Zone

Crash of a Gulfstream G200 in Abuja

Date & Time: Jan 29, 2018 at 1520 LT
Type of aircraft:
Operator:
Registration:
5N-BTF
Survivors:
Yes
Schedule:
Lagos - Abuja
MSN:
180
YOM:
2007
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5300
Captain / Total hours on type:
280.00
Copilot / Total flying hours:
5700
Copilot / Total hours on type:
93
Aircraft flight hours:
1421
Aircraft flight cycles:
921
Circumstances:
On 25th January 2018 at 14:28 h, a Gulfstream 200 (G200) aircraft with nationality and registration marks 5N-BTF operated by Nestoil Plc, departed Murtala Mohammed International Airport, Lagos (DNMM) as a charter flight to Nnamdi Azikiwe International Airport, Abuja (DNAA) on an Instrument Flight Rules (IFR) flight plan. Onboard were four passengers and three flight crew members. The Pilot in command (PIC) was the Pilot Monitoring (PM) and the Co-pilot was the Pilot Flying (PF). The departure, cruise and approach to Nnamdi Azikiwe International Airport were normal. At 14:45 h, 5N-BTF contacted Abuja radar and was subsequently cleared for Radar vectors ILS approach Runway 22. Abuja Airport Automatic Terminal Information Service (ATIS) Papa for time 14:20 h was monitored as follows; “Main landing runway 22, wind 110/07 kt, Visibility 3,500 m in Haze, No Significant Clouds, Temperature/Dew point 33/- 01°C, QNH 1010 hPa, Trend No Significant Change, End of Information Papa”. At 15:17 h, 5N-BTF reported 4 NM on Instrument approach (ILS) and was requested to report 2 NM because there was a preceding aircraft (Gulfstream 5) on landing roll. Thereafter, 5N-BTF was cleared to land runway 22 with reported wind of 070°/07 kt. At 15:18 h, the aircraft touched down slightly left of the runway centre line. According to the PF, in the process of controlling the aircraft to the centre line, the aircraft skidded left and right and eventually went partly off the runway to the right where it came to a stop. In his report, the PM stated that on touchdown, he noticed the aircraft oscillating left and right as brakes were applied. The oscillation continued to increase and [the aircraft] eventually went off the runway to the right where the aircraft came to a stop, partially on the runway. During the post-crash inspection, the investigation determined that the skid marks on the runway indicated that the aircraft steered in an S-pattern continuously with increasing amplitude, down the runway. On the last right turn, the aircraft exited the right shoulderof the runway, the right main wheel went into the grass and on the final left turn, the right main landing gear strut detached from its main attachment point after which the aircraft finally came to a complete stop on a magnetic heading of 160°. The ATC immediately notified the Aircraft Rescue and Fire Fighting Services (ARFFS), Approach Radar Control, and other relevant agencies about the occurrence. All persons on board disembarked with no injuries. Instrument Meteorological Conditions (IMC) prevailed at the time of the occurrence. The serious incident occcurred in daylight.
Probable cause:
Causal Factor:
The use of improper directional control techniques to maintain the aircraft on the runway.
Contributory Factor:
Improper coordination in taking over control of the aircraft by the PM which was inconsistent with Nestoil SOP.
Final Report:

Crash of an Embraer EMB-120ER Brasília in Lagos: 16 killed

Date & Time: Oct 3, 2013 at 0932 LT
Type of aircraft:
Operator:
Registration:
5N-BJY
Flight Phase:
Survivors:
Yes
Schedule:
Lagos - Akure
MSN:
120-174
YOM:
1990
Flight number:
SCD361
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
16
Aircraft flight hours:
27362
Aircraft flight cycles:
34609
Circumstances:
The crew discussed some concerns about the aircraft prior to departure but at this time we are not prepared to elaborate on those concerns as there remains a lot of work to complete on the CVR analysis in order to determine the specific nature of the crew’s concerns. Associated 361 was cleared for take-off on runway one eight left at Lagos international airport. The wind was calm and weather is not considered a factor in this accident. Approximately 4 seconds after engine power was advanced to commence the take-off roll, the crew received an automated warning from the onboard computer voice which consisted of three chimes followed by “Take-off Flaps…Take-off Flaps”. This is a configuration warning that suggests that the flaps were not in the correct position for take-off and there is some evidence that the crew may have chosen not to use flaps for the take-off. The warning did not appear to come as any surprise to the crew and they continued normally with the take-off. This warning continues throughout the take-off roll. As we are in the process of verifying the accuracy of the flight data, we have not yet been able to confirm the actual flap setting however we expect to determine this in the fullness of time. It was determined from the CVR that the pilot flying was the Captain and the pilot monitoring and assisting was the First Officer. The ‘set power‘ call was made by the Captain and the ‘power is set’ call was confirmed by the First Officer as expected in normal operations. Approximately 3 seconds after the ‘power is set’ call, the First Officer noted that the aircraft was moving slowly. Approximately 7 seconds after the ‘power is set’ call, the internal Aircraft Voice warning system could be heard stating ‘Take off Flaps, Auto Feather’. Auto feather refers to the pitch of the propeller blades. In the feather position, the propeller does not produce any thrust. The FDR contains several engine related parameters which the AIB is studying. At this time, we can state that the Right engine appears to be producing considerably less thrust than the Left engine. The left engine appeared to be working normally. The aircraft automated voice continued to repeat ‘Take-off Flaps, Auto Feather’. The physical examination of the wreckage revealed that the right engine propeller was in the feather position and the engine fire handle was pulled/activated. The standard ‘eighty knots’ call was made by the First Officer. The first evidence that the crew indicated that there was a problem with the take-off roll was immediately following the ‘eighty knots’ call. The First Officer asked if the take- off should be aborted approximately 12 seconds after the ‘eighty knots’ callout. Our investigation team estimates the airspeed to be approximately 95 knots. Airspeed was one of the parameters that, while working in the cockpit, appeared not to be working on the Flight Data Recorder. We were able to estimate the speed based on the radar data that we synchronized to the FDR and CVR but it is very approximate because of this. In response to the First Officer’s question to abort, the Captain indicated that they should continue and they continued the take-off roll. The crew did not make a ‘V1’ call or a Vr’ call. V1 is the speed at which a decision to abort or continue a take-off is made. Vr is the speed at which it is planned to rotate the aircraft. Normally the non-flying pilot calls both the V1 and the Vr speeds. When Vr is called the flying pilot pulls back on the control column and the aircraft is rotated (pitched up) to climb away from the runway. During the rotation, the First Officer stated ‘gently’, which we believe reflects concern that the aircraft is not performing normally and therefore needs to be rotated very gently so as not to aerodynamically stall the aircraft. The First Officer indicated that the aircraft was not climbing and advised the Captain who was flying not to stall the aircraft. Higher climb angles can cause an aerodynamic stall. If the aircraft is not producing enough overall thrust, it is difficult or impossible to climb without the risk of an aerodynamic stall. Immediately after lift-off, the aircraft slowly veered off the runway heading to the right and was not climbing properly. This aircraft behavior appears to have resulted in the Air Traffic Controller asking Flight 361 if operation was normal. Flight 361 never responded. Less than 10 seconds after rotation of the aircraft to climb away from the runway, the stall warning sounded in the cockpit and continued to the end of the recording. The flight data shows characteristics consistent with an aerodynamic stall. 31 seconds after the stall warning was heard, the aircraft impacted the ground in a nose down near 90° right bank.
Probable cause:
The accident was the consequence of the decision of the crew to continue the take-off despite the abnormal No. 2 Propeller rpm indication and a low altitude stall as a result of low thrust at start of roll for take-off from No. 2 Engine caused by an undetermined malfunction of the propeller control unit.
The following contributing factors were identified:
- The aircraft was rotated before attaining V1.
- 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.
- Inadequate regulatory oversight.

Crash of a McDonnell Douglas MD-83 in Lagos: 159 killed

Date & Time: Jun 3, 2012 at 1545 LT
Type of aircraft:
Operator:
Registration:
5N-RAM
Survivors:
No
Site:
Schedule:
Abuja - Lagos
MSN:
53019/1783
YOM:
1990
Flight number:
DAV992
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
147
Pax fatalities:
Other fatalities:
Total fatalities:
159
Captain / Total flying hours:
18116
Captain / Total hours on type:
7466.00
Copilot / Total flying hours:
1143
Copilot / Total hours on type:
808
Aircraft flight hours:
60850
Aircraft flight cycles:
35220
Circumstances:
On 3rd June, 2012 at about 1545:00hrs, 5N-RAM, a Boeing MD-83, a domestic scheduled commercial flight, operated by Dana Airlines (Nig.) Limited as flight 0992 (DANACO 0992), crashed into a densely populated area of Iju-Ishaga, a suburb of Lagos, following engine number 1 loss of power seventeen minutes into the flight and engine number 2 loss of power while on final approach to Murtala Muhammed Airport Lagos, Nigeria. Visual Meteorological Conditions prevailed at the time and the airplane was on an instrument flight plan. All 153 persons onboard the airplane, including the six crew were fatally injured. There were also six confirmed ground fatalities. The airplane was destroyed. There was post impact fire. The flight originated at Abuja (ABV) and the destination was Lagos (LOS). The airplane was on the fourth flight segment of the day, consisting of two round-trips between Lagos and Abuja. The accident occurred during the return leg of the second trip. DANACO 0992 was on final approach to runway 18R at LOS when the crew declared a Mayday call “Dual Engine Failure – negative response from the throttles.” According to records, the flight arrived ABV as Dana Air flight 0993 at about 1350:00hrs and routine turn-around activities were carried out. DANACO 0992 initiated engine start up at 1436:00hrs. Abuja Control Tower cleared the aircraft to taxi to the holding point of runway 04. En-route ATC clearance was passed on to DANACO 0992 on approaching holding point of runway 04. According to the ATC ground recorder transcript, the aircraft was cleared to line-up on runway 04 and wait, but the crew requested for some time before lining-up. DANACO 0992 was airborne at 1458:00hrs after reporting a fuel endurance of 3 hours 30 minutes. The aircraft made contact with Lagos Area Control Centre at 1518:00hrs and reported 1545:00hrs as the estimated time of arrival at LOS at cruising altitude of 26,000 ft. The Cockpit Voice Recorder (CVR) retained about 30 minutes 53 seconds of the flight and started recording at 1513:44hrs by which time the Captain and First Officer (F/O) were in a discussion of a non-normal condition regarding the correlation between the engine throttle setting and an engine power indication. However, they did not voice concerns then that the condition would affect the continuation of the flight. The flight crew continued to monitor the condition and became increasingly concerned as the flight transitioned through the initial descent from cruise altitude at 1522:00hrs and the subsequent approach phase. DANACO 0992 reported passing 18,100ft and 7,700ft, at 1530:00hrs and 1540:00hrs respectively. After receiving radar vectors in heading and altitude from the Controller, the aircraft was issued the final heading to intercept the final approach course for runway 18R. According to CVR transcript, at 1527:30hrs the F/O advised the Captain to use runway 18R for landing and the request was made at 1531:49hrs and subsequently approved by the Radar Controller. The crew accordingly changed the decision height to correspond with runway 18R. At 1531:12hrs, the crew confirmed that there was no throttle response on the left engine and subsequently the Captain took over control as Pilot Flying (PF) at 1531:27hrs. The flight was however continued towards Lagos with no declaration of any distress message. With the confirmation of throttle response on the right engine, the engine anti-ice, ignition and bleed-air were all switched off. At 1532:05hrs, the crew observed the loss of thrust in No.1 Engine of the aircraft. During the period between 1537:00hrs and 1541:00hrs, the flight crew engaged in prelanding tasks including deployment of the slats, and extension of the flaps and landing gears. At 1541:46hrs the First Officer inquired, "both engines coming up?" and the Captain replied “negative” at 1541:48hrs. The flight crew subsequently discussed and agreed to declare an emergency. At 1542:10hrs, DANACO 0992 radioed an emergency distress call indicating "dual engine failure . . . negative response from throttle." At 1542:35hrs, the flight crew lowered the flaps further and continued with the approach and discussed landing alternatively on runway 18L. At 1542:45hrs, the Captain reported the runway in sight and instructed the F/O to retract the flaps and four seconds later to retract the landing gears. At 1543:27hrs, the Captain informed the F/O, "we just lost everything, we lost an engine. I lost both engines". During the next 25 seconds until the end of the CVR recording, the flight crew attempted to recover engine power without reference to any Checklist. The airplane crashed into a densely populated residential area about 5.8 miles north of LOS. The airplane wreckage was approximately on the extended centreline of runway 18R, with the main wreckage concentrated at N 06o 40.310’ E 003o 18.837' coordinates, with elevation of 177ft. During the impact sequence, the airplane struck an uncompleted building, two trees and three other buildings. The wreckage was confined in a small area, with the separated tail section and engines located at the beginning of the debris trail. The airplane was mostly consumed by post crash fire. The tail section, both engines and portions of both wings representing only about 15% of the airplane, were recovered from the accident site for further examination.
Probable cause:
Probable Causal Factors:
1. Engine number 1 lost power seventeen minutes into the flight, and thereafter on final approach, Engine number 2 lost power and failed to respond to throttle movement on demand for increased power to sustain the aircraft in its flight configuration.
2. The inappropriate omission of the use of the Checklist, and the crew’s inability to appreciate the severity of the power-related problem, and their subsequent failure to land at the nearest suitable airfield.
3. Lack of situation awareness, inappropriate decision making, and poor airmanship.

Tear down of the engines showed that the no.1 engine was overhauled in the U.S in August 2011 and was not in compliance with Service Bulletin SB 6452. Both engines had primary and secondary fuel manifold assemblies fractured, cracked, bent, twisted or pinched which led to fuel leaks, fuel discharge to bypass duct, loss of engine thrust and obvious failure of engine responding to
throttle movement. This condition was similar to the no.1 engine of a different Dana Air MD-80, 5N-SAI, that was involved in an incident in October 2013 when the aircraft returned to the departure airport with the engine not responding th throttle movements. This engine also was not in compliance with Service Bulletin SB 6452. This bulletin was issued in 2003 and called for the installation of new secondary fuel manifold assemblies, incorporating tubes fabricated from new material which has a fatigue life that was approximately 2 times greater than the previous tube material.
Final Report:

Crash of a Boeing 727-221F in Accra: 10 killed

Date & Time: Jun 2, 2012 at 1910 LT
Type of aircraft:
Operator:
Registration:
5N-BJN
Flight Type:
Survivors:
Yes
Schedule:
Lagos - Accra
MSN:
22540/1796
YOM:
1982
Flight number:
DHC111
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
14000
Captain / Total hours on type:
1464.00
Copilot / Total flying hours:
22463
Copilot / Total hours on type:
4180
Aircraft flight hours:
40251
Aircraft flight cycles:
25380
Circumstances:
On 2nd June, 2012 at 1828hrs Allied Air Ltd Flight DHV 111, a Boeing 727-221 Cargo aircraft, Registration: 5N-BJN, departed Murtala Muhammed International Airport, Ikeja, Lagos-Nigeria to Kotoka International Airport, estimating Accra, Ghana at 1904hrs, en-route to Abidjan. While taxiing for take-off, the Flight Engineer observed that the CSD amber light (caution) had illuminated on the panel. With the Captain’s permission, it was disconnected. The flight was cleared Flight Level 240 and to maintain by Accra Area Control on 130.9MHz. The Flight was operating under Instrument Flight Rules (IFR) conditions and the flight was turbulent, the aircraft was cruising at a speed of 280kts which is the recommended turbulence speed. On the descent into Accra, the aircraft was cleared by Accra Approach on 119.5MHz initially to Flight Level 50 and later cleared to 2000ft. It was again instructed to climb to 3000ft due to high ground. On arrival at Accra, the Captain flew an Instrument Landing System (ILS) coupled approach, until he saw the runway. He then disconnected the autopilot at 500ft and manually flew the aircraft. After disconnecting the auto-pilot, he came into heavy IMC conditions in rain. The aircraft experienced an unstable approach at a high speed of 167kts and landed with a wind of 050/15kts at 154 kts and about 5807 ft from Runway 21 in nil visibility. The crew deployed thrust reversers and applied the normal brakes as well as the emergency pneumatic brakes but these actions were ineffective to stop the aircraft. Normally deploying the thrust reversers or applying the brakes would bring the nose wheel down. However, the nose gear was kept up. The speed brakes were not deployed. The crew reported seeing red lights rushing towards them soon after the main wheels touched the ground for the landing run. The aircraft nose gear never touched the ground until the aircraft went over the fence wall. A Lufthansa Flight DLH 566 operated on behalf of Lufthansa (LH) by Private Air which had landed earlier at 1902hrs reported a wind of 050/15kts and visibility of 3800m in rain. From the 2nd intersection where DLH 566 had stopped, ready to backtrack Runway 21, the crew observed Allied Air appeared to have landed at very high speed when the aircraft went past and could not determine whether the aircraft was taking off. A Lufthansa ground engineer who was waiting at the intersection to receive DLH 566 indicated the approximate touchdown point of DHV 111. Both the controller at the Tower and the Marshaller in the “follow me” vehicle waiting at the 1st Intersection saw Allied Air land between the 1st and 2nd intersections. The FDR indicated that the aircraft landed 4000 ft to the end of Runway 21. The full length of Runway 21 is 3403 m (11,162ft for take-off) but available for landing is 2990 m (9,807 ft). The FDR readout showed that the aircraft landed at 150 kts, and at 1.6 G, 5807 ft from the beginning of Runway 21 and 4000ft from the threshold of the Runway 03. The runway surface condition for braking as described by DLH crew was good. Shortly after Turkish Airline (THY 629) had landed, DLH 566 also landed followed by DHV 111. The aircraft over-run the runway and destroyed the Threshold Lights and the Approach lights on Runway 03. It knocked out the ILS Localizer transmitter structure and mounts, broke through the airport perimeter wall. The aircraft crossed Giffard Road, collided with a passenger mini bus killing all ten (10) persons on board. It uprooted a tree by the road side before finally coming to a stop at an open space near El-Wak Sport Stadium. The Emergency Locator Transmitter (ELT) was triggered by the impact. The right side of a taxi cab on the road was grazed by flying debris from the localizer transmitter structures carried along by the right wing of the aircraft. The leading edge of the wing was extensively damaged. The aircraft came to a rest outside the airport perimeter wall 1171 ft (350m) from the Threshold of Runway 03, heading 215° southwest, coordinates 05 35 13.67N 000o 10 29.20W. The four (4) crew members sustained minor injuries. The aircraft and the mini bus were all destroyed. At 1910hrs, RFFS was alerted by the Tower Controller through the crash alarm bell. It took 9 minutes for the firemen to get to the crash site. The Airport was closed for 45minutes during which runway inspection was carried out. No pool of water was found anywhere on the runway. Approximately one hour after the aircraft had over-run the runway, the Airport was re-opened to traffic. Other airlines including KLM and British Airways, landed. Even though the Technical Log Book had no records of deferred defect, the Captain in an interview said the windshield wipers where switched on during the landing phase but were unable to clear the rain. It was observed during the investigation that the windshield wipers were rather ¾ switched on.
Probable cause:
The probable causes of the accident were:
The decision of the Captain to continue with the landing instead of aborting at the missed approach point especially when he could hardly see through the windshield and when he did not know how far he had gone down the runway because of the rain and the tail wind components.
Contributory factors:
a. The Captain disconnected the auto-pilot and flew the aircraft manually in an unstable approach.
b. The Captain landed the aircraft at 4000ft to the threshold of Runway 03, 6060ft from Runway 21. He could not stop within the available distance.
c. The Captain chose to land with a tailwind of 050/15Kts in excess of maximum allowable tailwind of 10Kts.
d. The crew concentrated on tracking the Localizer rather than watching for threshold and runway edge lights. They suffered from fixation.
e. The Captain did not deploy speed brakes on landing.
Final Report:

Crash of a Cessna 560XL Citation XLS in Port Harcourt

Date & Time: Jul 14, 2011 at 1953 LT
Operator:
Registration:
5N-BMM
Survivors:
Yes
Schedule:
Lagos – Port Harcourt
MSN:
560-5830
YOM:
2008
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11751
Captain / Total hours on type:
684.00
Copilot / Total flying hours:
13302
Copilot / Total hours on type:
612
Aircraft flight hours:
982
Circumstances:
5N-BMM departed Lagos at 1856 hrs for Port Harcourt on an Instrument Flight Rules (IFR) and estimated Port Harcourt at 1940 hrs. The aircraft was cleared to maintain FL330. The aircraft’s first contact with Port Harcourt was at 1914 hrs. The pilot reported maintaining FL330 with six souls onboard, four hours fuel endurance and estimating POT VOR at 1940hrs. The aircraft was cleared to POT, to maintain FL330 with no delay expected for ILS Approach Runway 21, QNH 1011 and to report when released by Lagos. At 1921 hrs the pilot reported 100 NM to POT and requested for descent. The aircraft was cleared to descend to FL150. At 1927 hrs the pilot requested for further descent and was cleared to 3,300 feet on QNH 1011 but the pilot acknowledged 3500 feet. At 1931 hrs the aircraft was re-cleared to FL090 initially due to departing traffic on Runway 03. At 1934 hrs 5N-BMM reported maintaining FL090 and was re-cleared to FL050. The aircraft was re-cleared to 2,000 feet on QNH 1011 at 1936 hrs and cleared for the straight-in ILS Approach Runway 21 and to report on the localizer. At 1947 hrs the pilot reported final for Runway 21 and was asked to contact Tower on 119.2 and the Tower asked 5N-BMM to report on glide slope Runway 21. At 1950 hrs the Tower asked 5N-BMM to confirm on the glide slope and the crew confirmed “Charlie, we have three miles to run”. The Tower cleared 5N-BMM to land with surface wind calm but to exercise caution since the Runway surface was wet and 5N-BMM responded “wind calm”. At 1952:26 hrs the auto voice callout "minimums minimums” alerted the crew. At 1952:40 hrs the pilot flying (PF) said "I am not on the centerline". At 1952:48 hrs he said "I can't see down". At 1952:55 hrs the pilot monitoring (PM) said to the pilot flying; " I am telling you to go down" and the pilot flying said " I will go down", five seconds later the aircraft crashed. The crew exited the aircraft without accomplishing the Emergency Evacuation Checklist and therefore left the right engine running for about 28 minutes after the crash. The Fire Service eventually used their water hose to shutdown the running engine. At 19:54 hrs the Tower called 5N-BMM to pass on the landing time as 19:53 hrs, but no response from 5N-BMM. There was no indication that the aircraft was taxing on the Runway because it was dark and no light was visible hence the need to alert the Fire personnel. The watch room was asked to give the Tower information, which they could not give since they do not have a two – way contact with the Fire trucks. The Tower could not raise the Fire truck since there was no two - way communication between them; however, the Fire truck was later cleared to proceed to the Runway as the Tower could not ascertain the position of the aircraft. The aircraft was actually turned 90° because of the big culvert that held the right wing and made the aircraft spin and turned 90o facing the runway, two meters from the active runway, the culvert was uprooted due to the aircraft impact forces. The wheel broke off because of the gully that runs parallel to the runway.
Probable cause:
The decision of the pilot to continue the approach without the required visual references.
Contributory Factors:
- Poor crew coordination (CRM),
- Pairing two captains together,
- The weather was marginal.
Final Report:

Crash of a Boeing 737-282 in Port Harcourt

Date & Time: Jul 14, 2008 at 1844 LT
Type of aircraft:
Operator:
Registration:
5N-BIG
Survivors:
Yes
Schedule:
Lagos – Port Harcourt
MSN:
23044/973
YOM:
1983
Flight number:
NCH138
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
41
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8688
Captain / Total hours on type:
452.00
Copilot / Total flying hours:
7500
Copilot / Total hours on type:
2500
Aircraft flight hours:
55508
Aircraft flight cycles:
36263
Circumstances:
On 14th July, 2008 at 16:49 h, a Boeing 737–282 aircraft with nationality and registration marks 5N-BIG, operated by Chanchangi Airlines Ltd, commenced a scheduled domestic flight from Murtala Muhammed International Airport, (DNMM) with call sign NCH138 for Port Harcourt International Airport (DNPO). Instrument Flight Rules (IFR) flight plan was filed for the flight. There were 47 persons on board (41 passengers, 2 flight crew and 4 flight attendants) and 3 hours fuel endurance. The Captain was the Pilot Flying (PF) and The First Officer (FO) was the Pilot Monitoring (PM). The FO stated that NCH138 was initially scheduled to depart at 15:30 h, but the flight was delayed due to loading of passenger baggage. The Captain stated that NCH138 was cleared to FL290 and the flight continued normally. According to the DNPO Air Traffic Control (ATC) watch supervisor on duty, NCH138 contacted DNPO Approach Control (APP) at 17:05 h with flight information estimating POT at 17:50 h. NCH138 was issued an inbound clearance to POT1 VOR2 with the following weather information for 17:00 h as: Wind calm, Visibility 10 km, Broken clouds 270 m, Scattered clouds 600 m, Cumulonimbus clouds scattered, temperature 25/24°C, Thunderstorms, Temporarily Variable 8 kt, gusting 18 kt, Visibility 3000 m, Thunderstorms and rain, and expect runway (RWY) 21 for landing. According to the First Officer NCH138 requested descent into POT at about 100 NM. The Captain added that due to ATC delay, the descent commenced at about 80 NM. The Control Tower Watch Supervisor stated that at 18:00 h, NCH138 requested to hold over POT at 3500 ft for weather improvement, because there was rain overhead the station with build-up closing in at the threshold of RWY 21. At about 15 NM, between radials 180° and 210°, NCH138 reported breaking out of weather. At 18:19 h, NCH138 requested weather information from the Tower. Tower advised the flight crew that RWY 03 was better for landing. At this time, NCH138 requested RWY 03 for approach and Approach Control cleared NCH138 for the approach to RWY 03. At 18:27 h, the flight crew reported established on approach to RWY 03, leaving 2000 ft. The Approach Control then transferred NCH138 to DNPO Tower for landing instructions. At 18:28 h, the Tower instructed NCH138 to report field in sight. The flight crew acknowledged and reported RWY 03 in sight. Tower cleared NCH138 to land on RWY 03 and NCH138 was cautioned that the runway was wet. At 18:34 h, NCH138 executed and reported a missed approach. NCH138 requested a climb to 3500 ft. NCH138 was cleared to climb and instructed to report overhead POT. At 18:39 h, NCH138 requested a descent and clearance for an approach to RWY 21. Approach Control cleared NCH138 to descend to 2000 ft and report to Tower when established on the approach and also to report leaving 2000 ft. At 18:42 h, NCH138 reported inbound maintaining 2000 ft. The Approach Control requested the distance from the runway and sought consent of NCH138 for Arik 514 at the holding point to take off. NCH138 declined, as they were about 10 miles to touchdown. At 18:45 h, NCH138 reported five miles to touchdown. Approach Control acknowledged and instructed NCH138 to report field in sight and thereafter handed over to Tower on 119.2 MHz. When contacting the Tower, NCH138 was cleared to land on RWY 21, wind 0100 /10 kt and was advised to exercise caution due to wet runway. NCH138 acknowledged the clearance. NCH138 landed hard and bounced three times on the runway. According to the ATC controller, after touch down the aircraft rolled in an s-pattern before it overran the runway. NCH138 made a 180° turn with the right engine hitting the ground. The aircraft came to a final stop on the left side and 10 m beyond the stopway. The accident occurred at night in Instrument Meteorological Conditions (IMC). The Aerodrome Rescue and Fire Fighting Service (ARFFS) arrived the scene and commenced rescue operations immediately. All occupants on board were evacuated; one passenger sustaining a minor injury.
Probable cause:
The decision to land following an unstabilized approach (high rate of descent and high approach speed. A go-around was not initiated.
Contributory factors:
1. The deteriorating weather conditions with a line squall prevented a diversion to the alternates.
2. The runway was wet with significant patches of standing water.
Final Report:

Crash of a Beechcraft 1900D in Bushi: 3 killed

Date & Time: Mar 15, 2008 at 0920 LT
Type of aircraft:
Operator:
Registration:
5N-JAH
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Lagos - Bebi
MSN:
UE-322
YOM:
1998
Flight number:
TWD8300
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
9730
Captain / Total hours on type:
852.00
Copilot / Total flying hours:
444
Copilot / Total hours on type:
204
Aircraft flight hours:
5578
Circumstances:
The aircraft, Beech 1900D with flight number TWD8300 on a positioning flight, filed an Instrument Flight Rule (IFR) with Air Traffic Services (ATS) at Murtala Muhammed Airport (MMA) Lagos for departure to Bebi airstrip, Obudu on a filed flight plan LAG – UA609 – POTGO – DCT – ENU – DCT - OBUDU. But the actual route flown was LAG – UA609 – POTGO – LIPAR – LUNDO – IKROP – BUDU. The aircraft departed MMA at 0736 hrs as per the flight plan, climbed to FL250, estimated MOPAD at 0755 hrs, BEN at 0814hrs, POTGO at 0837hrs, LIPAR at 0844hrs, LUNDO at 0902 hrs and OBUDU destination at 0917hrs. The aircraft was transferred to Port Harcourt at 0845 hrs thereafter the crew requested descent. It was cleared to FL110 but on passing through FL160 requested further descent and was then released to Enugu at 0856 hrs by Port Harcourt. Enugu cleared it to FL050. The aircraft deviated from the flight plan route, and flew on airway UA609 direct to IKROP from POTGO. The inputs into Global Positioning System (GPS) gave the crew different distances to Bebi. The crew agreed on a coordinate to input and thereafter were busy trying to locate the airstrip physically. During this process the Ground Proximity Warning System (GPWS), warning signals and sound of “Terrain, terrain…..pull up” was heard several times without any of the pilot following the command. The aircraft flew into terrain, crashed and was destroyed. At 0923hrs, the Radio Operator at Bebi called the aircraft to confirm its position, but received no reply. The FDR showed that the aircraft crashed at about 0920:15 hrs at an altitude of about 3,400ft at Bushi Village during the hours of daylight with three fatalities. The aircraft flew for 103.75 minutes before impact.At 0924 hrs, Bebi Radio Operator called Calabar, to confirm if in contact with 5N-JAH, Calabar replied negative contact. The burnt wreckage was found by hunters in a dense wooded area on 30 August 2008.
Probable cause:
The flight crew conducted an approach into a VFR airfield in an instrument meteorological condition and did not maintain terrain clearance and minimum safe altitude which led to Controlled Flight Into Terrain. The crew did not respond promptly to GPWS warning.
Contributory Factors:
- The flight crew was not familiar with the route in a situation of low clouds, poor visibility and mountainous terrain.
- The Area Controllers did not detect the estimate as passed by the pilot for positions not in the filed flight plan (LIPAR and LUNDO) and omitting ENUGU.
- The flight crew changed from IFR flight to VFR flight without proper procedure and ATC clearance.
- The crew did not use Jeppesen charts as approved in WINGS AVIATION Operational Specifications by NCAA.
- The Lagos Area Control Center (ACC) did not detect or question the disparity in waypoints and routing as read back by the crew, compared with the filed flight plan.
Final Report:

Crash of a Boeing 727-277 in Lagos

Date & Time: Sep 7, 2006 at 1305 LT
Type of aircraft:
Operator:
Registration:
ZS-DPF
Flight Type:
Survivors:
Yes
Schedule:
Abidjan - Accra - Lagos
MSN:
22644/1768
YOM:
1981
Flight number:
DHL110
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17295
Captain / Total hours on type:
7820.00
Copilot / Total flying hours:
2972
Copilot / Total hours on type:
2422
Aircraft flight hours:
52728
Aircraft flight cycles:
34063
Circumstances:
On the day of the accident, Flight DV110 routing was Abidjan – Accra - Lagos. It departed Abidjan at 1015 hrs for Lagos via Accra. The aircraft finally departed Accra for Lagos at 1145 hrs with a total declared cargo weight of 50014 lbs (22733 kgs). The aircraft contacted Lagos Area Control at 1242 hrs, while maintaining FL 210 (21, 000ft) and was given an in-bound clearance to Lagos VOR (LAG) for ILS approach on runway 18L. At 1252 hrs, Lagos Approach cleared it to FL050 (5,000 feet) and at 12 NM, it was further cleared down to 3500ft on QNH 1013 hpa, and finally to 2,200 feet and to report established on the ILS. At 4 NM to the runway, the aircraft reported fully established on the ILS and was handed over to Control Tower for landing instructions. At 1303 hrs and 2 NM to the runway, the aircraft was cleared to land on runway 18L but to exercise caution, as the runway surface was wet. The cloud was low; the Captain said in his statement that the cloud base was about 100 feet above minimum. Speci weather was also available to the crew. The pilot was advised to exercise caution due to the rain and the weather at that time. In spite of all the warnings the copilot was still allowed to proceed with the landing. At the point of touch down the captain observed that it was impossible to stop on the runway and he called for a go-around. The procedure was not properly executed and thus the aircraft overshot the runway 400m into the grass area. There was no fire outbreak and no injury was sustained by any of the crew members. There was serious damage to the aircraft.
Probable cause:
Causal Factor:
The decision of the crew to continue an unstabilised approach despite the prevailing adverse weather condition.
Contributory Factors:
- The captain did not take over the control of the flight from the first officer in the known bad weather situation,
- The crew resource management was inadequate.
Final Report:

Crash of a Boeing 737-2L9 in Lisa: 117 killed

Date & Time: Oct 22, 2005 at 2040 LT
Type of aircraft:
Operator:
Registration:
5N-BFN
Flight Phase:
Survivors:
No
Schedule:
Abidjan – Accra – Lagos – Abuja
MSN:
22734
YOM:
1981
Flight number:
BLV210
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
111
Pax fatalities:
Other fatalities:
Total fatalities:
117
Captain / Total flying hours:
13429
Captain / Total hours on type:
153.00
Copilot / Total flying hours:
762
Copilot / Total hours on type:
451
Aircraft flight hours:
55772
Aircraft flight cycles:
36266
Circumstances:
The accident was reported to erstwhile Accident Investigation and Prevention Bureau (AIPB) now Accident Investigation Bureau (AIB) on Saturday 22nd of October, 2005. The site of the wreckage was located on the 23rd of October, 2005 and investigation began the same day. On October 22, 2005, at 2040 hrs, Bellview Airlines (BLV) Flight 210, a Boeing B737-200, 5N-BFN, crashed while climbing to cruise altitude shortly after take-off from Murtala Muhammed Airport, Lagos (LOS). The flight was operating under the provisions of the Nigerian Civil Aviation Authority (NCAA) Air Navigation Regulations (ANRs) as a scheduled domestic passenger flight from LOS to Abuja International Airport (ABV). The flight departed LOS for ABV at 2035 hrs, with 2 pilots, 1 licensed engineer, 3 flight attendants, and 111 passengers on board. The airplane entered a descent and impacted open terrain at Lisa Village, Ogun State. All 117 persons were killed and the airplane was destroyed by impact forces and fire. Instrument meteorological conditions prevailed. The airplane was operated on an Instrument Flight Rule (IFR) plan. The accident occurred on the final leg of a one-day round trip from Abuja to Abidjan with intermediate stops at Lagos and Accra for both the outbound and inbound segments. The trip through the second stop at Accra (the fourth leg) was reported without incident. On the fifth leg, during the taxi for takeoff at Accra, the pilot and the engineer discussed the low pressure reading of 650 psi in the brake accumulator system according to the pilot that flew the aircraft from Accra to Lagos. Normal accumulator brake pressure is 1000 psi. The captain continued the flight to the destination, LOS, without incident, where the discrepancy was logged. The engineer briefed the maintenance crew about the low pressure reading. The crew consisted of two Licensed Aircraft Engineers (LAEs) and the outbound engineer for Flight 210. LAEs and engineer on riding coverage worked together to troubleshoot the brake system, which included verifying the pressure reading with the pressure gauge from another Boeing 737 (5N-BFM) in the fleet. It was determined that the source of the low pressure was due to a faulty brake accumulator. On checking the Minimum Equipment List (MEL), the maintenance engineers decided that the aircraft could be released for operation with the fault. Before Flight 210 departed, the captain discussed en-route weather with another pilot who had just completed a flight from Port Harcourt to Lagos. The other pilot informed the accident captain of a squall line in the vicinity of Benin. The accident captain indicated that he experienced the same weather condition on his previous flight from Abuja to Lagos. The chronology of the flight was determined from the transcript of the recorded radio communications between Air Traffic Control and Flight 210 and post accident interviews of air traffic personnel. According to the transcript, the pilot of Flight 210 contacted the tower at 1917:02 UTC and requested for startup and clearance was given. The controller gave him the temperature and QNH, which were 27 degrees Centigrade and 1010 millibars respectively. At 1924:08 UTC, the Pilot requested and got approval for taxi to Runway 18L. At 1927 UTC, the tower requested for Persons on Board (POB), endurance and registration. In response, the pilot indicated the number of persons on board as 114 minus 6 crew, fuel endurance as 3 hours and 50 minutes and registration 5N-BFN. The tower acknowledged the information and issued the route clearance via Airway UR778, Flight Level 250, with a right turn-out on course. The pilot read back the clearance and the controller acknowledged and instructed the pilot to report when ready for takeoff. At 1927:55 UTC, the pilot requested “can we have a left turn out please?” and soon afterwards his request was granted by the controller. At 1928:08 UTC, the tower cleared BLV 210 as follows: "BLV 210 RUNWAY HEADING 3500FT LEFT TURN ON COURSE" At 1928;12 UTC, BLV 210 replied "3500FT LEFT TURN ON COURSE 210". 1928:47 UTC, the pilot reported ready for takeoff, and after given the wind condition as 270 degrees at 7 knots the controller cleared Flight 210 for departure at 1928:50 UTC. The pilot acknowledged the clearance, and at 1929:14 UTC requested “And correction, Bellview 210, please we will take a right turn out. We just had a sweep around the weather and right turn out will be okay for us.” The controller responded “right turn after departure, right turn on course” and the pilot acknowledged. According to the transcript, at 1931:52 UTC, the controller reported Flight 210 as airborne and instructed the pilot to contact LOS Approach Control. During the post-crash interview, the controller indicated he saw the airplane turn right, but was unable to determine its attitude due to darkness. He indicated the airplane sounded and appeared normal. At 1932:22 UTC, the pilot made initial contact with Approach Control and reported “Approach, Bellview 210 is with you on a right turn coming out of 1600 (feet)”. The Approach Control replied “report again passing one three zero.” The pilot acknowledged at 1932:35 UTC, and that was the last known transmission from the flight. According to the transcript, the controller attempted to regain contact with the flight at 19:43:46 UTC. Repeated attempts were unsuccessful. Emergency alert was then sent out to relevant agencies including the National Emergency Management Agency (NEMA) for search and rescue operations to commence. The airplane struck the ground on flat terrain in a relatively open and wooded area, 14NM north of the airport (6˚ 48’ 43” N and 3˚ 18’ 19” E).
Probable cause:
The AIB, after an extensive investigation, could not identify conclusive evidence to explain the cause of the accident involving Bellview Flight 210. The investigation considered several factors that could explain the accident. They include the PIC training of the Captain before taking Command on the B737 aircraft which was inadequate, the cumulative flight hours of the pilot in the days before the accident which was indicative of excessive workload that could lead to fatigue. Furthermore, the investigation revealed that the airplane had technical defects. The airplane should not have been dispatched for either the accident flight or earlier flights. The absence of forensic evidence prevented the determination of the captain’s medical condition at the time of the accident. The missing flight recorders to reconstruct the flight also precluded the determination of his performance during the flight. Due to lack of evidence, the investigation could not determine the effect, if any, of the atmospheric disturbances on the airplane or the flight crew’s ability to maintain continued flight. The operator could not maintain the continuing airworthiness of its aircraft, in ensuring compliance of its flight and maintenance personnel with the regulatory requirements. The Civil Aviation Authority’s safety oversight of the operator’s procedures and operations was inadequate.
Final Report:

Crash of a Boeing 747-258C in Lagos

Date & Time: Nov 29, 2003 at 0235 LT
Type of aircraft:
Operator:
Registration:
ZS-OOS
Flight Type:
Survivors:
Yes
Schedule:
Brussels – Lagos – Johannesburg
MSN:
21190
YOM:
1975
Flight number:
HYC501
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Brussels on a cargo flight to Johannesburg with an intermediate stop in Lagos. On approach by night, the crew was cleared to land on runway 19R that was closed to traffic due to resurfacing process. After touchdown, the aircraft collided with several equipments then veered off runway to the left and came to rest. All nine occupants escaped uninjured while the aircraft was damaged beyond repair. ATC cleared the crew to land on runway 19R while the runway 19L was the one in service at the time of the accident.
Probable cause:
The AIPB reported that the Nigerian Civil Aviation Authority did not know of the closure of the runway, nor that it was aware of the NOTAM until the accident occurred. Runway 19R was not properly closed in accordance with standard practice, as the runway lights were all switched on indicating runway serviceability.