Dana Air Crash: Accident Investigation Bureau submit preliminary report
Less than two months after the ill-fated Dana flight from Abuja to
Lagos, the Accident Investigation Bureau (AIB) led by Capt. M.S. Usman
has submitted its preliminary report of Investigation over the actual
cause of the Crash.
According to the preliminary Investigation by Capt. Usman, the Dana
flight On 3rd June 2012 about 1545 hours [1], 5N-RAM, a Boeing MD-83, a
domestic scheduled commercial flight, operated by Dana Airlines Limited
as flight 992 (DAN 992), crashed into a densely populated area during a
forced landing following a total loss of power in both engines while on
approach to Muhammed Murtala Airport (LOS), Lagos, Nigeria. Visual
meteorological conditions prevailed at the time and the airplane was on
an instrument flight plan. All of the 153 persons aboard the airplane,
including the 6 crew members were fatally injured. There were 10
confirmed ground fatalities. The airplane was destroyed. There was post
impact fire. The flight originated at Abuja (ABV) and the destination
was 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. DAN 992 was on final approach for
runway 18R at LOS when the crew reported the total loss of power.
According to interviews, the flight arrived in ABV as Dana Air flight
993 about 1350. According to Dana Air ground personnel, routine
turn-around activities occurred, including refueling of the airplane.
DAN 992 initiated engine startup at 1436, taxied to the runway and was
later airborne at 1458 after the flight had reported that it had a fuel
endurance of 3.5 hours. Shortly after takeoff, DAN 992 reported 1545 as
the estimated time of arrival at LOS as the flight climbed to a cruise
altitude of 26,000 ft[2]. DAN0992 made contact with Lagos Area Control
Center at 1518 hours.
The report revealed that the cockpit voice recorder (CVR) retained
about 31 minutes of the flight and starts about 1515 at which time the
captain and first officer were in a discussion of a non-normal condition
regarding the correlation between the engine throttle setting and an
engine power indication[3]. 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 transition through the initial descent from
cruise altitude at 1522 and the subsequent approach phase.
The report stated that “DAN 992 reported passing through 18,100 and
7,700 ft, respectively, at 1530 and 1540 hours. After receiving a series
of heading and altitude assignments from the controller, DAN 992 was
issued the final heading to intercept the final approach course for
runway 18R.
During the period of 1537 and 15:41 the flight crew engaged in
pre-landing tasks including deployment of the slats, and extension of
the flaps and landing gear. At 15:41:16 the first officer (FO) inquired,
“both engines coming up?” and the captain (Capt) replied “negative.”
The flight crew subsequently discussed and agreed to declare an
emergency. At 1542:10, DANA 992 radioed an emergency distress call
indicating “dual engine failure . . . negative response from throttle.”
“At 1542:35, the flight crew lowered the flaps further and continued
with the approach and discussed landing alternatively on runway 18L. At
1542:45, the Capt reported the runway in sight and instructed the FO to
raise the flaps up and 4 seconds later to raise the landing gear.
At 1543:27 hours, the Capt informed the FO “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 was attempting to
restart the engines”.
The airplane crashed in a residential area about 5.8 miles north of
LOS. The airplane wreckage was on approximately the extended centerline
of runway 18R. During the impact sequence, the airplane struck an
incomplete building, two trees and three buildings. The wreckage was
confined, with the separated tail section and engines located at the
beginning of the debris field.
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.
The two flight recorders, the Cockpit Voice Recorder (CVR) and the
flight data recorder (FDR) were analysed at the facilities of the
National Transportation Safety Board (NTSB), Washington, D.C., USA. The
solid state based memory in the CVR was in good condition and retained
31 minutes of audio information. The digital tape based memory in the
FDR succumbed to the post crash fire and melted, consequently no data
could be recovered.
The captain, age 55, held an airline transport pilot license with
type ratings in the A-320[4], DC-9, FK-28[5], and SF-340[6]. He had over
18,116 hours of total time, including 16,416 hours of pilot-in-command
time (PIC). The captain had 7,461 hours in the accident model airplane
all of which was as PIC. He was employed with Dana Air on 14 March 2012.
He began flying line operations for the company in late May 2012 and
had since accrued over 120 hours of flight time. The captain had
acquired about 3, 78, and 116 flight hours, respectively, in the
preceding 24 hours, 30 and 90 days.
The first officer, age 34, held a commercial pilot license he was
type rated in MD-83. He had 1,143 hours of total time, including about
200 hours as pilot-in-command. The first officer had 808 hours in the
accident model airplane all of which was second-in-command. He had been
previously employed with Dana Air as the Director of Cabin Service
before he was hired as a pilot about January 2011. The first officer had
accrued about 3, 42, and 154 flight hours, respectively, during the
preceding 24 hours, 30 and 90 days.
The airplane was manufactured in 1990 and according to maintenance
records it had accumulated 60,846 hours (35,219 cycles) of total time.
The left and right engines respectively had 54,322 (30,933 cycles) and
26,025 (12,466 cycles) hours of total time since new. A review of the
aircraft technical logs did not reveal of the previous 30 days did not
indicate a condition. The airplane had last undergone maintenance on 1st
June 2012, and after a return to service flight on 2nd June 2012, it
was operated on four revenue flights (two round trips between LOS and
ABV) and another four flights on 3rd June 2012.
Fueling records indicated the airplane was uplifted with 8000 lbs of
fuel before departure from ABV. The flight crew reported to ATC they had
26,000 lbs of total fuel. Preliminary analysis of fuel samples from the
refueling truck and the supply tank at ABV were negative for
contamination.
The investigative activities have included, in part, visual
examination of the aircraft wreckage, review of maintenance records and
other historical information of the aircraft, documentation of the
training and experience of the flight crew, determination the chronology
of the flight, review of recorded data, reconstructing the aircraft
refueling, and collection of related fuel samples, and interviews of
relevant personnel.
Future investigative activities will include, but is not limited to, the
detailed examination of the engines, further testing of fuel samples,
continued factual gathering of relevant historical, operational,
maintenance and performance information of the accident airplane in
addition to other similar airplane models, further development of the
background of the flightcrew, further analysis of the CVR audio
recording and review of pertinent issues associated with regulatory
oversight.
As the State of Occurrence, the Accident Investigation Bureau (AIB)
has instituted an investigation in accordance with the standards and
recommendations specified in the provisions of Annex 13 of the
International Civil Aviation Organization. As the State of manufacture
of the airplane and engine, a US Accredited
Representative has been appointed and assisted by US technical advisors
from the NTSB, US Federal Aviation Administration, Boeing Airplane
Company, and Pratt & Whitney Engines.
In accordance with Annex 13, “the sole objective of the investigation
of an accident or incident shall be the prevention of accidents and
incidents. It is not for the purpose of this activity to apportion blame
or liability.”
Accordingly, the AIB with the participation of the parties, including
the NCAA, will seek to identify any areas of safety concerns during the
investigation and implement the appropriate actions for correction or
improvement.
Capt. Usman has also pointed out that the content of the report is based
on preliminary information. The Bureau will continue to conduct the
investigation in a meticulous and methodical manner and release facts as
they become validated.
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