Osinbajo’s Helicopter Accident Caused By Human Error, AIB Reveals

The Accident Investigation Bureau (AIB) has released the final report of the February 2, 2019 helicopter accident involving the Vice President, Professor Yemi Osinbajo in Kogi and three other accidents.

In its preliminary report, the AIB had said the crew lost visual contact with the ground at about 50 feet owing to dust generated when landing on a sandy area.

But in the new report made available on Tuesday, the AIB said the incident was as result of human error.

The Agusta Westland helicopter conveying the Vice President and 11 others crashed in the Kabba area of Kogi State during the 2019 presidential election campaign.

APC, PDP React To Osinbajo’s Helicopter Crash Survival
A helicopter conveying Vice President Yemi Osinbajo crash-landed in Kogi State on February 2, 2019.

The chopper managed by Caverton Helicopter had managed to land at the township stadium before its propeller suddenly pulled off to the surprise of supporters of the All Progressives Congress (APC) who had gathered to welcome the Vice President.

Read the full report on the Vice President’s helicopter crash and three other incidents released by the Bureau below:

THE SPEECH OF THE COMMISSIONER/CEO OF ACCIDENT INVESTIGATION BUREAU (AIB), AKIN OLATERU AT THE MEDIA BRIEFING ON THE RELEASE OF FOUR OCCURRENCE REPORTS HELD ON 28 JULY, 2020 AT CORPORATE HEADQUARTERS, NNAMDI AZIKIWE INTERNATIONAL AIRPORT, ABUJA

Gentlemen of the press,

It is with great pleasure that I welcome you all to this very important occasion where we will be releasing four final accident and serious incident reports to the general public.

For us at AIB Nigeria, safety is very crucial and our investigations are geared towards ensuring a safer airspace in Nigeria and in the region.

These reports are the strong foundation on which safety of the aviation industry is built and timely release of these reports is as critical as Accident Investigation itself. The purpose of accident investigation, however, is not to apportion blame or liability but to prevent future recurrence of similar incidents.

Since the inception of this administration at AIB, we have been able to keep to our promise of ensuring timely release of accident and serious incident reports. We have before now released 27 final accident reports to the public and today, we will be releasing an additional four reports, which will bring the total final report released by this administration from 2017 till date to 31.

These Four Final Reports include a total of 9 Safety Recommendations, making a total of 51 Final Reports and 187 Safety Recommendations since the inception of AIB.

Safety Recommendations in accident reports have impacted air safety positively not only in Nigeria, but globally. They are very important towards preventing recurrence of such accidents or serious incidents when safety recommendations are adhered to.

Below is a breakdown of the reports and safety recommendations we have turned out so far.

 

  FINAL REPORTS RELEASED
  2007 – 2016 2017 – Date Total
Occurrences 19 31 50
Incident (Safety Bulletin) 1 1
Total 19 32 51
Percentage of Final Reports 37.3% 62.7%  
   
  SAFETY RECOMMENDATIONS ISSUED
Occurrences 81 102 159
Incident (Safety Bulletin) 4 4
Total 81 106 187
Percentage of Safety Recommendations Issued 43.3% 56.7%  

 

A total of 32 Final Reports have been released since January 2017, which makes up 62.7% of AIB’s total of 51 Final Reports released since inception (2007).

The 106 safety recommendations issued since 2017 account for 56.7% of the total 187 issued since inception.

Before the end of the year, we should be able to release an additional six Final Reports to the public.

I would like to appreciate the relentless efforts of AIB staff in achieving this milestone by turning out these reports in a timely manner. In order to ensure timely release of reports, we have simplified our investigation process by encouraging teamwork. Investigations are now done in groups and they all work together to ensure investigations are done efficiently and timely. Like I always say a simple, not complex investigation, should not last more than 18 months.

One of the reports that is being released today is the accident of an Agusta Westland (AW139) helicopter with nationality and registration marks 5N-CML owned and operated by Caverton Helicopters Limited which occurred on the 2nd of February 2019, in Kabba, Kogi State, Nigeria. The helicopter had 12 persons on-board, including the Vice President of the Federal Republic of Nigeria, his entourage and three crew members which included the Captain, Co-Pilot and an Engineer.

Also, I would like to appreciate the continuous support of the supervisory ministry, particularly the Honourable Minister of Aviation.

In all, we have established a system in AIB that is working.

We are committed to swift response to accident and serious incident occurrences through our well-equipped Command and Control Centre. Accident reporting has also been simplified through our Mobile Application which was introduced to interface with the public and make it easy for them to communicate with AIB digitally.

Please feel free to visit our website www.aib.gov.ng  for the full details of these reports and all other reports that we have issued in the past. You can also download our Mobile App, AIB Nigeria, on Google Play Store and IOS.

The four reports we are releasing today are as follows:

  1. Report on the Serious Incident involving Bombardier DHC-8-Q400 aircraft owned and operated by Aero Contractors Company of Nigeria Ltd. with nationality and registration marks 5N-BPU, which occurred at FL240, 80 NM to Lagos on 18th April 2017.
  2. Report on the Serious Incident involving a Diamond DA-42 aircraft with Nationality and Registration Marks 5N-BNH owned and operated by the International Aviation College, which occurred on Runway 23 Ilorin International Airport on 1st of May, 2019
  3. Report on the Serious Incident involving a Diamond DA-40 aircraft with Nationality and Registration Marks 5N-BRM owned and operated by International Aviation College, which occurred on Runway 23, Ilorin International Airport On 27th of March, 2014
  4. Report on the Accident involving an Agusta-Westland AW139 Helicopter operated by Caverton Helicopters Limited with Nationality and Registration Marks 5N-CML, which occurred at Kabba Stadium, Kogi State on 2nd February, 2019.

1. Report on the Serious Incident involving Bombardier DHC-8-Q400 aircraft owned and operated by Aero Contractors Company of Nigeria Ltd. with nationality and registration marks 5N-BPU, which occurred at FL240, 80 NM to Lagos On 18th April 2017

SYNOPSIS

Accident Investigation Bureau (AIB) was not officially notified of the serious incident but got to know about it through social media on 19th April, 2017.

On the 18th of April, 2017 at about 17:50 h, a Bombardier DHC-8-Q400 aircraft with registration marks 5N-BPU, operated by Aero Contractors Company of Nigeria Ltd as a scheduled flight NIG316, while cruising at FL240, 80 NM inbound Lagos from Port Harcourt, experienced bluish smoke which gradually increased in density within the cabin.

The smoke progressed into the cockpit. The lavatory smoke detector aural warning activated, and the AFT BAGGAGE light illuminated on the Fire Panel but there was no burning smell perceived. At 17:55 h the crew donned Oxygen masks and requested clearance to descend. NIG316 was cleared for immediate descent to 2,200 ft AMSL and requested to contact Lagos Approach. The aircraft contacted Lagos Approach requesting fire assistance on the ground.

The crew followed the FUSELAGE FIRE, SMOKE or FUMES in the QRH and executed “SMOKE” (Warning Light) checklist procedure, the aircraft landed safely on runway 18L at about 18:03 h and taxied to Aero Contractors maintenance facility at the General Aviation Terminal (GAT).

The passengers disembarked normally without injuries.

The investigation identified the following causal and contributory factors:

CAUSAL FACTOR

Engine oil leaked onto a hot surface of the engine causing fumes which mixed with the engine bleed air supply to the air conditioning system, resulting in smoke in the aircraft cabin, cockpit and lavatory/ cargo compartments.

Two Safety Recommendations were made.

SAFETY RECOMMENDATIONS

Safety Recommendation 2019-024

Aero Contractors Company of Nigeria Limited should ensure that Cockpit and Cabin Crew are alive to their responsibilities during emergencies vis-à-vis establishing effective two-way communication.

Safety Recommendation 2019-025

Nigerian Civil Aviation Authority should ensure that operators utilize the New Oil Analysis Technology made available by Pratt & Whitney Canada in order to identify impending failure of the carbon seals on PW150A engines that are yet to comply with SB 35342R1.

2. Report on the Serious Incident involving a Diamond DA-42 aircraft with Nationality and Registration Marks 5N-BNH owned and operated by the International Aviation College which occurred on Runway 23 Ilorin International Airport on 1st of May, 2019

SYNOPSIS

The accident involved a Diamond DA-42 aircraft with Nationality and Registration Marks 5N-BNH, which occurred on Runway 23, Ilorin International Airport, Ilorin on 1st May 2019.

The flight was a Commercial Pilot Licence (CPL) mock test with two persons onboard, a Flight Instructor (FI) and a Student Pilot (SP) with the flight instructor flying while the student pilot was monitoring.

At about 09:13 h, 5N-BNH took off from runway 23, Ilorin International Airport to Sector One Charlie (1C) and reported established at 09:28 h.

Several manoeuvres were carried out including steep turn, stall in all configurations, emergency descent, one engine inoperative procedure etc.

After two hours of flying at the training area, 5N-BNH was cleared back to the field for RNAV, VOR hold and ILS Approach and missed approach exercises.

At 11:12 h, the aircraft 5N-BNH reported right downwind Runway 23, requesting full stop landing and was granted. The flight instructor did his pre-landing checks.

At 11:15 h, the aircraft touched down with gears up on the runway centreline at a distance of 1,387 m from the threshold, veered right of the runway centerline and stopped 205m from the touchdown point, 9m to the right of the runway centreline.

The incident occurred in daylight.

The investigation identified the following causal and contributory factors:

CAUSAL FACTOR

The crew carried out the approach and landed with landing gears not extended.

CONTRIBUTORY FACTORS 

  1. Inadequate crew coordination during the approach to landing phase of flight.
  2. Lack of situational awareness on the position of the landing gears by the flight crew during approach to land.
  3. The inappropriate execution of approach and landing check list.

Three Safety Recommendations were made.

SAFETY RECOMMENDATIONS

Safety Recommendations 2019-026

NCAA should intensify its oversight on International Aviation College (IAC) and ensure that it adheres strictly to the use of Checklists and appropriate procedures during all training sessions and phases of flight.

Safety Recommendations 2019-027

International Aviation College (IAC) should improve on its Crew Resource Management training vis-à-vis the need for trainees to be assertive when necessary.

Safety Recommendations 2019-028

NAMA should devise means to ensure duty air traffic controllers, DATCOs, maintain continuous watch on all aircraft movements within the vicinity of the aerodrome.

3. Report on the Serious Incident involving a Diamond DA-40 aircraft with Nationality and Registration Marks 5N-BRM owned and operated by International Aviation College which occurred on Runway 23, Ilorin International Airport On 27th of March, 2014

SYNOPSIS

On 27th March 2014, at about 10:26 h, a Diamond DA-40D aircraft, 5N-BRM was on a training flight with a Student Pilot and an Instructor. After two successful landings under supervision of the Instructor, the Student Pilot was released for his first solo flight. The Instructor disembarked and the Student Pilot proceeded to fly solo. The Student Pilot took off flying the runway 23 circuit and executed a Touch and Go landing, requesting a full stop on the second landing, which ATC granted. On the second landing at touchdown, the aircraft lost directional control and veered off left of Runway 23 centreline into the grassy area.

The Air Traffic Controller sounded the crash alarm and the Aerodrome Rescue and Fire-fighting Services (ARFFS) arrived the site of the accident thereafter. The Student Pilot disembarked the aircraft without injury.

The investigation identified the following causal and contributory factors:

CAUSAL FACTOR

Loss of directional control after touchdown and subsequent veer of the aircraft off the runway.

CONTRIBUTORY FACTOR

Wrong engine power application during landing roll.

Two Safety Recommendations were made.

SAFETY RECOMMENDATIONS

The following Safety recommendations were made:

Safety Recommendations 2019-029

International Aviation College (IAC) should have in place a stringent flight training policy to discourage disruptions of students’ training during the stipulated period.

 Safety Recommendations 2019-030

International Aviation College (IAC) should develop and incorporate in their training manual, procedures to ensure that corrective actions are developed and implemented to prevent observed deficiencies such as “exceeding required minimum hours for solo flight”, duly signed out by Instructors and records kept in the student’s file prior to conducting a solo flight.

4. Final Report on the accident involving AgustaWestland AW139 helicopter operated by Caverton Helicopters Limited with nationality and registration marks 5N-CML, which occurred at Kabba, Kogi State on 2nd February, 2019.

SYNOPSIS 

On 2nd February, 2019 at about 07:26 h, an Agusta Westland (AW139) helicopter with nationality and registration marks 5N-CML operated by Caverton Helicopters Limited departed Lagos for Nnamdi Azikiwe International Airport in Abuja, to conduct a VIP charter flight from Abuja to Okene via Kabba and return to Abuja. The positioning flight to Abuja was normal. The helicopter was refuelled and the flight crew prepared for the VIP charter flight to Kabba.

At about 13:46 h, the helicopter departed Abuja runway 22 for Kabba. On board were 12 persons including the Vice President of the Federal Republic of Nigeria, his entourage and three crew members (Pilot, Co-pilot and an Engineer). The flight crew stated that they sighted the intended landing area as a result of the cloud of residual dust generated by the downwash of a Police helicopter.

After sighting the football field, the flight crew approached with the speed of 20 kt to about a 100 ft, and entered a hover to land. At about 50 ft above ground level, a brownout set in.  The flight crew lost visual contact with the ground and external surroundings. The Co-pilot began radio altitude callouts “35, 30, 25, 20 and 15”. At about 14:34 h, the helicopter experienced a hard landing on the right main landing gear and rolled over onto its right side. All persons on board were evacuated uninjured.

CAUSAL FACTOR

The flight crew encountered a brownout condition during the hover to land, which led to the loss of external visual references, spatial disorientation and loss of situational awareness resulting in a misjudgement of distance and ground clearance, as the flight crew tried to control the helicopter’s movements for landing. The helicopter landed hard and rolled over on its right side.

CONTRIBUTORY FACTOR

Inappropriate landing technique used, non-adherence to company procedures for known or anticipated brownout condition during landing and lack of risk assessment, limited landing site preparation and planning prior to commencement of the flight.

Eleven days after the accident, the AIB issued two Interim Safety Recommendations, one to the Nigerian Civil Aviation Authority and one to Caverton Helicopters. The required safety actions were initiated and implemented promptly.

Two Safety Recommendations were issued in the Final Report. 

SAFETY RECOMMENDATIONS

Safety Recommendation 2020-001

NCAA should 

Conduct a Safety Management System (SMS) audit of Caverton Helicopters. The SMS audit by the NCAA should ensure that Caverton Helicopters has implemented the Immediate Safety Recommendation 2019-003, the NCAA All Operators Letter (FSG 002), and the recommendations documented in the Caverton Helicopters internal SMS investigation of this accident. The NCAA audit should also ascertain that the Caverton Helicopters internal SMS processes in the maintenance activities require the establishment of the reasons/causes of equipment failure/malfunction (reference is made to the failures of the Multi-Purpose Flight Recorder (MPFR) and the unavailability of the reasons of the failures).

Safety Recommendation 2020-002

The Office of the National Security Adviser (NSA) should

Consider whether the Presidential Air Fleet (PAF) Unit should be involved in the coordination and preparation of all high profile Executive VIP mission (flights) in order to ensure that all Executive VIP flights are conducted in accordance with the PAF Unit’s Standards and in line with its approved operating procedures.

CHANNELS

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