Incident Overview

Description
Dana Air flight 992, an MD-83, crashed while on approach to Lagos-Murtala Muhammed Airport, Nigeria, killing all 153 occupants and 6 persons on the ground. 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. The first officer was Pilot Flying. Flight DAN992 initiated engine startup at 14:36, taxied to runway 04 at Abuja Airport and was later airborne at 14:58. Fuel endurance was 3.5 hours. The flight climbed to a cruise altitude of 26,000 ft. DAN992 made contact with Lagos Area Control Center at 15:18. At the time the captain and first officer were in a discussion of a nonnormal condition regarding the correlation between the engine throttle setting and an engine power indication. 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 15:22 and the subsequent approach phase. DAN992 reported passing through 18,100 at 15:30. Shortly afterwards the crew confirmed that there was no throttle response on the left engine and subsequently the Captain took over control as Pilot Flying (PF). The flight was however continued towards Lagos with no declaration of any distress message. With the confirmation of throttle response on the right engine, the engine anti-ice, ignition and bleed-air were all switched off. At 15:32, the crew observed the loss of thrust in engine no. 1. Between 15:37 and 15:41 the flight crew were 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 inquired, “both engines coming up?” and the captain replied “negative.” The flight crew subsequently discussed and agreed to declare an emergency. At 15:42:10, DANA 992 radioed an emergency distress call indicating “dual engine failure…negative response from throttle.” At 15:42:35, the flight crew lowered the flaps further and continued with the approach and discussed landing alternatively on runway 18L. At 15:42:45, the captain reported the runway in sight and instructed the first officer to raise the flaps and 4 seconds later to raise the landing gear. At 15:43:27 hours, the captain informed the first officer “we just lost everything, we lost an engine. I lost both engines”. During the next 25 seconds the flight crew was attempting to restart the engines. The airplane did not reach the runway and crashed in a residential area about 9,3 km short of the 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. A fire erupted. An investigation by AIB Nigeria showed that the captain was employed by Dana Air on 14th March, 2012. He was originally from the United States, but was suspended in 2009 by the United States Federal Aviation Administration (FAA) for some misdemeanours. It was noted that most of the recommendation letters submitted by the captain were also signed. Further, the line trainings that preceded the captain’s checkout had a lot of adverse remarks made by the training captain. He started flying as checked out captain on 2nd May, 2012 and had accrued over 120 hours of flight time before the accident. Tear down of the engines showed that the no.1 engine was overhauled in the U.S in August 2011 and was not in compliance with Service Bulletin SB 6452. Both 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. This condition was similar to the no.1 engine of a different Dana Air MD-80, 5N-SAI, that was involved in an incident in October 2013 when the aircraft returned to the departure airport with the engine not responding th throttle movements. This engine also was not in compliance with Service Bulletin SB 6452. This bulletin was issued in 2003 and called for the installation of new secondary fuel manifold assemblies, incorporating tubes fabricated from new material which has a fatigue life that was approximately 2 times greater than the previous tube material. 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 crews 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.
Source of Information
http://www.bbc.co.uk/news/world-africa-18316130, http://nz.news.yahoo.com/a/-/world/13874192/nigerian-crash-toll-rises-as-airline-license-pulled/http://www.bbc.co.uk/news/world-africa-18316130, http://nz.news.yahoo.com/a/-/world/13874192/nigerian-crash-toll-rises-as-airline-license-pulled/Primary Cause
Inadequate pre-flight monitoring, improper checklist adherence, and a failure to adequately assess and address a critical engine malfunction, leading to a rapid loss of thrust and subsequent crash.Inadequate pre-flight monitoring, improper checklist adherence, and a failure to adequately assess and address a critical engine malfunction, leading to a rapid loss of thrust and subsequent crash.Share on: