Bellview B732 near Lagos on Oct 22th 2005, near vertical impact shortly after takeoff for unknown reasons
Last Update: February 17, 2013 / 20:36:34 GMT/Zulu time
Nigeria's AIB completed their final report in Feb 2009 but did not publish the report until Feb 2013 concluding:
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 captainÂ’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 crewÂ’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 AuthorityÂ’s safety oversight of the operatorÂ’s procedures and operations was inadequate.
Nigeria's Accident Investigation Board (NAIB) reported the captain (49, ATPL, 13,429 hours total, 1053 hours on type - editorial note: in section 1.5.1 the NAIB wrote 153 hours, in section 2.1.1 it became clear the number 1053 hours however) had flown 296 hours in the 90 days prior to the crash, 91 hours in the 28 days prior the crash and 2.5 hours in the 24 hours prior to the crash. The first officer (42, CPL, 762 hours total, 451 hours on type) had flown 248 hours in the 90 days, 84 hours in the 28 days and 2 hours in the 24 hours prior to the crash.
The aircraft had accumulated 55,772 hours in 36,266 flight cycles since new. The aircraft had last undergone a C-maintenance check between Dec 24th 2004 and Feb 12th 2005, the next C-check was due in August 2006.
The NAIB reported: "There was also a satellite imagery report produced by Boeing Aircraft Company over Lagos and its environs. The report indicated strong convective storm activity near the accident site at the time of the accident and that the freezing level was likely between 14500ft and 15000ft. The report also stated that windshear and or heavy rain and or hail are associated with strong convection. Icing might have been a factor but only above Flight Level 150."
The NAIB reported that neither black box could be found and recovered from the crash site. The aircraft had impacted at a "steep attitude", almost vertical, at high speed, however at less than 90 degrees nose down evident by an engine imprint at the crater.
The time of the impact was computed to have been 19:40Z, which was supported by a wristwatch recovered from the crash site, which had stopped at 20:40L.
Engine parts recovered from the crash site showed only damage consistent with a high speed impact with engines turning and delivering power.
Two pieces of the left fuselage carrying portion of the registration number were found about 100 feet away from the crater, the pieces showed fire damage those rose suspicion of a possible explosion. The materials were taken to the FBI and underwent laboratory analysis which concluded there was no evidence of an explosion.
The NAIB analysed that the captain had accumulated 1053 hours on type in one year of employment with Bellview, however, the total was 1,864 hours in 10 months (limit 1,000 hours in 12 months). The NAIB said: "Cumulatively, the pilotÂ’s total flight hour in ten months was 1,864:45 hrs in gross violation of 1,000 flight hours in twelve calendar months."
The NAIB reported that both fuel flow indicators were unserviceable according to a technical log entry of Oct 14th 2005. Maintenance response was "Noted", the problem was not rectified and the aircraft released to service although a dispatch with this condition, not even under minimum equipment list requirements, was not permitted. An A-check on Oct 17th 2005 also did not fix the faults.
The tech log also noted the right hand engine had surged during takeoff on Oct 5th 2005, however no maintenance action was noted in the technical documentation.
On Sep 29th 2005 a pilot noted "controls heavy and stiff with autopilot elevator channel engaged", maintenance reaction "noted" with no corrective action taken.
Either of the three tech log entries would have precluded a return to service without fixing the problem.
on Oct 14th a tech log entry reported "No. 1 Reverser unlock light flickers on in flight", maintenance cleaned a proximity switch and carried out a test successfully. The problem was again logged on Oct 21st 2005, maintenance reaction "T/R proximity switch is being looked into" A dispatch with one thrust reverser inop is possible under minimum equipment list requirements provided the inoperative thrust reverser is locked in its closed position. There was no tech log entry indicating the thrust reverser had been locked however. A detailed inspection of the thrust reverser assemblies by the NTSB concluded that the thrust reversers were not causal to the crash.
The rudder control unit was determined not causal to the crash by Boeing.
It was discovered that the documentation of the captain's training did not permit issuance of the ATPL. For example, the captain had claimed to have 80 hours on the Boeing 737-200 prior to being issued the ATPL, it turned out however that these 80 hours were not on the aircraft or approved simulator, but were a ground course at a Miami flight school. The proper procedure to verify the documentation had not been maintained - a similiar problem with the training documentation was discovered for the first officer. As a result, the captain, after being out of flying for 12 years, returned to flying with 15 hours simulator training as pilot flying, 10 hours simulator training as pilot monitoring and 8 days of ground school training and became Boeing 737-200 pilot in command. As a result: "The captain did not meet minimum requirement on type experience required by the company to fly as pilot in command ... The Company required 500 hours of flight time on type to serve as PIC, the captain had only accrued 47 hours of flight time when he was assigned to the B737-200."
This article is published under license from Avherald.com. © of text by Avherald.com.
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