Go Back  PPRuNe Forums > PPRuNe Worldwide > African Aviation
Reload this Page >

Preliminary report of Dana Crash

Wikiposts
Search
African Aviation Regional issues that affect the numerous pilots who work in this area of the world.

Preliminary report of Dana Crash

Thread Tools
 
Search this Thread
 
Old 12th Jul 2012, 17:20
  #1 (permalink)  
Thread Starter
 
Join Date: Apr 2012
Location: Abuja
Posts: 11
Likes: 0
Received 0 Likes on 0 Posts
Preliminary report of Dana Crash

Less than two months after the*ill-fated Dana flight from Abuja to*Lagos, the Accident Investigation Bureau (AIB) led by Capt. M.S. Usman has submitted its preliminary report of Investigation over the actual cause of the Crash.
According to the preliminary Investigation by Capt. Usman, the Dana flight On 3rd*June 2012 about 1545 hours*[1], 5N-RAM, a MD83, a domestic scheduled commercial flight, operated by Dana Airlines Limited as flight 992 (DAN 992), crashed into a densely populated area during a forced landing following a total loss of power in both engines while on approach to Muhammed Murtala Airport (LOS), Lagos, Nigeria.**Visual meteorological conditions prevailed at the time and the airplane was on an instrument flight plan. All of the 153 persons aboard the airplane, including the 6 crew members were fatally injured. There were 10 confirmed ground fatalities. The airplane was destroyed.**There was post impact fire. The flight originated at Abuja (ABV) and the destination was LOS.
The airplane was on the fourth flight segment of the day, consisting of two round-trips between Lagos and Abuja.**The accident occurred during the return leg of the second trip.**DAN 992 was on final approach for runway 18R at LOS when the crew reported the total loss of power.
According to interviews, the flight arrived in ABV as Dana Air flight 993 about 1350.**According to Dana Air ground personnel, routine turn-around activities occurred, including refueling of the airplane.***DAN 992 initiated engine startup at 1436, taxied to the runway and was later airborne at 1458 after the flight had reported that it had a fuel endurance of 3.5 hours.**Shortly after takeoff, DAN 992 reported 1545 as the estimated time of arrival at LOS as the flight climbed to a cruise altitude of 26,000 ft[2]. DAN0992 made contact with Lagos Area Control Center at 1518 hours.
The report revealed that the cockpit voice recorder (CVR) retained about 31 minutes of the flight and starts about 1515 at which time the captain and first officer were in a discussion of a non-normal condition regarding the correlation between the engine throttle setting and an engine power indication[3].**However, they did not voice concerns then that the condition would affect the continuation of the flight.**The flight crew continued to monitor the condition and became increasingly concerned as the flight transition through the initial descent from cruise altitude at 1522 and the subsequent approach phase.
The report stated that “DAN 992 reported passing through 18,100 and 7,700 ft, respectively, at 1530 and 1540 hours. After receiving a series of heading and altitude assignments from the controller, DAN 992 was issued the final heading to intercept the final approach course for runway 18R.
During the period of 1537 and 15:41 the flight crew engaged in pre-landing tasks including deployment of the slats, and extension of the flaps and landing gear.**At 15:41:16 the first officer (FO) inquired, “both engines coming up?” and the captain (Capt) replied*“negative.”*The flight crew subsequently discussed and agreed to declare an emergency.**At 1542:10, DANA 992 radioed an emergency distress call indicating “dual engine failure . . . negative response from throttle.”
“At 1542:35, the flight crew lowered the flaps further and continued with the approach and discussed landing alternatively on runway 18L.**At 1542:45, the Capt reported the runway in sight and instructed the FO to raise the flaps up and 4 seconds later to raise the landing gear.
At 1543:27 hours, the Capt informed the FO “we just lost everything, we lost an engine. I lost both engines”.**During the next 25 seconds until the end of the CVR recording, the flight crew was attempting to restart the engines”.
The airplane crashed in a residential area about 5.8 miles north of LOS. The airplane wreckage was on approximately the extended centerline of runway 18R.**During the impact sequence, the airplane struck an incomplete building, two trees and three buildings. The wreckage was confined, with the separated tail section and engines located at the beginning of the debris field.
The airplane was mostly consumed by post crash fire. The tail section, both engines and portions of both wings, representing only about 15% of the airplane were recovered from the accident site for further examination.
The two flight recorders, the Cockpit Voice Recorder (CVR) and the flight data recorder (FDR) were analysed at the facilities of the National Transportation Safety Board (NTSB), Washington, D.C., USA.**The solid state based memory in the CVR was in good condition and retained 31 minutes of audio information.**The digital tape based memory in the FDR succumbed to the post crash fire and melted, consequently no data could be recovered.
The captain, age 55, held an airline transport pilot license with type ratings in the A-320[4], DC-9, FK-28[5], and SF-340[6].**He had over 18,116 hours of total time, including 16,416 hours of pilot-in-command time (PIC).**The captain had 7,461 hours in the accident model airplane all of which was as PIC.**He was employed with Dana Air on 14 March 2012. He began flying line operations for the company in late May 2012 and had since accrued over 120 hours of flight time. The captain had acquired about 3, 78, and 116 flight hours, respectively, in the preceding 24 hours, 30 and 90 days.
The first officer, age 34, held a commercial pilot license he was type rated in MD-83.**He had 1,143 hours of total time, including about 200 hours as pilot-in-command.**The first officer had 808 hours in the accident model airplane all of which was second-in-command.**He had been previously employed with Dana Air as the Director of Cabin Service before he was hired as a pilot about January 2011.*The first officer had accrued about 3, 42, and 154 flight hours, respectively, during the preceding 24 hours, 30 and 90 days.
The airplane was manufactured in 1990 and according to maintenance records it had accumulated 60,846 hours**(35,219 cycles) of total time.**The left and right engines respectively had 54,322 (30,933 cycles) and 26,025 (12,466 cycles) hours of total time since new.**A review of the aircraft technical logs did not reveal of the previous 30 days did not indicate a condition.**The airplane had last undergone maintenance on 1st*June 2012, and after a return to service flight on 2nd*June 2012, it was operated on four revenue flights (two round trips between LOS and ABV) and another four flights on 3rd*June 2012.
Fueling records indicated the airplane was uplifted with 8000 lbs of fuel before departure from ABV. The flight crew reported to ATC they had 26,000 lbs of total fuel.**Preliminary analysis of fuel samples from the refueling truck and the supply tank at ABV were negative for contamination.
The investigative activities have included, in part, visual examination of the aircraft wreckage, review of maintenance records and other historical information of the aircraft, documentation of the training and experience of the flight crew, determination the chronology of the flight, review of recorded data, reconstructing the aircraft refueling, and collection of related fuel samples, and interviews of relevant personnel.
Future investigative activities will include, but is not limited to, the detailed examination of the engines, further testing of fuel samples, continued factual gathering of relevant historical, operational, maintenance and performance information of the accident airplane in addition to other similar airplane models, further development of the background of the flightcrew, further analysis of the CVR audio recording and review of pertinent issues associated with regulatory oversight.
As the State of Occurrence, the Accident Investigation Bureau (AIB) has instituted an investigation in accordance with the standards and recommendations specified in the provisions of Annex 13 of the International Civil Aviation Organization.**As the State of manufacture of the airplane and engine, a US Accredited Representative has been appointed and assisted by US technical advisors from the NTSB, US Federal Aviation Administration, Boeing Airplane Company, and Pratt & Whitney Engines.
In accordance with Annex 13,*“the sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents.**It is not for the purpose of this activity to apportion blame or liability.”
Accordingly, the AIB with the participation of the parties, including the NCAA, will seek to identify any areas of safety concerns during the investigation and implement the appropriate actions for correction or improvement.
*
Capt. Usman has also pointed out that the content of the report is based on preliminary information. The Bureau will continue to conduct the investigation in a meticulous and methodical manner and release facts as they become validated.


Citizens Platform
fly5N is offline  
Old 14th Jul 2012, 10:43
  #2 (permalink)  
 
Join Date: Sep 2003
Location: DNMM/UK
Posts: 286
Likes: 0
Received 0 Likes on 0 Posts
Fuel contamiation

I agree the fuel may not have been contaminated i.e. no water, but was it actually jetA1?
Its a usual practice in the Nigerian petroleum industry to mix (blend) fuels with cheaper grades. For example it is almost impossible to find pure diesel in Nigeria as marketers blend diesel with cheaper kerosine to maximise profits.
There was a media report that a fuel marketer was selling JET A1 despite not recieving any new supplies. This was because they were mixing Jet A1 (Aviation turbine Kerosine ATK) with the cheaper Dual purpose kerosine (DPK).
I'm very much interested in the results of testing of samples taking by the NTSB for analysis.
Capt. Manuvar is offline  
Old 14th Jul 2012, 13:57
  #3 (permalink)  
 
Join Date: Apr 2003
Location: Germany
Age: 76
Posts: 1,561
Likes: 0
Received 0 Likes on 0 Posts
As previously noted...

No other aircraft reported fuel-related problems after fueling at Abuja. This fact makes it unlikely that fuel contamination was the main cause of this accident.

Unfortunately, the FDR was damaged by fire, so that all the investigators have is the CVR and whatever other evidence can be gathered from the crash site. This means that we may never know for sure what the cause was.
chuks is offline  
Old 15th Jul 2012, 01:00
  #4 (permalink)  
 
Join Date: Mar 2006
Location: Far, far away.....
Posts: 111
Likes: 0
Received 0 Likes on 0 Posts
Is it possible that Dana would have tried to "farouk" the AIB to ensure that the dana accident report is "bellview-ed"?
DRPAM007 is offline  
Old 15th Jul 2012, 11:02
  #5 (permalink)  
 
Join Date: Jul 2007
Location: Bucks
Posts: 225
Likes: 0
Received 0 Likes on 0 Posts
I agree with chuks' theory on the other machines that uplifted out of the same station on the same day & yes we may never really find out.

The big question remains, was the FDR really destroyed?
NaijaNinja is offline  
Old 16th Jul 2012, 06:27
  #6 (permalink)  
 
Join Date: Apr 2003
Location: Germany
Age: 76
Posts: 1,561
Likes: 0
Received 0 Likes on 0 Posts
Good question!

Somewhere in the reports it is written that this was an older FDR, one that used tape for recording, when the tape was destroyed or made unreadable or whatever. Given that we have seen far worse crashes in terms of post-crash damage that FDRs have survived, it is a very, very good question why this FDR should be unreadable, but.... The people who can answer that question are the very ones we mistrust. 'The FDR is unreadable?'

'Oh! Yes, Sah!'

'Umm.... Okay, then!' What else can one ask?

I was just reminded the other day of the fire in the Nitel Building in Lagos. As it happened, I was in the area a few hours earlier to get a photo for a new passport. On the way back to Ikeja I heard the sirens and saw the smoke, so that I must have just missed being in the middle of all Hell breaking loose.

That was a case of financial records being stored in a skyscraper, highly combustible financial records. Big wahallah, nothing finally concluded, back to 'business as usual...' An air crash is very small potatoes compared to that, plus it's plausible that the FDR really is unreadable. This one might be a case of 'Move along! There is nothing to be seen!' Bet on Dana folding to reappear under another name, leaving the families of the victims left stood around looking stupid.
chuks is offline  
Old 17th Jul 2012, 15:27
  #7 (permalink)  
 
Join Date: Dec 2008
Location: Benin City, Nigeria
Posts: 92
Likes: 0
Received 0 Likes on 0 Posts
Yep, DRPAM007, money's been spread around

Then again, it's a rumour, although the source commanded, (seemed to deserve), hearing.
The Indians also made the extremely few Naijans who hesitated look stupid as they watched their colleagues bite the bullet. Uniformed types fell for what will eventually amount to crumbs too.
Ultimately, it didn't occur to the traitors that Indians (and Lebanese) understand our people better than they understand themselves...
flareout BC is offline  
Old 18th Jul 2012, 08:30
  #8 (permalink)  
 
Join Date: Mar 2006
Location: Far, far away.....
Posts: 111
Likes: 0
Received 0 Likes on 0 Posts
I'm just concerned that this may rob the industry of not just the valuable information that may forestall re-occurence, but also status and integrity of our maintenance systems.
It may have been a chance event that the FDR was genuinely destroyed in the post crash fire but what if some one deliberately ensured the data became unreadable by exposing it to it's design sustained temperature 1100 degrees centigrade for 30 minutes. This is not easy to achieve except:
  • Dana had installed an unserviceable FDR which did not meet the specifications detailed in ICAO annex 6: Operations of aircraft. OR
  • Some interested parties have some data they want to conceal.

After 1990, these devices are designed to withstand at least these minimum requirement:
  • Fire (High Intensity) - 1100°C flame covering 100% of recorder for 30 minutes. (60 minutes if ED56 test protocol is used)
  • Fire (Low Intensity) - 260°C Oven test for 10 hours
  • Impact Shock - 3,400 Gs for 6.5 ms
  • Static Crush - 5,000 pounds for 5 minutes on each axis
  • Fluid Immersion - Immersion in aircraft fluids (fuel, oil etc.) for 24 hours
  • Water Immersion - Immersion in sea water for 30 days
  • Penetration Resistance - 500 lb. Dropped from 10 ft. with a Ľ-inch-diameter contact point
  • Hydrostatic Pressure - Pressure equivalent to depth of 20,000 ft.
DRPAM007 is offline  
Old 18th Jul 2012, 09:05
  #9 (permalink)  
 
Join Date: Apr 2003
Location: Germany
Age: 76
Posts: 1,561
Likes: 0
Received 0 Likes on 0 Posts
Where was the FDR sent for data read-out? I would assume it went back to the American manufacturer, and if it's the FDR's manufacturer saying it's unreadable, that might be taken as reliable information.

A double flame-out is no joke; if there's some problem with this series of aircraft then the industry really needs to see those data. As is, I suppose everyone else just shrugs and assumes some sort of screw-up that is unique to Nigeria, something down to a lack of operating standards. There certainly have been plenty of accidents caused by that, and that situation probably persists despite all the fancy rhetoric about FAA approval and what-not.

Abuja-Lagos is a fairly short sector so that it's hard to imagine an accident caused by running out of fuel, but that is the most common cause for a dual engine failure! A dual bird-strike (at five thousand feet?), synchronous catastrophic mechanical failures in both engines, some way the power levers ('throttles') came disconnected from both engines, fuel contamination... all of these seem like pretty wild guesses, compared to simple fuel starvation.

This would have to be tracked down by looking at some chain of events such as mis-fueling coupled with fuel level indicator problems and a failure to verify the fuel state prior to departure. That's doable, just not as simple as looking at the FDR read-out to see indications of fuel starvation.

It will be interesting to see where the accident investigation goes from the point where we have been told that the FDR is unreadable.
chuks is offline  
Old 20th Jul 2012, 15:37
  #10 (permalink)  
 
Join Date: Mar 2011
Location: Southampton, UK
Posts: 3
Likes: 0
Received 0 Likes on 0 Posts
Just replying to register my interest in this thread.

The possible fuel issues are very interesting. I do remember when BA first opened the route back in 1999 having to pop in to Accra on the way home as Jet A1 could not be guaranteed at ABV. This was still going on as late as 2003 and probably beyond.

Unfortunately the local carriers don't have the option, I guess.
Rob446 is offline  
Old 22nd Jul 2012, 14:06
  #11 (permalink)  
 
Join Date: May 2002
Location: GC Paradise
Posts: 1,100
Likes: 0
Received 4 Likes on 3 Posts
The report revealed that the cockpit voice recorder (CVR) retained about 31 minutes of the flight and starts about 1515 at which time the captain and first officer were in a discussion of a non-normal condition regarding the correlation between the engine throttle setting and an engine power indication
The flight crew continued to monitor the condition and became increasingly concerned as the flight transition through the initial descent from cruise altitude at 1522 and the subsequent approach phase.
At 15:41:16 the first officer (FO) inquired, “both engines coming up?” and the captain (Capt) replied*“negative.”*The flight crew subsequently discussed and agreed to declare an emergency.**At 1542:10, DANA 992 radioed an emergency distress call indicating “dual engine failure . . . negative response from throttle.”
It all seems to tell us a story...the amount of fuel metered by the throttles no longer corresponded with the response of both engines...until finally both engines stopped regardless of throttle setting...strangulation of the fuel flow to both engines is indicated. Blocked fuel filters springs to mind...ice crystals, fuel waxing or contamination..?

Fueling records indicated the airplane was uplifted with 8000 lbs of fuel before departure from ABV. The flight crew reported to ATC they had 26,000 lbs of total fuel.**Preliminary analysis of fuel samples from the refueling truck and the supply tank at ABV were negative for contamination.
Only 8000 lbs of the 26,000 lbs on departure was loaded at ABV. So, why is their no mention of fuel supply checks from other sources of uplift?
FlexibleResponse is offline  
Old 22nd Jul 2012, 14:45
  #12 (permalink)  
Mistrust in Management
 
Join Date: Mar 2000
Location: UK
Posts: 973
Received 0 Likes on 0 Posts
Blocked fuel filters springs to mind...ice crystals, fuel waxing or contamination.
Forget fuel waxing - the sector is about 50 minutes on average and the fuel temp never even gets close to zero regardless of ambient temps. The fuel can never get below the Jet A1 freeze point.
exeng is offline  
Old 23rd Jul 2012, 19:50
  #13 (permalink)  
 
Join Date: Jan 2005
Location: here and there
Age: 53
Posts: 58
Likes: 0
Received 0 Likes on 0 Posts
Maintenace

How about the A-check just 4/5 sectors prior the accident ????
Fuel Filter replacement ? ( Critical task item !!), packings required and so on......... maybe no new o-rings on stock, .........

Far too many maybies................... guess no way to find out !!!!!
stallfail is offline  
Old 23rd Jul 2012, 20:15
  #14 (permalink)  
 
Join Date: Mar 2011
Location: Southampton, UK
Posts: 3
Likes: 0
Received 0 Likes on 0 Posts
Maybe nowhere near the freezing point of Jet A1, but were the tanks full of entirely uncontaminated, premium grade Jet A1? Uplift at ABV seems to be blameless (although we don't know when the samples tested were taken etc.) but as pointed out - the tanks already had fuel in them.
Maybe the fuel taken up at ABV didn't mix well with whatever was in the tanks already?

Who knows? With so many things that happen in this wonderful, perplexing country - we may never know.
Rob446 is offline  
Old 26th Jul 2012, 12:34
  #15 (permalink)  
 
Join Date: May 2002
Location: GC Paradise
Posts: 1,100
Likes: 0
Received 4 Likes on 3 Posts
Simultaneous double jet engine failure resulting from different and unrelated faults is statistically extremely remote and is generally ruled out as a non-player.

Double engine failure mostly results from a common fault:

1. Fuel supply to the engines.
2. Fuel quality.
3. Environmental conditions affecting fuel supply to the engines.
4. Maintenance or systemic error related to such critical tasks such as engine lubrication or inspection ports not secure...
5. External environmental conditions such as extreme weather events...torrential rain and hail or multiple bird strikes.

Take your pick...

Last edited by FlexibleResponse; 26th Jul 2012 at 12:41.
FlexibleResponse is offline  
Old 26th Jul 2012, 19:59
  #16 (permalink)  
 
Join Date: May 2010
Location: Atioro
Posts: 63
Likes: 0
Received 0 Likes on 0 Posts
Devil

@Flexible Response,sorry,None of the above
Gidigba is offline  
Old 26th Jul 2012, 20:44
  #17 (permalink)  
 
Join Date: Jan 2011
Location: Douala
Age: 44
Posts: 286
Likes: 0
Received 0 Likes on 0 Posts
Wonder

Very very stressful situation, dual engine flame out while on final above one of the most densely populated cities in the world.
One thing that I don't understand though is why after realising the engines were not responding, the crew decided to lower the flaps further down anyway. One would tend to think you would give yourself the best possible glide ratio by reducing flaps, even if it means flying 12° nose up. Just a thought though, since they probably would not have made it to the runway anyway.
737-NG is offline  
Old 26th Jul 2012, 22:25
  #18 (permalink)  
Mistrust in Management
 
Join Date: Mar 2000
Location: UK
Posts: 973
Received 0 Likes on 0 Posts
737NG

One would tend to think you would give yourself the best possible glide ratio by reducing flaps
If you read the report:

At 1542:45, the Capt reported the runway in sight and instructed the FO to raise the flaps up and 4 seconds later to raise the landing gear.
exeng is offline  
Old 27th Jul 2012, 02:36
  #19 (permalink)  
 
Join Date: Jan 2011
Location: Douala
Age: 44
Posts: 286
Likes: 0
Received 0 Likes on 0 Posts
Thanks Exeng

Yes I see now.

I find it (still) odd to do after having lowered them in the first place 10 seconds earlier. AND worse the gear was down. Although they already knew something was wrong with the engines, they treated the approach like a classic one with early configuration.

But once again, not trying to blame anybody, as who knows if they could have made it past the houses, as the runway was obviously out of gliding distance.
737-NG is offline  
Old 27th Jul 2012, 13:38
  #20 (permalink)  
 
Join Date: May 2002
Location: GC Paradise
Posts: 1,100
Likes: 0
Received 4 Likes on 3 Posts
Gidigba
Devil
@Flexible Response,sorry,None of the above
Mmmm...? In that case, do you think that the cause will be made known?
FlexibleResponse is offline  

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off
Trackbacks are Off
Pingbacks are Off
Refbacks are Off



Contact Us - Archive - Advertising - Cookie Policy - Privacy Statement - Terms of Service

Copyright © 2024 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.