Aviation Lawyer Examines The Dana Air Final Accident Report

Specialist aviation lawyer and former RAF pilot expresses concern at the devastating chain of events that contributed to the catastrophic loss of this airliner in Nigeria.

Jim Morris, who during his flying career in the RAF flew a large Boeing aircraft, is shocked by the handling of a difficult in-flight emergency that became an in-flight catastrophe.

On 3 June 2012, a Dana Air Boeing / McDonnell Douglas MD-83 aircraft flying from Abuja, Nigeria, crashed in a suburb five miles north of Murtala Muhammed International Airport in the capital city of Lagos. All 153 people on-board, and a number of people on the ground, were tragically killed.

Finally, almost five years after the accident, the Nigerian authorities published the Final Accident Report in March 2017. The Report confirms that the Flight Data Recorder (FDR) suffered extensive heat damage in the fire which meant that no data on the aircraft engines or systems could be recovered. Although the data on the Cockpit Voice Recorder (CVR) was recovered, the lack of FDR data meant that the information to determine what exactly happened was limited, meaning that the investigators could not determine what caused both engines to lose power.

The report concludes that the probable causal factors were:

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 situation awareness, inappropriate decision making, and poor airmanship.

The report also identified that the Captain had been suspended in 2009 by the US FAA, he had recently joined Dana Air and that his line training with Dana Air was hurried.

Jim specialises in representing the victims of air accidents and during his RAF career flew the Boeing AWACS aircraft on operations around the world and was the Squadron Flight Safety Officer. As a specialist aviation lawyer he has represented victims of the Dana Air tragedy and many other international airliner accidents.

From a professional pilot perspective, Jim analysed the Final Accident Report and commented: “To lose power in both engines in an airliner is an extreme situation and should never occur. Looking in detail at the events on the day of the accident gives an insight into a difficult in-flight emergency (that could have been recoverable) that became an in-flight catastrophe. At the start of the CVR recording (around 17 minutes after take-off) the crew were discussing an issue with the left engine. At this point they should have been going through the relevant checklist process to identify / rectify the problem. Also, having identified a problem with an engine, they should have been considering the nearest suitable airfield to divert to. Unfortunately, the crew did not do this and continued the flight on the right engine without using any checklists.”

“During the final approach to Lagos, the Captain indicated that he had lost power on both engines and an emergency was transmitted. At this point, the Captain should have asked the First Officer to commence the double engine failure checks and the Captain should have selected a gear / flap / speed configuration that would maximise the glide range to give the greatest chance of reaching the runway – again, these procedures were not followed.”

“When an aircraft loses total engine power, the priority for the pilot is to maximise its gliding range, which increases the chance of reaching a suitable runway. Glide range is maximised by minimising the aircraft drag (gear and flaps retracted) and flying at the glide speed for the aircraft.”

“However, the Captain did not call for gear and flap retraction until 2 minutes after loss of power. If the Captain had correctly maximised glide range at the point that he realised that he had lost both engines, this would have provided more time and would have given them the best chance of reaching the runway, if it was within glide range. In addition, had the double engine failure checks been completed it may have been possible to re-start one of the engines and land on the runway with power.”

“This Final Accident Report identifies a devastating series of events that contributed to the tragedy.

Notwithstanding the difficult technical problem(s) with the aircraft, the poor airmanship and failure to use the required checklists made matters far worse, so these human factors were a major contribution to the catastrophic loss of the aircraft. Clearly the Nigerian aviation authorities and the aviation industry need to learn lessons from this accident and implement all necessary measures to prevent a similar future accident and improve flight safety in Nigeria.”

23/03/2017
Jim Morris