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The Accident Investigation Bureau, Nigeria (AIB-N), on Wednesday, released three serious incident final reports, including 20 Safety Recommendations which were addressed to the regulatory body, the Nigerian Civil Aviation Authority (NCAA), the affected airlines, the Nigerian Airspace Management Agency (NAMA), an aircraft manufacturer, the Federal Airport Authority of Nigeria (FAAN), among others.
The reports released are: the Final Report on the serious incident involving a Boeing 747-400 aircraft with nationality and registration marks 5N-DBK operated by Max Air Limited, which occurred at the Minna Airport, Nigeria on 7th September, 2019; the Final Report on the serious incident involving Cessna Citation 560 XLS aircraft with nationality and registration marks 5N-HAR operated by the Nigerian Police Airwing which occurred at Sir Abubakar Tafawa Balewa Airport, Bauchi, Nigeria on 3rd October, 2018, and the Final Report on the serious incident involving a Boeing 737-500 aircraft with nationality and registration marks 5N-AIS operated by Azman Air service Limited, which occurred at Port Harcourt, Nigeria on 3rd January, 2019
Chief Executive Officer, AIB-N, Engr. Akin Olateru while speaking on the report said the newly released reports make a total of 75 aircraft accident reports released by the Bureau since its establishment in 2007 and a total of 56 reports released by the current administration from 2017 till date.
“This year alone, seven reports have been released. The Bureau has also released a total of 252 Safety Recommendations since inception with 171 of the recommendations released by this administration.”, he said.
Having identified failure of number 4 and 5 bearings of engine number 2 leading to loss of power during approach as the first cause of Azman Air incident, said some contributory gactors include the failure to recognise the abnormal engine conditions (surge) during cruise phase and hence, not making appropriate decision.
“This might have been connected to the insufficient technical knowledge and loss of situational awareness.”.
It also identified non implementation of the Flight Data Monitoring programme in accordance with 2.2.5.1 of Azman Air Safety Management System Manual and non rectification of the number two engine vibration anomalies recorded over a period of 8 months.
The AIB said it issued one immediate safety recommendation to the Nigerian Civil Aviation Authority (NCAA) in the preliminary report.
“NCAA should ensure Azman Air Services Limited immediately takes further necessary step to ensure that it reviews the training of the incident flight crew in order to be able to understand and recognise engine failure/malfunctions and its effect (s) at every phase of flight before they are allowed to resume flight duties.No Action taken by the NCAA.”, Olateru said.
Seven further Safety Recommendations were issued in this Final Report.
That Azman Air Services Limited should implement fully, the Flight Data Monitoring programme as stipulated in 2.2.5 of the Azman Air Safety Management System Manual, including holding regular FDM meetings, timely corrective actions on the anomalies identified in FDM reports, distribution to all concerned personnel for timely corrective actions, entering the anomalies into the safety risk management processand presentation during the senior management review, if relevant.
That Azman Air Services Limited should review relevant portions of its Operations Manual, including 5.1.3 of Azman Air Ltd Operations Manual Part A to specify the criteria for determining the experience level required for crew composition.
That Azman Air Services Limited should ensure that all its flight crew possess the requisite qualification as contained in Azman Air Services Operations Manual Part A chapter 6 before they are assigned flight duties/responsibilities.
Azman Air Services Limited should develop strategies to implement its safety policy, including the propagation of safety culture in the organisation.
Azman Air should include the one/single engine out manoeuvre during approach in its simulator curriculum.
That the Nigerian Civil Aviation Authority should carry out safety audit of Azman Air Ltd to ensure all the elements of safety management system are implemented accordingly.
The NCAA should review the Nigeria Civil Aviation Regulation (Nig. CARs) 2015 to meet the International Standards and Recommended Practices as contained in the Annexes to the Chicago Conventions, including 9.2.2.10 to incorporate the provisions that mandated an AOC holder that operates aircraft with a maximum certificated take-off mass of more than 27,000 kg to include a flight datamonitoring programme as part of its safety management system.
Details of the reports, which include the factual information, findings, analysis, conclusions and safety recommendations on the investigations are available for download on the AIB-N website.