Max B744 at Minna on Sep 7th 2019, "epileptic" ILS and engine pod strike on landing

Last Update: May 27, 2022 / 16:03:28 GMT/Zulu time

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Incident Facts

Date of incident
Sep 7, 2019

Classification
Incident

Airline
Max Air

Destination
Minna, Nigeria

Aircraft Registration
5N-DBK

Aircraft Type
Boeing 747-400

ICAO Type Designator
B744

Airport ICAO Code
DNMN

A Max Air Boeing 747-400, registration 5N-DBK performing Hajj flight NR-2092 from Jeddah (Saudi Arabia) to Minna (Nigeria) with 560 passengers and 18 crew, was on final ILS approach to Minna's runway 05 descending through 2000 feet when the crew determined both localizer and glideslope signals were erratic. The crew disconnected the autopilot and continued manually on visual cues for landing on runway 05 at about 05:1L (04:17Z), following touchdown the aircraft drifted slightly to the right of the runway, while applying corrections the aircraft overbanked causing the #1 engine pod to contact the runway surface and be dragged along the runway surface. After roll out the crew advised ATC that the ILS was not well calibrated. There were no injuries, the aircraft sustained minor damage to the #1 engine cowl and thrust reverser cowl, one runway edge light was damaged.

Nigeria's Accident Investigation Board opened an investigation into the occurrence and dispatched 5 investigators on site.

The occurrence aircraft was still on the ground in Minna about 34 hours after landing.

On Sep 8th 2019 the airline reported the aircraft landed in a heavy downpour and gusting winds, the ILS was "epileptic" with unreliable signals. The crew performed the approach using their wealth of knowledge about the terrain and environment and performed a safe landing and stop on the runway, one of the engine pods however did contact the runway surface and was slightly brushed. The slight brush of the engine was due to the complex landing maneouvers occasioned by a strong downdraft. The aircraft did not crash land or skid off the runway.

Nigeria's AAIB reported they have opened an investigation into the serious incident, that occurrend during final approach to runway 23. The #1 engine (outboard left hand) pod scraped the runway surface. The AIB asks for videos, evidence and other information that could assist in the investigation.

On Feb 11th 2020 Nigeria's AIB released their preliminary report correcting their earlier information the aircraft had landed on runway 23 now stating the aircraft performed an approach to runway 05.

The AIB reported the captain (63, ATPL, 25,033 hours total, hours on type not available) was pilot flying, the first officer (53, ATPL, 24,894 hours total, hours on type not available) was pilot monitoring.

The AIB wrote:

Examination of the marks on the runway revealed the following; The aircraft crossed the threshold right of centre line, was in a left bank, the left main wheels touched down and the number one engine nacelle contacted the runway on the centre line, 203 m from the threshold, and was dragged on the runway along the centre line for approximately 44 m. The body wheels touched down, followed by the right main wheels. The touchdown point was 203 m from the threshold on the right side of the runway centreline, the aircraft gradually steered to the centre line.

On examining the number one engine, the bottom surface of the nacelle was abraded, thereby releasing the cowl latches resulting in the fan cowls being blown off the engine by the slipstream.

The aircraft received damage to the bottom intake, fan cowl, thrust reverser cowl as well as damage to the transfer tube between angle gear box and main gear box of engine #1 and a puncture of a left wing flap fairing. One (conventional) runway edge light was destroyed (the solar runway edge light next to it remained undamaged). In addition a witness mark of a bird strike onto the edge of the nose radome was discovered.

The AIB reported the aircraft's CVR was not serviceable.

On Sep 8th 2021 the AIB released an interim statement reporting the draft final report has been completed and sent to the stakeholders, who now have 60 days time to comment.

On May 25th 2022 the AIB released their final report concluding the probable causes of the serious incident were:

Causal factor

Excessive rudder and aileron inputs at short finals phase of the approach.

Contributory factors

- The decision to continue the ILS approach runway 05 with erratic localizer signals.

- An un-stabilized approach with a no go-around decision.

The AIB analysed:

The take-off, climb, cruise and initial descent phases of the flight were normal.

ATC initial clearance to NGL2092 was for ILS approach RWY 05 at Minna. ATC should have been aware that ILS was two months past due for calibration (as mentioned in AIP supplement S38/2019). Moreover, the flight dispatch documents indicated that VOR/DME and RNAV approach RWY 05 were available.

The flight crew of NGL2092 had access to the NOTAM which had detailed information about the status of Jeppesen NAVDATA change notice indicating that ILS RWY (05) approach procedure was not included in the NAVDATA.

Had it been the flight crew had gone through the flight plan all the way to the Jeppesen information they could have been alerted on the status of the ILS procedure which was not in use. Therefore, the flight crew could have rejected the ILS approach clearance given by ATC.

NGL2092 cleared the weather, joined final approach path and reported established on the ILS. However, on short finals the flight crew realized that the aircraft was not aligned with RWY 05 centre line indicating that the aircraft deviated right of the centre line and a goaround should have been executed. However, the flight crew attempted to correct the deviation to align the aircraft back to centre line by using the combined inputs of aileron and rudder. The inputs applied were excessive in trying to align the aircraft with the runway centre line before touchdown.

Calibration past due of ILS/DME at Minna airport

According to the AIP supplement (S38/2019), ILS/DME RWY 05 at Minna airport was calibration past due since July, 2019.

Recall that after landing, ATC was informed by NGL2092 about the erratic signal of the localizer, this was corroborated by the FDR information. This is an indication of the unreliability and out of tolerance (OOT) of the localizer which might not be unconnected with its calibration status.

Metars:
DNMN 070500Z 00000KT 7000 FEW007 23/22 Q1014 NOSIG=
DNMN 070400Z 01014KT 9999 SCT008 24/22 Q1014 TEMPO FEW018CB=
DNMN 070200Z 03004KT 9999 FEW007 23/22 Q1013 NOSIG=
DNMN 070100Z 05005KT 9999 FEW007 23/21 Q1013 NOSIG=
DNMN 062200Z 05004KT 9999 SCT008 24/22 Q1014=
Incident Facts

Date of incident
Sep 7, 2019

Classification
Incident

Airline
Max Air

Destination
Minna, Nigeria

Aircraft Registration
5N-DBK

Aircraft Type
Boeing 747-400

ICAO Type Designator
B744

Airport ICAO Code
DNMN

This article is published under license from Avherald.com. © of text by Avherald.com.
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