Human Error Seen in Nigeria Air Crash WSJ
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Human Error Seen in Nigeria Air Crash WSJ
Article is a tad "rough" on the technical part, but if the engines were idling the Suction Feed asset might not be enough for fuel flow, with the pumps off?
Tragic if all they had to do is turn on the fuel pumps. Reckon the odds are a tad high for dual engine failure. Checklist? Tragic if true. Rowan
WSJ
The world's deadliest air disaster last year—a crash in Nigeria that killed all 153 people aboard and helped deflate the country's booming airline industry—was likely caused by a pilot's failure to turn on certain fuel pumps or valves, according to people familiar with the joint investigation by U.S. and Nigerian officials. (God Help Us - Rowan imput)
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.
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Associated Press
Rescuers at the Lagos, Nigeria, site of a crash that left 159 people dead in all. A preliminary U.S.-Nigerian investigation is said to fault the pilots.
.
It was Nigeria's first fatal commercial airline accident in six years and resulted in significant economic and political fallout, spurring something like a bill collectors' run on the nation's airlines: Contractors, airports and government agencies stopped servicing Nigerian airlines until they honored years-overdue invoices, while unpaid pilots demanded back pay.
An official accident report hasn't been released. The investigation's tentative conclusions haven't been reported and could still be revised, the people familiar with the probe cautioned. Muhtar Usman, the commissioner of Nigeria's Accident Investigation Bureau, said he hadn't yet heard results from the U.S. forensic labs.
By ending the mystery surrounding the crash, the findings stand to return a sense of normalcy to Nigeria's booming but dysfunctional air travel industry, analysts say.
"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."
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.
A preliminary report issued last year by Nigeria's Accident Investigation Bureau didn't say why the engines shut down.
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."
The crash brought an end to six unexpectedly encouraging years in Nigerian aviation, during which the country recorded no fatal commercial airline crashes. Before that time, the country, Africa's most populous, had been a byword for air disasters. A raft of new regulations, however, had turned Nigeria into a nascent success story.
Commercial passenger traffic rose to 14.3 million passengers per year in 2012, up 74% from 2006, according to government figures.
But as Nigeria's airlines acquired new planes to carry surging passenger loads, the largest of them incurred heavy debt. The June crash, analysts say, led the government to ground Nigeria's most severely indebted airlines. Three of the country's top four airlines by fleet size halted operations last year.
Airline executives also complained that members of Nigeria's graft-troubled government sought to leverage the tragedy for personal gain. In September, top airline Arik Air halted flights, saying the aviation minister had threatened to ground the company if shareholders didn't give her a 5% share in the airline. Aviation Ministry spokesman Joe Obi called that accusation false. Right....... Not likely........
Even with the Lagos crash, 2012 wasn't an unusually bad year for African air safety. The region's accident rate for Western-built jets was about four major crashes per million flights, roughly the same as 2011, based on statistics gathered by the International Air Transport Association. Nonetheless, that was nearly 10 times the world-wide accident rate for such jets.
Flew a 1 year contract, not too long ago, out of Lagos.
Definitely into the Fray.
Tragic if all they had to do is turn on the fuel pumps. Reckon the odds are a tad high for dual engine failure. Checklist? Tragic if true. Rowan
WSJ
The world's deadliest air disaster last year—a crash in Nigeria that killed all 153 people aboard and helped deflate the country's booming airline industry—was likely caused by a pilot's failure to turn on certain fuel pumps or valves, according to people familiar with the joint investigation by U.S. and Nigerian officials. (God Help Us - Rowan imput)
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.
Enlarge Image
Close
Associated Press
Rescuers at the Lagos, Nigeria, site of a crash that left 159 people dead in all. A preliminary U.S.-Nigerian investigation is said to fault the pilots.
.
It was Nigeria's first fatal commercial airline accident in six years and resulted in significant economic and political fallout, spurring something like a bill collectors' run on the nation's airlines: Contractors, airports and government agencies stopped servicing Nigerian airlines until they honored years-overdue invoices, while unpaid pilots demanded back pay.
An official accident report hasn't been released. The investigation's tentative conclusions haven't been reported and could still be revised, the people familiar with the probe cautioned. Muhtar Usman, the commissioner of Nigeria's Accident Investigation Bureau, said he hadn't yet heard results from the U.S. forensic labs.
By ending the mystery surrounding the crash, the findings stand to return a sense of normalcy to Nigeria's booming but dysfunctional air travel industry, analysts say.
"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."
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.
A preliminary report issued last year by Nigeria's Accident Investigation Bureau didn't say why the engines shut down.
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."
The crash brought an end to six unexpectedly encouraging years in Nigerian aviation, during which the country recorded no fatal commercial airline crashes. Before that time, the country, Africa's most populous, had been a byword for air disasters. A raft of new regulations, however, had turned Nigeria into a nascent success story.
Commercial passenger traffic rose to 14.3 million passengers per year in 2012, up 74% from 2006, according to government figures.
But as Nigeria's airlines acquired new planes to carry surging passenger loads, the largest of them incurred heavy debt. The June crash, analysts say, led the government to ground Nigeria's most severely indebted airlines. Three of the country's top four airlines by fleet size halted operations last year.
Airline executives also complained that members of Nigeria's graft-troubled government sought to leverage the tragedy for personal gain. In September, top airline Arik Air halted flights, saying the aviation minister had threatened to ground the company if shareholders didn't give her a 5% share in the airline. Aviation Ministry spokesman Joe Obi called that accusation false. Right....... Not likely........
Even with the Lagos crash, 2012 wasn't an unusually bad year for African air safety. The region's accident rate for Western-built jets was about four major crashes per million flights, roughly the same as 2011, based on statistics gathered by the International Air Transport Association. Nonetheless, that was nearly 10 times the world-wide accident rate for such jets.
Flew a 1 year contract, not too long ago, out of Lagos.
Definitely into the Fray.
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I read the news paper "todays" trust" this morning, and was so angry after!
what a load of bull****. I don't fly the MD, but find it REALLY hard to believe than bough engines quit just by normal idle trust.
The flight had problems on the sectors leading up to the crash and as I heard it, was the crew not happy flying it to Lagos.
The newpapir also said the MD's first engine had problems after just 17 min flight. At that point the must have been just a bit after WP BISAP, a short while after they bough quit on final app to LOS?! Wauw.. the made the flight in just about 20 min then?
I fly a business jet, and a fast one, but we still takes us 45 min to get from ABV to LOS. good job to do it in an MD in about 20?!
Further more. the article says the FDR was damaged in the fire, but leaves to tell that it was an illegal FDR that wow loooong overdue to be replaced.
It took Dana aprox. ½ a year to get flying again, and I still see some of the MD's on the ground. So the statement, that DANA or the airwortheness of the a/c is not to blame. well that sounds typical nigerian to me!
Total blame on the cpt (the expat) and make a ring of glory over the nigerian company (yes i know, its run by an indian) corruption 1 - aviation safety 0
sorry for my english.. it's not my native language.
what a load of bull****. I don't fly the MD, but find it REALLY hard to believe than bough engines quit just by normal idle trust.
The flight had problems on the sectors leading up to the crash and as I heard it, was the crew not happy flying it to Lagos.
The newpapir also said the MD's first engine had problems after just 17 min flight. At that point the must have been just a bit after WP BISAP, a short while after they bough quit on final app to LOS?! Wauw.. the made the flight in just about 20 min then?
I fly a business jet, and a fast one, but we still takes us 45 min to get from ABV to LOS. good job to do it in an MD in about 20?!
Further more. the article says the FDR was damaged in the fire, but leaves to tell that it was an illegal FDR that wow loooong overdue to be replaced.
It took Dana aprox. ½ a year to get flying again, and I still see some of the MD's on the ground. So the statement, that DANA or the airwortheness of the a/c is not to blame. well that sounds typical nigerian to me!
Total blame on the cpt (the expat) and make a ring of glory over the nigerian company (yes i know, its run by an indian) corruption 1 - aviation safety 0
sorry for my english.. it's not my native language.
Last edited by svaever; 13th Feb 2013 at 15:39.
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Why would the US NTSB blame the American pilot with no justification? The Nigerians have so far not released any report. I am not a pilot but find it strange that a pilot didnt switch some pumps on.
Mr svaever, I would advise restraint if you dont have the full story. I dont understand your referenc to 20mins. Please take a chill pill and read the preliminary report again. It is on the AAIB website f you to read and stop listening to people talking about engine problems on the previous flights. It took Dana 6 months to fly again because they were grounded by the Government. As far as I know, all their aircraft are flying apart from 1 that needs a part which is currently in the delivery process.
Can any MD80 series pilot confirm the possibility of switching on pumps cause this incident? I still lean to the theory of bad quality fuel.
Mr svaever, I would advise restraint if you dont have the full story. I dont understand your referenc to 20mins. Please take a chill pill and read the preliminary report again. It is on the AAIB website f you to read and stop listening to people talking about engine problems on the previous flights. It took Dana 6 months to fly again because they were grounded by the Government. As far as I know, all their aircraft are flying apart from 1 that needs a part which is currently in the delivery process.
Can any MD80 series pilot confirm the possibility of switching on pumps cause this incident? I still lean to the theory of bad quality fuel.
Last edited by Revnetwork; 14th Feb 2013 at 09:19.
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http://www.aib.gov.ng/reports/Interi...2%20prelim.pdf
That's the link for the preliminary report from the AIB. Nowhere does it mention pilot error
Svaever wrote
It took Dana aprox. ½ a year to get flying again, and I still see some of the MD's on the ground. So the statement, that DANA or the airwortheness of the a/c is not to blame. well that sounds typical nigerian to me!
Total blame on the cpt (the expat) and make a ring of glory over the nigerian company (yes i know, its run by an indian) corruption 1 - aviation safety 0
Total blame on the cpt (the expat) and make a ring of glory over the nigerian company (yes i know, its run by an indian) corruption 1 - aviation safety 0
My opinion is, IF (highly unlikely) they really forgot to turn the fuel pumps on, fuel starvation is more likely to occur at cruising altitude, not close to the ground.
Last edited by eagleflier; 14th Feb 2013 at 16:56.
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Might have been possible??
Eagleflier, a little different from your NG maybe? 
MD83 has fuel pressure problems and ultimately the engine fails. - NASA ASRS
MD83 has fuel pressure problems and ultimately the engine fails. - NASA ASRS
Last edited by ediks; 14th Feb 2013 at 20:31.
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Faulty fuel indication contributory?
I remember seeing this thread around the time of the crash, it made for interesting reading then, still does.
AA MD-80 Problems — Civil Aviation Forum | Airliners.net
AA MD-80 Problems — Civil Aviation Forum | Airliners.net
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MD80 Service Letter MD80-28-107
SUBJECT: DAILY DRAINING OF FUEL TANK SUMPS
MODEL: 717, C-9, DC-8, DC-9, DC-10, KC-10, KDC-10, MD-10, MD-11,
MD-80, and MD-90 Series
APPLICABILITY: All Douglas Heritage Series Airplanes
SUMMARY:
This service letter informs operators of a reported engine shutdown that occurred as the result of
erroneous output from fuel quantity gauging system components. Water contamination in the
fuel tanks may have contributed to the event. Boeing recommends that Douglas Heritage
airplane fuel tank sumps be drained daily.
BACKGROUND:
An operator reported that an MD-80 airplane left-hand engine shutdown during approach for
landing. The tank fuel quantity indicator read 2800 pounds of fuel; however, it was later verified
that the fuel tank was empty. The operator replaced the left and right wing fuel tank quantity
probes and compensators, the fuel tanks were treated with biocide, the left-hand engine fuel
control unit and fuel pump were replaced, and the airplane was returned to service. The fuel
tank low-level indication system had been previously deactivated.
On-aircraft troubleshooting determined that the probes and compensators provided incorrect
readings; however, bench testing of the components revealed no abnormal readings or
characteristics. Of note, on at least one previous occasion, the operator had experienced water
contamination affecting fuel quantity gauging system components.
DISCUSSION:
The fuel quantity gauging system on MD-80 series airplanes is a capacitance-type system.
Probes and compensators are immersed in the fuel, which acts as a dielectric media, and the
capacitance of the system indicates fuel quantity in the tanks. Water or biological contamination
can affect the dielectric constant of the fuel, which can result in erroneous fuel quantity
indications.
Before this event, the operator had extended daily fuel tank sump draining to every third day.
Because there were no adverse fuel quantity indications while daily sump draining was in effect,
the operator has since reverted to draining the fuel sumps daily.
Water permitted to remain in fuel tanks can contribute to erroneous fuel quantity indications and
permit biological contaminants to become established and proliferate. The combination of these
two factors can cause deterioration of fuel tank coatings and sealants, and result in structural
corrosion within the fuel tank.
The purpose of the continuous scavenge systems installed in Douglas Heritage airplanes is to
move water from areas that cannot drain to the vicinity of the pump inlets. However, relying on
these systems is not an acceptable alternative to daily fuel tank sump draining.
While it is understood that operators may establish the interval that they follow to drain airplane
fuel tank sumps, Boeing recommends that Douglas Heritage airplane fuel sumps be drained at
least daily. Note that draining fuel tank sumps is listed in each airplane’s maintenance check
manual as an item in the Overnight Check/Service Check work cards. In addition, each
airplane’s maintenance manual has steps listed to drain fuel tank sumps after each airplanerefueling
task. Although each manual contains statements that relate to how long the fuel should
sit before draining, this does not negate the need to drain the tank sumps.
Douglas Heritage airplanes’ maintenance manuals have been, or will be, revised to include the
International Air Transport Association (IATA) suggested fuel tank microbial contamination
detection procedures and matrix. Douglas Heritage and Boeing Heritage maintenance manual
processes, regarding fuel tank contamination, also have been standardized to the extent possible.
SUGGESTED OPERATOR ACTION:
Boeing recommends that operators implement and maintain a daily fuel tank sump-draining
schedule for all Douglas Heritage airplane fuel tanks. Operators also are advised to test fuel
tanks annually, or preferably more frequently, to determine the level of biological development
residing within the tanks. Finally, operators should treat, or clean and treat, fuel tanks per the
applicable IATA procedures and maintenance manuals.
Anyway, the amount of uplifted fuel in ABV seems to be known, so regardless of a false fuel quantity indication, they should have had enough fuel to reach LOS !!!
MODEL: 717, C-9, DC-8, DC-9, DC-10, KC-10, KDC-10, MD-10, MD-11,
MD-80, and MD-90 Series
APPLICABILITY: All Douglas Heritage Series Airplanes
SUMMARY:
This service letter informs operators of a reported engine shutdown that occurred as the result of
erroneous output from fuel quantity gauging system components. Water contamination in the
fuel tanks may have contributed to the event. Boeing recommends that Douglas Heritage
airplane fuel tank sumps be drained daily.
BACKGROUND:
An operator reported that an MD-80 airplane left-hand engine shutdown during approach for
landing. The tank fuel quantity indicator read 2800 pounds of fuel; however, it was later verified
that the fuel tank was empty. The operator replaced the left and right wing fuel tank quantity
probes and compensators, the fuel tanks were treated with biocide, the left-hand engine fuel
control unit and fuel pump were replaced, and the airplane was returned to service. The fuel
tank low-level indication system had been previously deactivated.
On-aircraft troubleshooting determined that the probes and compensators provided incorrect
readings; however, bench testing of the components revealed no abnormal readings or
characteristics. Of note, on at least one previous occasion, the operator had experienced water
contamination affecting fuel quantity gauging system components.
DISCUSSION:
The fuel quantity gauging system on MD-80 series airplanes is a capacitance-type system.
Probes and compensators are immersed in the fuel, which acts as a dielectric media, and the
capacitance of the system indicates fuel quantity in the tanks. Water or biological contamination
can affect the dielectric constant of the fuel, which can result in erroneous fuel quantity
indications.
Before this event, the operator had extended daily fuel tank sump draining to every third day.
Because there were no adverse fuel quantity indications while daily sump draining was in effect,
the operator has since reverted to draining the fuel sumps daily.
Water permitted to remain in fuel tanks can contribute to erroneous fuel quantity indications and
permit biological contaminants to become established and proliferate. The combination of these
two factors can cause deterioration of fuel tank coatings and sealants, and result in structural
corrosion within the fuel tank.
The purpose of the continuous scavenge systems installed in Douglas Heritage airplanes is to
move water from areas that cannot drain to the vicinity of the pump inlets. However, relying on
these systems is not an acceptable alternative to daily fuel tank sump draining.
While it is understood that operators may establish the interval that they follow to drain airplane
fuel tank sumps, Boeing recommends that Douglas Heritage airplane fuel sumps be drained at
least daily. Note that draining fuel tank sumps is listed in each airplane’s maintenance check
manual as an item in the Overnight Check/Service Check work cards. In addition, each
airplane’s maintenance manual has steps listed to drain fuel tank sumps after each airplanerefueling
task. Although each manual contains statements that relate to how long the fuel should
sit before draining, this does not negate the need to drain the tank sumps.
Douglas Heritage airplanes’ maintenance manuals have been, or will be, revised to include the
International Air Transport Association (IATA) suggested fuel tank microbial contamination
detection procedures and matrix. Douglas Heritage and Boeing Heritage maintenance manual
processes, regarding fuel tank contamination, also have been standardized to the extent possible.
SUGGESTED OPERATOR ACTION:
Boeing recommends that operators implement and maintain a daily fuel tank sump-draining
schedule for all Douglas Heritage airplane fuel tanks. Operators also are advised to test fuel
tanks annually, or preferably more frequently, to determine the level of biological development
residing within the tanks. Finally, operators should treat, or clean and treat, fuel tanks per the
applicable IATA procedures and maintenance manuals.
Anyway, the amount of uplifted fuel in ABV seems to be known, so regardless of a false fuel quantity indication, they should have had enough fuel to reach LOS !!!
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In the last three trips into Abuja, we've had the bowser do a fuel check. Two out of three times, the fuel did not pass and had a lot of water in it. Clearly the aircraft in question had more than enough fuel for the trip - I really wonder what happened, especially when I've read in mulitiple places the PIC has quite a bit of time on the MD's and seemed to be an extremely competent pilot. I've not flown an MD, so I don't know their fuel system, but I'm sure like any other turbine, they have engine driven fuel pumps and electrical back-ups.
Do bowsers have some sort of a way in sumping their fuel? I only wonder because it seems one in a million for two engines to shut down/starve - but when the bowsers themselves can't pass a basic test - one has to wonder.
Sucks no matter how you look at it, and I'd take the AP info with a grain of salt.
Do bowsers have some sort of a way in sumping their fuel? I only wonder because it seems one in a million for two engines to shut down/starve - but when the bowsers themselves can't pass a basic test - one has to wonder.
Sucks no matter how you look at it, and I'd take the AP info with a grain of salt.
Last edited by Mr. Maximus; 17th Feb 2013 at 03:35.
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Have always done a fuel check for water or sediments out of every bowser we uplift from in Abuja and have had no issues at all. Actually apart from the long wait for the bowser to arrive they seem to be ok....
With regards to this issue of fuel starvation and the whole procedure with pumps and not having them on or not I am not particularly convinced.
To come out with such a story the investigation has to be thorough and transparent and the evidence has to be glaring considering the vast and extensive experience of the captain . So far it is not.
With regards to this issue of fuel starvation and the whole procedure with pumps and not having them on or not I am not particularly convinced.
To come out with such a story the investigation has to be thorough and transparent and the evidence has to be glaring considering the vast and extensive experience of the captain . So far it is not.
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Experience......
Just a thought but experienced pilots make mistakes also.
After Captain W left Spirit Airlines in 2009 do we know what airplane(s) he flew and therefore how much recent experience he had on the MD-83 before joining Dana?
After Captain W left Spirit Airlines in 2009 do we know what airplane(s) he flew and therefore how much recent experience he had on the MD-83 before joining Dana?
A few recent articles now that the final report has been released. Not particularly flattering:
https://www.flightglobal.com/news/ar...mergen-435148/
https://aviation-safety.net/database...?id=20120603-0
http://aib.gov.ng/files/Dana-Airlines-MD83-5N-RAM.pdf
https://www.flightglobal.com/news/ar...mergen-435148/
https://aviation-safety.net/database...?id=20120603-0
http://aib.gov.ng/files/Dana-Airlines-MD83-5N-RAM.pdf
