Dana Air Flight 992

Dana Air Flight 992
5N-RAM, the aircraft involved in the accident, seen here in Murtala Muhammed International Airport in 2009.
Accident
Date 3 June 2012
Summary Engine failure, subsequent pilot error leading to the crash
Site Lagos, Nigeria
06°40′19″N 03°18′50″E / 6.67194°N 3.31389°E / 6.67194; 3.31389Coordinates: 06°40′19″N 03°18′50″E / 6.67194°N 3.31389°E / 6.67194; 3.31389
Aircraft
Aircraft type McDonnell Douglas MD-83
Operator Dana Air
Registration 5N-RAM
Flight origin Nnamdi Azikiwe International Airport, Abuja, Nigeria
Destination Murtala Muhammed International Airport, Lagos, Nigeria
Passengers 147
Crew 6
Fatalities 153
Survivors 0
Ground casualties
Ground fatalities 10

Dana Air Flight 992 was a scheduled domestic commercial passenger flight from Abuja to Lagos, Nigeria. On Sunday, 3 June 2012, the McDonnell Douglas MD-83 aircraft on the flight crashed into a furniture works and printing press building in the Iju-Ishaga neighbourhood of Lagos.[1] The crash resulted in the deaths of all 153 people on board and 10 more on the ground.[2] The crash of Flight 992 is the deadliest aviation disaster involving a McDonnell Douglas MD-83, as well as the second-deadliest involving an MD-80 series aircraft, behind Inex-Adria Aviopromet Flight 1308. It is also the second-deadliest aircraft crash on Nigerian soil, behind the Kano air disaster of 1973.

Aircraft

The aircraft was a twin-engined McDonnell Douglas MD-83, registered in Nigeria as 5N-RAM, built in 1990 and used by Alaska Airlines until 2007. It was sold to another airline before being acquired by Dana Air in February 2009.[3][4][5] The airframe had accumulated more than 60,800 hours of total flight time since new.[6] The aircraft engines had over 55,300 and 26,000 hours of total flight time before the crash. The last maintenance on the aircraft was performed on 1 June 2012, two days before the accident.[6]

Accident

Flight 992 departed Abuja at 14:58 local time and was cleared to flight level 260. At this point, the flight was still normal.[7]

17 minutes after taking off from Abuja, the crew of Flight 992 noticed an abnormality on the left engine and started to discuss the problem. The Captain later stated that "we just want to get home". The First Officer then asked the Captain if he should call the Engineer to analyse the problem, but the Captain declined. The Captain stated that he and the First Officer could figure the cause of the problem by themselves, and declared that the Engineer's help was not needed.[7]

The Captain asked the First Officer if one of the ground crews had tampered with the panel near the plane's rear door, and subsequently stated that "the guy" had problems and was pissed at them. The flight continued to Lagos and the crew continued to discuss the problem they were facing. They noticed that there were differences on the EPR value on the engines. The crew also noticed that there was no response from the left engine when they advanced the throttle lever, thus concluded that the left engine was inoperative. The crew decided to start their descent towards Lagos. As a failure on the left engine occurred, the crew should have looked at their Quick Reference Handbook (QRH) and followed procedures accordingly, but failed to do so.[7]

The Captain then ordered the First Officer to increase Flight 992's rate of descent, however the First Officer declined, stating that the gradual descent was far more effective in order to maintain their height. The crew was then cleared by Lagos for an approach to Runway 18L. The crew later asked for clearance for an approach to Runway 18R and was subsequently cleared by Lagos ATC.[7]

At 15:31 local time, the crew finally declared that there was no throttle response from either engine. As a result, the Captain took over the control from the First Officer. Even though the left engine of Flight 992's was inoperative, the crew didn't issue an emergency call. After the left engine failed, the right engine also started to fail, which was confirmed later by the crew. The crew then switched off several systems on the plane's engine, which were the engine anti – ice, ignition, and bleed – air. At the time, the Captain was still calm and still did not declare an emergency, stating "okay this one is good for us so far".[7]

At 15:35, the Captain stated that they will be investigated by the NCAA.[7]

As the crew received several instructions of headings and radar vectors by the ATC, the crew started to worry about their condition. The crew then started their pre-landing tasks, including the deployment of the air brakes and the setting of the flaps and slats. The engine problem became compounded as thrust was required to continue the final approach.[7]

The First Officer then asked the Captain if both engines were operative, to which the Captain replied, "negative". Both engines failed to produce the commanded thrust. There was never a call for the checklist both normal and non-normal/emergency throughout the flight and there is no indication the Quick Reference Handbook (QRH) was consulted.[7]

At 15:41, the crew declared an emergency when they were 11 nautical miles (20 km) from the airport.[8] and repeated the following messages until they were directed by ATC:

Dual Engine Failure, negative response from throttles.

The crew later selected flaps 28. At the time, the situation seemed to be under control and the crew asked the passengers to prepare for landing.[7]

A few minutes later, the "altitude" warning sounded, and the Captain stated that he had sighted the runway. The flaps were selected up and the crew selected the landing gears up. The Captain stated that he did not want to stall the plane. The Captain then concluded that "we just lost everything, we lost an engine, I lost both engines". During the next twenty five seconds, the Captain requested everything that could help recover thrust including "relight", "ignition override" "just anything" to be given to him. The crew then applied stabilizer trim several times as they tried to avoid obstacles and buildings ahead of them, but their attempts were useless. The plane lost altitude rapidly and the altitude warning sounded until the end of the recording.[7]

The MD-83 crashed into a crowded neighbourhood near the airport, with its tail section first striking an uncompleted building, two trees and three other ground structures. The tail detached from the plane, and the rest of the plane (the front part and the middle part) crashed into the building. The plane then exploded, consumed by its own 8,000 lbs of fuel. Fire occurred throughout the neighbourhood. The uncompleted building was storing flammable liquids in preparation for its intended use as a press building,[9] increasing the fire.[10]

The crash scene became chaotic, with The Sun reporting that thousands of Lagos residents attempted to approach the site. Crowds attempted to bring hoses to the site while soldiers attempted to disperse onlookers with punches and rubber whips. The onlookers then threw stones at the soldiers in retaliation.[9] Water for firefighting was scarce for several hours due to the city's shortage of fire trucks, and civilians attempted to fight the fire by hand with water from plastic buckets. Water trucks commandeered from nearby construction projects had difficulties reaching the site due to the narrow roads.[11]

Passengers and crews

Passengers

People on board by nationality
CountryPersons
 Nigeria138
 China4
 United States3
 India2
 Benin1
 Canada1
 France1
 Germany1
 Indonesia1
 Lebanon1
 Total153

Flight 992 was carrying 147 passengers, including 15 foreigners from 9 countries. The foreigners, confirmed by the Nigerian AAIB, were 4 Chinese nationals, 3 Americans, 2 Indians, and one each from Indonesia, Lebanon, Germany, France, Canada and Benin. Nigerian press stated that a newly-married couple were among the victims. Local media reported that several senior military officials were on the flight, including three army generals.[7]

Notable passengers included:[12]

  • Alhaji Ibrahim Damcida, the Under-Secretary of the Ministry of Industries.[13][14]

Crews

The Captain was Peter Waxtan, a 55-year old American with a total flying experience of 18,116 hours, with 7,466 hours on the MD-83. The Captain was hired by Dana Air on 14 March 2012. He began flying line training operations under the supervision of a training captain on 26 April 2012 after completing ground school and simulator training. He held several ratings, including Airbus A320, McDonnell Douglas DC-9, Fokker F-27 and Saab 340.[7]

According to documents retrieved by the Nigerian AAIB, in 2009, the Captain was suspended by the United States Federal Aviation Administration (FAA) for misdemeanours related to a heavy landing and fixing of panels that were neither entered in the aircraft logbook nor reported. The revalidated licence issued to him by NCAA was stamped but not signed by any NCAA official. The AAIB reported there was no documented evidence that the crew performed the mandatory Cockpit Resource Management training.[7]

The First Officer, Mahendra Singh Rathore, was a 34-year old Indian with a total flying experience of 1,143 hours, with 808 hours on the MD-83. He was previously employed at Dana Air as the Director of Cabin Service before he was hired as a pilot in January 2011.[7]

Autopsy

An autopsy was carried on the victims by the former vice chancellor of Lagos State University and pathologist Prof. John Obafunwa, who claimed to have successfully identified all of the dead.[15] The Nigerian AAIB claimed that all bodies were not identified; at least three bodies could not be identified by the forensic team.[7]

Investigation

The tail section of Flight 992

Access to the site was initially limited by the fire and crowds,[9] and later by strong winds and heavy rain. Rescuers also expressed concern that a damaged three-story apartment building might collapse on the crash site.[1]

A Joint Senate and House of Representatives Committee was set up by the federal government to investigate the accident.[16]

Both the cockpit voice recorder (CVR) and flight data recorder (FDR) were recovered and given to Nigeria's Accident Investigation Bureau (AIB).[8] Because the aircraft was American-made, the United States National Transportation Safety Board had observer status for the investigation.[10] The FDR was found to have been too heavily damaged in the post-crash fire to yield any information, but 31 minutes of conversation were recovered from the CVR. The captain reported engine warning lights and then a twin engine failure during the approach, as the landing gear and flaps were extending.[17]

On 3 June 2014, the AIB released a second interim statement on the investigation into the crash. It stated: "Investigative reviews of the engine teardown especially the fuel systems are still ongoing. During this process a similar incident occurred on another MD 83 aircraft of Dana Airlines on 6 October 2013. AIB is currently investigating in-depth systematic and safety issues associated with this second incident vis-à-vis the crashed sister ship, 5N-RAM. The safety actions adopted by the operator to redress the findings are being monitored and analyzed."[8]

Cause of dual engine failure

Nigerian AAIB examined both engines' fuel system components. Investigators revealed that the fuel feeder lines that attach to the No. 5 fitting (primary and secondary) were both fractured flush. These fractures caused fuel leaks that explained why the engines were unresponsive even when the crew applied throttle.[7]

Final report

On 13 March 2017, a 210-page final report by Nigeria's AIB into the crash was released and made public.[18]

The investigation identified the following 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 situational awareness, inappropriate decision making, and poor airmanship

Reactions

Accident location shown within Nigeria

Nigerian president Goodluck Jonathan declared three days of national mourning. He noted that the accident had "sadly plunged the nation into further sorrow on a day when Nigerians were already in grief over the loss of many other innocent lives in the church bombing in Bauchi state".[9] Jonathan also pledged that "every possible effort" would be made to boost the nation's aviation safety.[19]

Dana Air set up a 24-hour hotline for relatives to call and added a message to its website reading "Our thoughts and prayers are with the families of guests who were involved in the Dana Air mishap. May the souls of the deceased rest in peace".[20]

The federal government seized the license and also banned the MD-83 aircraft type used by Dana Air after the crash.[21] They also set up a nine-man technical and administrative panel to audit all airlines operating in the country.[22] On 5 September 2012, the suspension on Dana Air's operating license was lifted, and the airline started recertification and retraining processes.[23]

See also

References

  1. 1 2 Jon Gambrell (5 June 2012). "Rains Slow Search in Nigeria Plane Crash". Time. Associated Press. Archived from the original on 5 June 2012. Retrieved 4 June 2012.
  2. ↑ "Aviation Safety Network".
  3. ↑ "Nigeria: Tears As Relations Of Crash Victims Storm Airport | General News | Peacefmonline.com". News.peacefmonline.com. Archived from the original on 7 June 2012. Retrieved 10 June 2012.
  4. ↑ "The Nation Online Nigeria".
  5. ↑ "FAA Registry". Federal Aviation Administration. Retrieved 4 November 2014.
  6. 1 2 "UPDATED REPORT ON DANA AIR 0992" (PDF). AIB. Archived from the original (PDF) on 26 August 2014. Retrieved 16 August 2012.
  7. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 "Final Report of Dana Air Flight 992" (PDF). AAIB.
  8. 1 2 3 Hradecky, Simon (3 June 2012). "Crash: Dana MD83 at Lagos on Jun 3rd 2012, collided with power line on approach". Aviation Herald. Retrieved 3 June 2014.
  9. 1 2 3 4 "Lagos air crash: All aboard feared dead, officials say". BBC News. 3 June 2012. Retrieved 3 June 2012.
  10. 1 2 Adam Nossiter and Matthew L. Wald (4 June 2012). "Engine Trouble Was Reported Before Nigerian Crash". The New York Times. Retrieved 4 June 2012.
  11. ↑ Gambrell, Jon (3 June 2012). "Death from above in Lagos: Airplane crash kills 153". The Globe and Mail. Toronto. Retrieved 3 June 2012.
  12. ↑ "UPDATED: Dana Air Flight 9J-992-Air Passengers List". Sahara Reporters. Retrieved 22 April 2017.
  13. ↑ "Victims Of Dana Crash: NNPC Spokesman Levi Ajuonuma, Northern Elder Ibrahim Damcida, son of late Rear Admiral Augustus Aikhomu, Ehime". Naija News. Naija 247 News. 4 June 2012. Retrieved 4 June 2012.
  14. ↑ "120 Bodies Recovered from Wreckage of Dana Air Flight 922; as President Jonathan Inspects Crash Site". Nigeriaplus.com. Archived from the original on 9 June 2012. Retrieved 10 June 2012.
  15. ↑ "Dana plane crash inquest obafunwas cross examination fixed for July 3". The Eagles Online. Lagos. 21 May 2013. Retrieved 3 December 2016.
  16. ↑ "The Nation Online". Archived from the original on 25 June 2012.
  17. ↑ "BBC News". 13 July 2012.
  18. ↑ "Investigation into 2012 Nigeria plane crash faults pilots". NewsOK. 14 March 2017.
  19. ↑ "Official: 153 on plane, at least 10 on ground dead after Nigeria crash". CNN. 3 June 2012. Retrieved 3 June 2012.
  20. ↑ "Lagos plane crash: Nigeria leader in air safety promise". BBC News. 4 June 2012. Retrieved 4 June 2012.
  21. ↑ "The Nation Online". Archived from the original on 22 February 2013.
  22. ↑ "BusinessDay online". Archived from the original on 3 February 2016.
  23. ↑ Dana Air. "DANA AIR BEGINS RE-CERTIFICATION EXERCISE, RE-TRAINING PROGRAMME". Archived from the original on 5 June 2012. Retrieved 19 September 2012.
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