| Summary | Second to the loss of power of the engines, crew actions and decision making were major contributing factors to the accident. |
Crew Decision Making
| Synopsis – Crew Actions and Crew Decision Making | As mentioned in the Executive Summary, two of the three Probable Causal Factors in this accident were:
The CVR transcripts provide a number of examples of poor crew decision making. The crew did not follow the dictates of the Operations Manual as approved by NCAA. Checklists were not used. Occasionally, the call out for completion of checklist was made without checklist being read. The Crew Resource Management (CRM) between the technical crew was poor as evident in the CVR transcript. Swear words were frequently used. 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. The recruitment procedures and training record of the captain indicate that he was hurriedly hired. The performance assessment by all the training captains (on the accident captain) had always called for improvement which bordered on: inadequate cockpit discipline, non-standard ICAO phraseology and inadequate radio communications technique. Others included non-adherence to company/ICAO procedures, limited crew experience and inadequate line training on MD-83 aircraft type. The training was hurriedly performed. |
| Details | Details of the Crew Actions and Crew Decision making are contained in the following document, and specific sections:
http://www.aib.gov.ng/media/1117/dana-airlines-md83-5n-ram.pdf
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Crew Details
| Details are contained in in the following document, and specific sections:
https://aib.gov.ng/wp-content/uploads/2019/09/dana-airlines-md83-5n-ram.pdf
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Injuries to Person
| Details are contained in in the following document, and specific sections:
https://aib.gov.ng/wp-content/uploads/2019/09/dana-airlines-md83-5n-ram.pdf
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Survival Aspects
| The nature of the crash greatly reduced the chances of survival due to massive post crash fire. There was no liveable volume within the forward section of the aircraft. The ground impact, with over eighteen thousand pounds (18,000lbs) of fuel onboard the aircraft, and a printing press with a warehouse of printed books and paper materials turned the whole area into a huge fire ball.
The pathology report showed that some passengers died of smoke inhalation, that is, of carbon monoxide poisoning. “This suggests that the victims were alive for some time in the fire that probably followed the crash, that is, they did not die immediately after the impact.” Though the response of the search and rescue team was prompt, the operation of the fire services was hampered by inaccessibility to the crash site as a result of a bad road network. The massive crowd at the scene did not help the situation; crowd control became a big problem to the fire services and the National Emergency Management Agency (NEMA). |
| Details are contained in in the following document, and specific sections:
https://aib.gov.ng/wp-content/uploads/2019/09/dana-airlines-md83-5n-ram.pdf
|