13 February 2013

Nigeria: Human Error Caused Dana Crash - Report

The Dana plane crash that killed all 153 people aboard in Lagos in June 2012 was likely caused by a pilot's failure to turn on certain fuel pumps or valves, The Wall Street Journal reported, quoting people familiar with the joint investigation by U.S. and Nigerian officials.

The McDonnell Douglas MD-83, operated by Nigeria's Dana Air, lost power from both engines while approaching the airport in Lagos last June and slammed into an apartment building, killing at least six more people on the ground.

The most likely cause of the accident was the crew's failure to properly monitor fuel flow and turn on certain fuel pumps, according to industry and government safety experts familiar with the investigation. That would result in both engines shutting down almost simultaneously from lack of fuel. No other significant problems were discovered with the engines or other aircraft systems, these people said, and the 22-year-old plane had plenty of fuel onboard to reach the airport.

Partly fed by that fuel, the crash sparked an intense fire that raged for nearly a day and compromised the flight-data recorder. So investigators had less data to rely on than is usual in modern jetliner crashes and are still working on the final wording of the report. The preliminary focus on pilot error could be toned down, according to two people familiar with the details.

The cockpit voice recorder, which survived intact, showed the pilots spent the last 25 seconds unsuccessfully trying to restart the engines.

The paper pointed out though that people familiar with the probe cautioned that an official accident report hasn't been released and investigation's tentative conclusions haven't been reported and could still be revised. Muhtar Usman, the commissioner of Nigeria's Accident Investigation Bureau, said he hadn't yet heard results from the U.S. forensic labs.

"We have nothing to hide," said Dana spokesman Tony Usidamen, who declined to comment on the crash's cause until the report is completed. "We hope that the government will take the decision to make the report public.... It may or may not affect how the average traveler views the industry."

A preliminary report issued last year by Nigeria's Accident Investigation Bureau didn't say why the engines shut down, the paper said. Some pilots and safety experts said crews flying MD-80 series jets need to pay close attention to turning on certain booster pumps and ensuring that valves controlling fuel flow from various tanks are in the proper position, because mistakes can result in one or both engines ending up starved of fuel.

"This is purely a case of human error," said one Nigerian official with knowledge of the situation.

A spokeswoman for the U.S. National Transportation Safety Board, which is helping in the investigation, declined to comment. The NTSB typically is asked to help local investigators when a U.S.-made plane is involved in a major accident.

Nigerian investigators have called the crash one of the most bewildering in recent aviation history. They spent last June and July focused on the possibility that bad fuel, or even an obstruction as simple as a stray rag in the fuel tank, might have caused two engines to fail nearly simultaneously.

"The fuel supply in Nigeria has been probably audited a dozen times in the past couple weeks," an industry official involved in the fuel review said in June. "People are kicking around obscure scenarios at this point."

When the engines initially stopped running, according to one person familiar with the probe, the pilots pushed the controls to maximum thrust but the engines didn't react. The preliminary report said the crew radioed an emergency distress call to controllers, reporting a "dual engine failure" and "negative response from throttle."

We're not aware of that finding - AIB

The Accident Investigation Bureau (AIB) told Daily Trust in Lagas yesterday the report is mere speculation for now. The AIB spokesman Tunji Oketunbi, told our correspondent on the phone that, the suggestion in World Street Journal is "mere speculation."

"We have not concluded the investigations. We sent the engines of the MD-83 aircraft to the United States for tear down analysis" and they are still being analysed he said.

"So, that human error caused the crash is not from the AIB and we are not aware of that finding. Until the investigations are complete, we can't say for certain, what caused the Dana Air MD-83 crash" he noted. Asked if there are indicators from the preliminary investigations as to the possible cause of the crash he said he wouldn't say if there are indicators or not but the evidences that should have even given immediate indicators got destroyed in the fire. "We are now looking at other avenues to finding out exactly what happened and the engine tear down is one of the ways" he said.

"Do not forget, a lot of parties are interested in the findings of what caused the Dana crash for safety reasons and to forestall future occurrences. The aircraft engine manufacturers are interested in the report, the aircraft manufacturers are interested in the findings, and indeed the global aviation industry is interested in the report for aviation safety" he said.

"People shouldn't think we are treating the investigation casually. The investigation has to be thoroughly done and we will ensure just that" he assured.

When contacted on the matter, Dana Air spokesman, Tony Usidemen, said since "AIB is yet to release its final report, it is premature to comment on mere speculation."

"You can be rest assured we will issue an official statement once the AIB/government releases the final report. But the theory that the accident may have been caused by human error was collaborated by an industry expert who wouldn't want his name mentioned because of the sensitivity of the matter.

He told our correspondent that from the information he got, there are strong indications the pilot of the ill fated aircraft made some wrong decisions.

"I got it on good authority that the first engine of the aircraft packed up 18 minutes after take. The second one parked up 11 minutes before landing. The pilot had the option of an air return immediately after the first engine packed up, just like Med-View Airline did recently and averted a disaster. The pilot also had the option of calling for an emergency landing at Ilorin Airport or some other airport on his route but he chose to risk it to Lagos. Unfortunately, he couldn't make it to tell the story" he said.

"I think all airlines should take a cue from the recent Med-Vie example were the pilot made an air return minutes after it notice a surge in one of the aircraft's engines. That is the global standard," he said.

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