Dana MD83 at Lagos on Jun 3rd 2012, collided with power line on approach following dual engine failure
Last Update: March 13, 2017 / 18:41:09 GMT/Zulu time
Incident Facts
Date of incident
Jun 3, 2012
Airline
Dana Air
Aircraft Registration
5N-RAM
Aircraft Type
McDonnell Douglas MD-83
ICAO Type Designator
MD83
Probable Causal Factors:
- 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.
- 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.
- Lack of situation awareness, inappropriate decision making, and poor airmanship.
The NAIB reported that the aircraft became airborne at 14:58Z, at 15:13Z the crew discussed an abnormal relationship between engine throttle setting and engine power, the crew did not appear to be concerned however. The crew however became increasingly concerned as the aircraft transitioned from cruise to descent at 15:22Z, on approach to Lagos the crew reported descending through 18100 feet at 15:30Z, at 15:31Z the crew commented the #2 engine no longer responded to thrust lever movements, the captain (55, ATPL, 18,116 hours total, 7,466 hours on type) took control of the aircraft, the first officer (34, CPL, 1,143 hours total, 808 hours on type) assumed the role as pilot monitoring, the crew however did not declare emergency or advise ATC. At 15:32Z the crew observed the #1 engine lost power. The crew engaged in landing configuration extending slats and flaps, reported descending through 7,700 feet at 15:40Z, at 15:42:10Z the crew declared emergency reporting "dual engine failure ... no response from throttle". The further extended the flaps, at 15:42:45Z the captain reported the runway in sight and instructed the first officer to retract the flaps and landing gear. At 15:43:27z the captain commented to the first officer: "we just lost everything, we lost an
engine. I lost both engines". During the following 25 seconds the crew attempted to recover engine power, however, without reference to the checklists.
The aircraft crashed into densely populated residential area at position N6.6718 E3.314 at an elevation of 177 feet about 5.8nm north of LOS VOR. 147 passengers and 6 crew on board of the aircraft lost their lives, there were 6 confirmed fatalities on the ground.
The NAIB reported the captain had been suspended by the FAA "for some misdemeanours related to a heavy landing and fixing of panels that were neither entered in the aircraft logbook nor reported." A revalidated license was stamped but did not carry any signatures. In addition the NAIB reported: "Most of the recommendation letters submitted by the captain were also not signed. The line trainings that preceded the captain’s checkout had a lot of adverse remarks made by the training captain."
The captain was checked out on May 2nd 2012 by Dana and accumulated flight 120 hours until the crash.
The tech log of the aircraft did not reveal any anomaly, the last maintenance had been done on Jun 1st 2012.
The fuel was examined, no contamination was found.
The NAIB analysed:
Finally, the passengers boarded and the crew requested for engine start up and FL330 (thirty three thousand feet) to Lagos from the Control Tower. Engine start up clearance was approved, temperature of 23oC, QNH 1013 and to squawk 0412.
Subsequently the aircraft was cleared to taxi to the holding point of runway 04. En-route clearance on airway UH340 was passed to DANACO 0992 to climb to FL180 (eighteen thousand feet) initially and to request level change en-route. On approaching holding point of runway 04, DANACO 0992 was cleared to line up on runway 04 and wait but DANACO 0992 requested for some time before lining-up, according to the ATC ground recorder transcript.
The aircraft was airborne Abuja for Lagos at 1458:00hrs. After airborne, DANACO 0992 contacted Kano Control Centre for traffic information and was further cleared to FL260 (Twenty six thousand feet). Thereafter, DANACO 0992 was cleared to continue with Kano Centre by Abuja ATC.
According to the CVR, as early as 17 minutes into the flight, the crew started discussing an unspecified problem with particular reference to the ‘left’ which AIB believed was a reference to the left engine. This coincided with the time the CVR 30-minutes limit started recording and at 1515:56hrs the Captain stated that “we just want to get # home” which AIB believed was the aircraft.
During further discussions, the First Officer asked if he can call in the Engineer who was repositioning to Lagos to help analyse the problem but the Captain refused. The Captain concluded, “well I don’t need him here cause we can figure it out, he’s not going to be able to help us”. During the period that the flight crew were discussing and trying to manage the situation they were facing, the Captain also asked the First Officer if any Engineer had tampered with the panel by the rear exit door on ground Abuja and finally concluded that “this is the guy that had an issue with us. uh he’s pissed off at us”; according to the CVR transcript. The flight however continued towards Lagos as the crew continuously discussed the problem with vague references to EPR and nonresponse from the throttle inputs, with the left engine operating at idle power or inoperative. The crew decided that they should start a gradual descent and accordingly established contact with Lagos ATC, passed the estimates of ERAMI at 1530:00hrs and LAG at 1543:00hrs which was followed with a request for descent clearance.
Meanwhile, from the CVR transcript, there was no evidence that the crew did call for the non-normal/emergency checklist in an attempt to ascertain the sudden and unexplained non-response of the left engine to throttle movement.
During the initial descent, the Captain wanted the F/O who was then the Pilot Flying (PF) to increase the rate of descent but the F/O stated that he would prefer a gradual descent in order to have enough height over Lagos. Lagos ATC had cleared DANACO 0992 to descend initially to FL160 (Sixteen thousand feet) and to expect radar vectors for an ILS approach for runway 18L and further approved high speed approach. The flight crew accordingly maintained a continuous monitoring watch of the situation. 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.
Earlier at 1531:12hrs, the crew confirmed that there was no throttle response on the left engine and subsequently the Captain took over control as PF at 1531:27hrs. Then 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 1534:33hrs the Captain confirmed that “okay this one is good for us so far”. At 1535:19hrs, the Captain instructed the F/O to call ‘it’ then since they were probably not going anywhere and concluded that “we’re gonna be investigated by the NCAA”.
The flight crew became increasingly concerned as the flight transitioned into the approach phase during which time the crew received series of heading and altitude radar vectors from the Radar Controller. At the same time, the crew also carried out some of the pre-landing tasks that included the extension of slats at 1537:07hrs and the speed-brakes were deployed at 1537:10hrs. The First Officer indicated that they were slightly high and the Captain replied that he was correcting and then requested for flaps eleven. At 1537:53hrs the Captain further requested for flaps one-five (flaps fifteen). And subsequently the problem became compounded as thrust was required to continue the final approach. Meanwhile, there was no evidence from the CVR transcript, that an engine-out descent profile was followed and flown towards Lagos.
At 1538:35hrs, both crew indicated that they were 21 miles on the localizer. At 1538:54hrs, there was EGPWS automated voice warning of “landing gear” which the Captain responded to at 1539:10hrs by requesting for the landing gear to be selected down. At 1539:56hrs, Lagos Radar Controller requested DANACO 0992 to verify passing seven thousand seven hundred feet which was confirmed by the First Officer. At 1540:42hrs, he confirmed to the Captain that they were five thousand, fifteen miles, which the Captain acknowledged with an increase in the rate of descent.
According to the CVR transcript at 1541:46hrs the First Officer inquired if “both engines come up” and the Captain replied “negative” at 1541:48hrs. The two engines finally did not respond to throttle inputs as both engines failed to produce the commanded thrust.
From evidence available, there was never any call for the checklist both normal and non-normal/emergency throughout the entire flight and the use of the Quick Reference Hand Book (QRH) was never detected.
At 1541:56hrs, the F/O asked the Captain if he can declare an emergency and they subsequently discussed and agreed to declare an emergency. At 1542:10hrs, DANACO 0992 radioed an Emergency Distress Call stating “Dual Engine Failure, negative response from throttles”. The Radar Controller then requested DANACO 0992 to “say again the last transmission” and the crew repeated the Distress message before the Radar Controller directed DANACO 0992 to contact the Control Tower on 118.1 MHz for landing instructions. DANACO 0992 was however unable to contact the Tower before the crash.
According to the CVR transcript, they tried to change frequency to 118.1 MHz which was indicated by a sound similar to radio frequency knob spinning at 1542:25hrs but were unable to select the Tower frequency. At 1542:35hrs the Captain requested for flaps twenty eight which the First Officer selected. This was after the crew had declared an Emergency of dual engine failure. At 1542:50hrs the First Officer informed the Purser through the intercom to prepare for landing and that, as of then the situation appeared under control.
At 1543:30hrs there was an automated voice of “altitude” followed by the Captain’s indication of sighting the runway at 1543:45hrs. He then instructed the First Officer to select the flaps up at 1543:49hrs followed by another instruction to select the landing gears up at 1543:50hrs. At this point, the Captain stated that he would not want to stall the aircraft. The Captain then concluded that “we just lost everything, we lost an engine, I lost both engines”. And during the next twenty five seconds, the Captain requested for everything that could help recover thrust including “relight”, “ignition override” “just anything” to be given to him. During the later stages of the approach, there were numerous sounds similar to stabilizer trim in motion as the Captain tried to keep the aircraft flying to avoid impacting obstacles but to no avail. From 1543:32hrs the automated voice of “altitude” continued sounding until the end of recording.
Indeed, the Captain expressed concern that he would not want to stall the aircraft, as the aircraft had no power. The last event captured on the CVR was “too low gear” at 1544:29hrs.
The aircraft crashed into a densely populated residential area about 5.8 miles north of Lagos airport at 1544:33hrs in daylight and in Visual Meteorological Conditions, reference point N06o 40.318, E003o 18.845, elevation of 177ft. The aircraft wreckage was on approximately the extended centre line of runway 18R.
The aircraft was largely consumed by impacts and post crash fire with the tail section, the two burnt engines and portions of both wings representing only about 15% of the airplane which was recovered from the crash-site for further examination. The flight recorders were recovered with signs of extreme exposure to fire, which made the FDR unreadable due to the damage caused by the fire. However, the CVR was downloaded successfully.
With respect to procedures the NAIB analysed:
At the time the crew did not get engine response from the throttle movement, appropriate checklists should have been used for the safe operation of the flight. Either of the pilots should have called for the dual engine failure Checklist; this Checklist would have helped to outline the commit points and prioritized their duties based on what to do and what not to do. The non-use or improper use of a Checklist can cause incidents/accidents. The purpose of these simple memory joggers is to improve aviation safety through crew co-ordination and proper accomplishment of multiple tasks.
Instead, the captain requested that the co-pilot should give him “anything”, “everything”, “gear down and flaps”. The gear and flap down changed the configuration and slowed the aircraft and reduced the stall speed. When it became obvious that the aircraft speed was dropping, the captain then requested for the gear and flaps to be retracted, this increased the stall speed. The captain was heard saying “I don’t want to stall, I don’t want to stall”. At a time the pilots were not sure which runway was nearer. The aircraft crashed into a built-up area in Lagos.
Inappropriate decision making was observed as deviation from regulatory and company procedures in considering diversion option to the officially filed alternate airport which was Ilorin. The crew also exhibited a lack of situation awareness which compounded their problem.
With respect to the engines the NAIB analysed:
5N-RAM No.1 Engine ESN 718142 (Fuel System Component Damage)
- Slight diameter reduction near nozzle No. 2 fittings.
- Fuel feeder lines attaching No.5 fittings were both (primary and secondary) fractured flush, exhibiting shear lips.
The left hand manifold exhibited the following damage and observations:
- Primary fuel transfer tube was pinched almost closed at the No. 8 fuel nozzle fitting and reduced diameter at fuel nozzle No.7 fittings.
- Engine was not responsive to throttle movement.
- The fuel-feeder lines attached to the No. 6 fittings were both fractured at the No.6 fitting while the secondary feeder tube was attached and twisted/crimped.
Engine was not in compliance with SB 6452 and was overhauled on 3rd August, 2011 at Millenium facility in Miami, USA.
5N-RAM No. 2 Engine ESN 728113 (Fuel System Component Damage):
- Secondary fuel feeder line to right hand manifold collapsed and bent.
- Right hand primary and secondary manifold supply tubes were bent at the No.5 fittings.
- Similar damage occurred on left hand primary and secondary manifold supply tube at the No. 6 fittings.
- The left hand primary manifold had a circumferential crack outboard of the fan bypass duct.
- Engine not responsive to throttle movement.
- Engine was in compliance with SB 6452 which was accomplished during one of the shop visits to Volvo Aero Engine Maintenance facility in Sweden on 27th September, 2005.
- Overhauled on 2nd December, 2011 in Millennium Engine Associates Inc.
The NAIB found a third engine showing deficiencies on 5N-SAI and continued analysis:
Summary
- All three engines were overhauled by the same Repair Station, Millenium Engine Associates Inc.
- The accident aircraft engines were overhauled within a time frame of four (4) months in the same facility, while the air return aircraft engine was overhauled much later.
- Out of the three engines in consideration, two were not in compliance with SB 6452 while the third was SB 6452-compliant, with new tube material which has significantly greater fatigue life, reducing the occurrences of fractures.
- All 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.
The work processes, ethics and culture in Global Engine Maintenance LLC formerly known as Millenium Engine Associates Inc. are subject of concern to Nigerian Civil Aviation Authority and AIB. This concern was as a result from the discovery made in the cause of investigation in the Air Return aircraft 5N-SAI, which shows the improper installation of the right hand fuel manifold inlet fairing. nstallation of distorted manifolds and incorrect shimming of the manifold which are capable of aggravating the condition as stated in SB 6452. There was lack of engagement of the front and rear sections of the manifold fairings on the inboard side.
The engine suffered thermal stress and fractured secondary manifold feeder line resulting in loss of power and failure to respond to throttle movement. The Nigerian Regulatory Authority (NCAA) directed on 18th December, 2013 after an audit was carried out on Dana Airlines, that all engines previously overhauled by Millenium Engines Associates Inc. be sent to other NCAA approved Engine Shop(s) for overhaul before they could be re-installed on any Dana Airlines aircraft. This was a clear safety concern by the Regulatory Authority.
Consequently, the loss of thrust and no response to throttle movement were common to failure sequence in all three engines with catastrophic result in 5N-RAM.
With respect to engine damage found during examination after the crash the NAIB analysed:
The engines teardown were successfully carried out without any core engine anomalies detected apart from the fuel manifold issues that would have made the aircraft mechanically unsafe. However, the observed damage to the engines was consistent with low-to no rotation speed at impact but no indications of core engine hardware preimpact malfunction was revealed at the engines teardown.
The NAIB analysed that there had been 94 similiar occurrences during which an engine had become unresponsive. All these cases showed commonalities which led to a service bulletin 6452 with the following reasoning:
Reason:
1. Problem: There have been several instances reported of secondary fuel manifold assembly fractures, causing fuel leaks, which resulted in 94 Unscheduled Engine Removals (UERs), one In-flight Shut Down (IFSD) and two Air Turn Backs (ATBs). There was also one contained fire in 2001 and the extent of the damage was confined to a dark streak of coked fuel on the Combustion Chamber Outer Case (CCOC), and fan duct damage.
2. Cause: Thermal expansion results in high stresses on the tubes, which do not have adequate fatigue life for those stresses. Also, installation of distorted manifolds and incorrect shimming of the manifold during installation can aggravate the condition.
3. Solution: Provide new secondary fuel manifold assemblies, incorporating tubes fabricated from new material which has a fatigue life that is approximately 2 times greater than the current tube material to improve the durability of the manifold assemblies.
Description:
Replace or modify the left and right secondary fuel manifold assemblies.
The NAIB analysed:
Witness accounts, from former Dana Airlines pilots, suggested an undesirable maintenance culture and defects not being entered in aircraft log books. They also mentioned other unhealthy work practices bordering on restricted background checks and references. AIB investigated these interview accounts and confirmed some of the alleged practices for which safety recommendations were issued.
However, the Bureau discovered that some of the former pilots of the Airlines were involved in some of these malpractices. These pilots failed to report these non-entries into the technical log book to the appropriate authorities when they were in the service of the Airline. If reports had been made to the Airline’s Quality Department and NCAA, these would have led to sanctions and actions to improve air safety.
With respect to the role of Nigeria's CAA the NAIB analysed:
NCAA general validation requirements are clearly stated in Nig. CARs. 2.2.4.1.
However, a thorough validation of the captain’s foreign licence was omitted. The captain had issues that were unresolved with FAA USA and background checks by NCAA were found to be inadequate. The validated licence was stamped but not signed by the authority. The authority should have looked more on the type of training given and the training required. The validation was done without compliance with the Nig. CARs, which stated that before validation is issued, the authenticity of the foreign licence would have been confirmed. The confirmation had not been concluded when the captain started flying for Dana Airlines. The Regulations state: The Authority will verify the authenticity of the licence, ratings, authorizations and the medical certificate with the state of licence issue prior to issuing the validation.
Incident Facts
Date of incident
Jun 3, 2012
Airline
Dana Air
Aircraft Registration
5N-RAM
Aircraft Type
McDonnell Douglas MD-83
ICAO Type Designator
MD83
This article is published under license from Avherald.com. © of text by Avherald.com.
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