years of delay in releasing the report among other accidents and serious incidences that are already 10 years old without their final reports.He said the bureau, under his watch, recognized the importance of timely release of reports and recommendations for safety and will work harder to prevent delays in accident investigation reports.
Other five reports released yesterday were the Final Report on the Accident involving Westlink Airlines Limited Piper Aztec23-250 Aircraft with Registration Number 5N-BGZ which occurred at Matseri Village, Bunza Local Government Area of Kebbi State, Nigeria on 11th August 2014.
Final Report on the Serious Incident involving two Bristow Helicopters (Nig.) Ltd aircraft, Bell 412 helicopters with Registration numbers 5N-BGS, and 5N-BDD, which occurred at the Addax Base Helipad, Calabar, Cross River State, Nigeria on 12th November, 2009.
Final Report on the Serious Incident involving a NAHCO Aviance Baggage Loader Vehicle Fleet No. L3-23 and a parked Bombardier DHC-8-400 aircraft belonging to Aero Contractors with registration 5N-BPT, which occurred at Aero Ramp, MMA, Lagos State on the 29th of April, 2014.
Final Report on the Serious Incident involving a Nigerian College of Aviation Technology (NCAT) Aircraft Tampico Club TB9 with Registration Number 5N-CBE, which occurred at Zaria Aerodrome, Kaduna State, Nigeria on 4th October 2012.And lastly, the Final Report on the Serious Incident involving Tampico TB–9 Aircraft belonging to the Nigerian College of Aviation Technology (NCAT) with Registration Number 5N-CBI which occurred at the Zaria Aerodrome in Kaduna State on 23rd May, 2012.