AIB Reveals How Poor Regulation, Pilot Error Caused Associated Flight Crash

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Chinedu Eze

The Accident Investigation Bureau (AIB) has revealed how poor regulation and lack of crew resource management caused the crash of Flight 561 operated by Associated Aviation on October 3, 2013 at the Murtala Muhammed International Airport (MMIA), Lagos, which led to 16 fatalities.

The crash which involved Embraer EMB 120 aircraft with registration number 5N-BJY occurred on takeoff as the flight destined to Akure Airport with the remains of the former Governor of Ondo State and one time Minister of Aviation, Olusegun Agagu, plunged into Jet A1 tank farm immediately after take-off from the domestic runway of the Lagos airport.

The Associated Aviation Flight 561 was part of the final reports of six accidents and major incidents released by AIB wednesday, which spanned the period between 2009 and 2014.

From the report of the Associated Aviation Flight 561 crash, it was indicative that the pilot-in-command of the flight received all possible signals from the aircraft to abort the flight but he decided to continue with the takeoff until it plunged nose-down and crashed.

Another accident report released was that of Westlink Airlines Limited Piper Aztec 23-250 aircraft with the registration number 5N-BGZ, which occurred at Matseri Village, Bunza Local Government Area of Kebbi State on August 11, 2014.

The serious incidents were Aero Contractor’s DHC-8-400 aircraft incident with registration 5N-BPT, with the Nigerian Aviation Handling Company (NAHCO) baggage loader on April 29, 2014 and another incident involving two Bristow Helicopters aircraft, Bell 412 helicopters with Registration numbers 5N-BGS, and 5N-BDD, at the Addax Base Helipad, Calabar, Cross River State, Nigeria on November 12, 2009.

Also covered in the reports were the serious incidents involving two aircraft belonging to Nigerian College of Aviation Technology (NCAT), including Tampico Club TB9 with the registration number 5N-CBE, which serious incident occurred at Zaria Aerodrome, Kaduna State on October 4, 2012 and another serious incident involving Tampico TB–9 Aircraft with registration number 5N-CBI that occurred at the same Zaria Aerodrome on May 23, 2012.

The Commissioner of AIB, Akin Olateru noted that the accident involving the Associated Aviation Limited aircraft, which led to a post impact fire resulting in 16 fatalities and four serious injuries identified several causal factors, some of which include the decision of the crew to continue the take-off despite danger warnings from the aircraft.

The bureau also identified low altitude stall as a result of low thrust at the start of roll for take-off from engine caused by an undetermined malfunction of the propeller control unit.

The agency’s four safety recommendations on the crash were all directed at the Nigeria Civil Aviation Authority (NCAA).
He called on NCAA to enhance the enforcement of the regulations with regards to the implementation of operators approved personnel training programme and intensification of its safety oversight function on the airline to ensure that flight operations were carried out in accordance with approved operations manuals in line with the provisions of Nigeria Civil Aviation Regulations (NCARs).

Other recommendations include improved safety oversight on the affected airlines to ensure that remunerations were settled promptly, adding that there should be the establishment of Confidential Voluntary Reporting System, which must be implemented in line with the State Safety Programme.

On the two Bristow Helicopters serious incidents at the Addax Base (APDNL) Helipad, Calabar in Cross River State on November 12, 2009, like Associated Aviation, the bureau also made four safety recommendations.

AIB recommended that the regulatory agency should ensure that Calabar Base Helipad Manual of APDNL be reviewed to comply with Nigeria Civil Aviation Regulations (NCARs), APDNL should ensure that helicopters are properly parked in designated locations, APDNL should ensure that Helicopter Landing Officers (HLOs) are always present during aircraft operations and the agency should ensure that helicopter flight operations at the Helipad were done in accordance with Nig. CARs.

AIB in the report, however, stated that NCAA responded to the safety recommendations of the bureau and implemented them.