Occurrence No.: AIBN-004-2019       Occurrence Type: Accident      Report Created: Jun 3/12
Title: Loss of Engine Power – Collision with Terrain       Flight Phase: Descent      Aircraft Type: MD-83
Carrier/Owner: Dana Airlines Nigeria Limited       A/C Registration: 5N-RAM
Location: Iju-Ishaga Area of Lagos State, Nigeria
Status: Final Last Update: Mar 13/17

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Conclusions

Summary Loss of power of the engines, crew actions and decision making were identified as major contributing factors to the accident.

With respect to engine power loss, the investigation did not lead to a definitive specific mechanical cause of the engine failures on 5N-RAM. Nor did the investigation lead to an explanation as to why both engines lost power on 5N-RAM, unlike similar occurrences where only one engine lost power.

Findings

1.    The flight crew were certified to fly the aircraft.
2.    The two pilots were foreigners.
3.    The Captain was new in the company having been employed on the 14th March, 2012 and was checked out as a line Captain on 1st May, 2012.
4.    The Captain had previous regulatory issues with the U.S.A Federal Aviation Administration (FAA) which led to his suspension at that time.
5.    All the reference letters presented by the Captain to Dana Airlines were neither signed nor authenticated.
6.   The background check on the Captain was inadequate.
7.   The line training given to the Captain was hurriedly carried out.
8.   There was no evidence that the deficiencies observed by the checkout Captain were addressed before the accident Captain was released for line operation.
9. The Co-pilot’s first experience on a commercial jet airplane was with Dana Airlines.
10. The aircraft was airworthy at the time of departure.
11. The aircraft came out from a check and was released to service on 1st June, 2012.
12. All deferred defects were cleared during the last check.
13. The left aileron bus cable was replaced on 1st June, 2012.
14.  A test flight was carried out on 2nd June, 2012 after the replacement of left aileron bus cable.
15.  5N-RAM Engine No.1 was not compliant with SB 6452 while Engine No. 2 was in compliance with the SB.
16.  Both 5N-RAM Engines were overhauled in Millenium Engine Associates Inc. within a time frame of four (4) months.
17. The aircraft departed Abuja with three hours and thirty minutes fuel endurance.
18.  The Engine number 1 lost power seventeen minutes into the flight.
19. There was no evidence that both normal and emergency Checklist were used throughout the duration of the flight before the crash.
20. The aircraft did not make any contact with the Control Tower before the crash.
21. The aircraft crashed five miles on the extended centreline of runway 18R.
22. The aircraft crashed into a residential area.
23. The aircraft first point of impact was an uncompleted building followed by a Mango tree, a Coconut tree, and finally three other buildings.
24. There was fire outbreak.
25. All 147 passengers and six crew were fatally injured.
26. There were other fatalities on ground.
27. The aircraft wreckage was concentrated in a small area.
28.The huge crowd of people at the crash site slowed down rescue efforts and investigation.
29. The Fire Service ran out of water and it was very difficult to replenish supply because of the crowd and poor road network.
30. Flight recorders (black boxes) were recovered but were badly burnt.
31. NCAA revalidation procedures were not followed before the captain’s licence was issued.
32. The validated licence issued by NCAA to the captain was stamped but not signed.
33. There was a related incident involving 5N-SAI, an aircraft in Dana Airlines’ fleet that led to an air return on 6th October, 2013 for which the Airline issued an Engineering Authorization No. MD83-EA-73-001.
34. Millenium Engine Associates Inc. (MRO) has changed its name to Global Engine Maintenance LLC with the same FAA certificate number Y2MR496Y.
35. 5N-SAI Engine No.1 was not compliant with SB 6452 and overhauled in Global Engine Maintenance LLC on 11th April, 2013.

Causes

Probable Causal Factors:

1. 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.

2. 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.

3. Lack of situation awareness, inappropriate decision making, and poor airmanship.

Other Factors and Concerns

Millenium Engine Associates Inc. (now Global Engine Maintenance LLC) Commonalities between 5N-RAM and 5N-SAI:

  • All three engines (two on 5N-RAM and one on 5N-SAI) 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. Installation 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.

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