The Crash of Dana Airlines Flight 0992

The Crash of Dana Airlines Flight 0992Lagos, Nigeria June 3, 2012

Dr. Bob BaronPresident/Chief Consultant The Aviation Consulting Group

Copyright 2017© The Aviation Consulting Group www.tacgworldwide.com

A Case Study in Human Factors Failures

http://www.tacgworldwide.com/

Dana Airlines Flight 0992Aircraft type-

Boeing MD-83

Accident date-June 3, 2012

Accident location-Iju-Ishaga Area Of Lagos State (Nigeria)

Meteorological conditions at time of accident-Good VFR

Fatalities-All aboard killed, including crew (153)Ground fatalities (6)



Initial news coverage at accident site

Click picture for video


https://www.youtube.com/watch?v=PoMIH9jj5ck


Purpose of this case studyNot to appoint blame or point fingers-

This can happen at any airline

To focus on human factors (soft skills) issues-Mechanical aspects, such as the cause of the engine failures, are not discussed in this presentation

To improve airline safety by understanding the Human Factors in this accident.

All information is factual, based on the official accident report by the AIB, Lagos, Nigeria.

You are encouraged to use this presentation for learning and teaching purposes.



Format of this case studyInformation is presented on focused topics by using various extracts and narratives from the official accident report.


Examples


Format of this case studyA “Talk Points” slide follows various accident report/extract slides.


Example


List of Abbreviations• ABV- Abuja Airport (Nigeria)• AIB- Accident Investigation Bureau (Nigeria) • ATC- Air Traffic Control • ATPL- Airline Transport Pilot License • Capt.- Captain• CAA- Civil Aviation Authority • CAR- Civil Aviation Regulation• CPL- Commercial Pilot License • CRM- Crew Resource Management • CVR- Cockpit Voice Recorder • DANACO 0992- Aircraft call sign • FAA- Federal Aviation Administration (USA) • FO- First Officer • ICAO- International Civil Aviation Organization • IFR- Instrument Flight Rules • LOC- Localizer• LOS- Lagos Airport (Nigeria)



List of Abbreviations• NCAA- Nigerian Civil Aviation Authority (Nigeria)• NTSB- National Transportation Safety Board (USA) • OCC- Operations Control Center • PAIFA- Pan Am International Flight Academy• PF- Pilot Flying• PIC- Pilot in Command• PM- Pilot Monitoring• QRH- Quick Reference Handbook• RT- Radio Telephony• SMS- Safety Management System• SOP- Standard Operating Procedures • SSP- State Safety Program • VFR- Visual Flight Rules • VMC- Visual Meteorological Conditions



Synopsis



Probable cause



History of the flight Flight originated in Abuja, Nigeria (ABV).Destination was Lagos, Nigeria (LOS).1458:00 hrs-

Flight was airborne from ABV after reporting a fuel endurance of 3 hours 30 minutes.

1513:44hrs-Capt. and FO discussed of a non-normal 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 transitioned through the initial descent from cruise altitude at 1522:00hrs and the subsequent approach phase.



History of the flight Crew reported passing 18,100ft and 7,700ft, at 1530:00hrs and 1540:00hrs respectively. After receiving radar vectors in heading and altitude from the Controller, the aircraft was issued the final heading to intercept the final approach course for runway 18R. 1531:12hrs-

Crew confirmed that there was no throttle response on the left engine and subsequently the Captain took over control as PF at 1531:27hrs. Crew continued towards Lagos with no declaration of any distress message.



History of the flight Between 1537:00hrs and 1541:00hrs-

Crew engaged in pre-landing tasks including deployment of the slats, and extension of the flaps and landing gear.

1541:46hrs-FO inquired, “both engines coming up?” and the Capt. replied “negative” at 1541:48hrs. The flight crew subsequently discussed and agreed to declare an emergency.

1542:10hrs-Crew radioed an emergency distress call indicating “dual engine failure . . . negative response from throttle.”

1542:35hrs-Crew lowered the flaps further and continued with the approach. At 1542:45hrs, the Capt. reported the runway in sight and instructed the FO to retract the flaps and four seconds later to retract the landing gear.



History of the flight 1543:27hrs-

Capt. informed 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 attempted to recover engine power without reference to any Checklist.

The airplane crashed into a densely populated residential area about 5.8 miles north of LOS.During the impact sequence, the airplane struck an uncompleted building, two trees and three other buildings.



History of the flight Airplane 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. Emergency response/investigation was hampered by looting, chaos, and “miscreants.”



Accident scene pictures



Recruitment of pilots



Talk PointsRecruitment of pilots-• Ambiguity regarding the meaning of “Quality

Department.”

• Typically, an airline Quality Department focuses on products rather than people.

• If this is meant to be the “Human Resources Department” (which focuses on people), then it should be named as such.



Captain information Expatriate pilot from the U.S.Suspended in 2009 by the FAA for misdemeanors related to a heavy landing and fixing of panels that were neither entered in the aircraft logbook nor reported.



Captain information The revalidated license issued to him by the NCAA was stamped but not signed by any NCAA official.



Captain information The line trainings that preceded the Capt.'s checkout had a lot of adverse remarks made by the Training Capt. They are as follows: 1. “Callout and operating procedures needs to improve,

Abuja Company Procedures to be adhered to, PM, RT procedures and callout” 26th April, 2012.

2. “Expanded checklist and cockpit flow time management” “RT procedures and reporting needs to be standardized to ICAO format” 27th April, 2012.

3. “Standardized Operating Procedures, RT to be standardized ICAO positioning” “SOP RT procedures” “SOP positioning” “SOP Positioning reporting” 28th April, 2012.



Captain information 4. “SOP Airport departures ABV to be adhered to”

“RT Procedure Positioning reporting” “SOP” “SOP RT Reporting to be improved, Standard call out” “RT Procedures & Positioning needs to [be] improved” 29th April, 2012.

5. “RT procedures to be improved” 30th April, 2012.6. “PM LOC approach Runway 18L” “Released for

final line check. 01st May, 2012.”7. “Good airmanship was shown on these 2 sectors.

Please observe transition altitudes/levels are different than the USA, monitor ATC transmissions constantly as ATC accent is also different here in Nigeria.” 01st May, 2012.



Dana Airlines internal investigation of Captain

1. No record of due diligence performed on Captain in respect to Falcon Airlines in U.S., where he was previously employed.

2. No record of security background check on Captain.

3. Recommendation letters submitted by Captain were not signed.

4. The following remarks were noted during the Captain’s checkout flight (Line Training)…



Dana Airlines internal investigation of Captain

(a) On 26/04/12: “Call-out & Operating procedures needs to improve.”

(b) On 26/04/12: “Company procedures to be adhered to.”

(c) On 27/04/12: “Procedures & position reporting needs to be standardized to ICAO format.”

(d) On 28/04/12: “Standard Operating procedures to be standardized to ICAO position.”

(e) ON 29/04/12: “RT Reporting to be improved.”(f) (f) On 29/04/12: “RT Procedures & positioning

reporting needs to improve.” (g) On 30/04/12: “RT procedures to be improved.”



Dana Airlines internal investigation of Captain 5. There was no record showing any improvement before

accident Capt. took command. 6. We tried to do a due diligence on accident Capt., as part

of this investigation, by contacting Spirit Airlines, where he flew 6500hrs on the MD83 as PIC. We were informed that they were already working with the NTSB and that we could contact the NTSB for any information we may need on accident Capt.

7. There are no records of Ground school attendance in Miami.

8. There are no records of Indoctrination courses conducted for Pilots.

9. Departure and arrival call-out to OCC, which is a standard procedure, was not complied with by all the pilots. Accident Capt. did not call Abuja or Lagos OCC throughout the flight.



Talk PointsCaptain background/training-• Red flags regarding the Capt.'s work history

(including license suspension). • Capt. conducted flying duties in violation of rules

and regulations.• Signatures missing-

• Recommendation letters not signed. • Revalidated license not signed by NCAA.

• Numerous adverse remarks noted in Dana Airlines training, particularly relating to-• SOP usage.• Checklist usage.



Talk PointsCaptain background/training-• No record of ground school training.• No record of indoctrination course.• No call to OCC (SOP) throughout the accident

flight.



Safety culture



Talk PointsSafety culture-• Exposed a poor safety culture…• Normalization of deviance-

• Not entering defects in the technical logbook. • Restricted background checks. • Limited or no verification of new-hire references.

• Some of the pilots became part of the problemwhen they failed to report to the Airline’s Quality Dept. and NCAA.



Conduct of the flight



Talk PointsConduct of the flight-• While discussing left engine problem with FO,

Capt. stated “we just want to get # home.”• Capt. declined assistance from the onboard

maintenance engineer-• “Well I don’t need him here cause we can figure it

out, he’s not going to be able to help us.”• “This is the guy that had an issue with us. Uh he’s

pissed off at us.” • Crew did not call for Non-Normal/Emergency

checklists.



Talk PointsConduct of the flight-• Capt. wanted FO to increase rate of descent.

• FO “preferred a gradual descent in order to have enough height over Lagos.”

• Capt. concluded that “we’re gonna be investigated by the NCAA.”

• Even when both engines were lost, there was no call for Normal/Non-Normal/Emergency checklists or the QRH.



Talk PointsConduct of the flight-• After crew declared an emergency for dual

engine failure, the FO told the Purser to “prepare for [normal] landing” and that “the situation appeared under control.”



Policies/Procedures/CRM



Talk PointsPolicies/Procedures/CRM-• Crew did not land at “the nearest suitable

airfield”(as per Emergency checklist/QRH)-• Pilots overflew Ilorin, Akure, and Ibadan on their

way to Lagos. Could have also returned to Abuja.• Capt. asserted “aircraft could not quit on them.”• Delay in declaring an emergency due to fear of

NCAA repercussions-• Why the unexplained fear?



Talk PointsPolicies/Procedures/CRM-• Unprofessional flightdeck environment.• Checklists not used-

• Capt. requested that the FO should give him “anything,” “everything,” “gear down and flaps.”

• There was poor/no CRM.• Swear words were frequently used.• Steep cockpit gradient (also known as Trans

Cockpit Authority)-• This made the FO less assertive.• FO voiced good input (such as “let’s have a late

descent”), but the Capt. overruled him.Copyright 2017© The Aviation Consulting Group www.tacgworldwide.com


Captain training records



Talk PointsCaptain training records-• Adverse comments not addressed before final

route check (no remedial training or improvement).

• No evidence of-• General written test.• Selection interview. • Background check.• Simulator appraisal check.• Company indoctrination.



Talk PointsCaptain training records-• Assessments by all training Capt.'s on accident

Capt. indicated-• Inadequate cockpit discipline. • Non-standard ICAO phraseology.• Inadequate radio communications.• Non-adherence to company and ICAO procedures.• Limited crew experience.• Inadequate line training on MD-83 aircraft.



Talk PointsCaptain training records-• There was no indication that the Capt.'s “soft

skills” deficiencies were ever corrected or had improved.

• Training was rushed, therefore many shortcuts were taken to get the Capt. on the line.



NCAA Regulations



Talk PointsNCAA regulations-• The Capt. operated in violation of NCAA

regulations-• The Capt. did not land at the nearest suitable

airport due to engine failure-• Was not even discussed by crew.

• The Capt. (and FO) did not use any checklists-• They carried out procedures in an inappropriate and

haphazard manner.



Talk PointsNCAA regulations-• The Regulator (NCAA) did not validate the

Capt.'s foreign license-• Capt. had unresolved issues with FAA.• Inadequate background checks on Capt. • Capt.'s license was stamped but not signed.



Safety recommendations



Talk PointsSafety recommendations-• Dana Airlines-

• Ensure background checks are conducted on foreign pilots/safety critical employees.

• Newly employed foreign Capt.'s must fly with a competent senior FO for at least first 100 hours.

• Noted training deficiencies must be corrected before final checkout as Line Capt.

• Training must be in compliance with company procedures (i.e., Ops. Manuals, SOPs, CARS).



Talk PointsSafety recommendations-• NCAA-

• Better reviews of foreign pilots’ backgrounds.• Complete details obtained before validation of

foreign licenses (inc. aeromedical and due diligence by airline).

• Ensure applicants declare all relevant information.• New Line Capt. checkouts must require an NCAA

Inspector as an observer.




Accident Summary and Review

Dana Airlines Flight 0992


Chain of Causal Factors for Flight 0992


Regulator (NCAA)• Failed to validate the

Captain's foreign license.

Captain’s Conduct on Accident Flight• Unprofessional.

• Steep cockpit gradient.

• Poor/no CRM.

• Declined assistance from onboard engineer (a CRM resource).

• Checklists/SOPs not used.

• Overflew suitable airports for landing.

• Feared declaring an emergency due to being investigated by NCAA.

Dana Airlines Safety Culture• Deficient vetting process for expatriate

pilots.

• Defects not being recorded in technical logbooks (normalization of deviance).

• Pilots/engineers quitting out of frustration.

• Adverse remarks for pilots not addressed (improved) before being released to the line.

End Result• Unrecoverable dual engine failure.

• Crash into buildings near Lagos Airport.

• All 153 aboard, and 6 on ground, killed.


Where Were the Failures in the Swiss Cheese Model?


Regulator (NCAA)


What Were the Mismatches in the SHELL Model?



• NCAA (Regulator)-• Regulator must provide oversight of operators and

enforcement of CARs. • The Regulator can be just as susceptible to

complacency, lackadaisical attitudes, assumptions, biases, etc., just like the operators it oversees.

• If an issue begins with the Regulator (a latent threat), in time it may cause an unsafe act (i.e., holes in the Swiss cheese)-• In this accident, this was the case.

• The Regulator must be a solution to, rather than part of, the problem.


Summary of Human Factors Failures


• NCAA (Regulator)-• NCAA has adapted a State Safety Program (SSP). • An SSP is a tool for CAAs to ensure safety, starting

at the State level (the top)-• In this case, the SSP failed.



http://www.ncaa.gov.ng/ncaa-unveils-nigeria-s-state-safety-policy-statement/


http://www.ncaa.gov.ng/ncaa-unveils-nigeria-s-state-safety-policy-statement/

• Dana Airlines Safety Culture-



At the time, where did Dana Airline’s safety culture fall on this chart?


• Dana Airlines Safety Culture-• At the time of the accident, the airline’s safety

culture was poor. • There was a “normalization of deviance”-

• Rushed hiring practices.• Insufficient background checks.• Discrepancies not being entered in aircraft logbooks.• Pilots failing to call OCC on departure/arrival, per

SOPs.• Training deficiencies (non-corrective/remedial

actions to address adverse remarks by training Capts.• Employees may have been afraid to report, for

fear of retribution or punitive actions-• A manifestation of a non-Just Culture.




• Dana Airlines Safety Culture-• A Safety Management System (SMS) is an

effective, systemic tool for managing safety.• It does not appear that the Airline had a

functional SMS at the time of the accident-• If an SMS did exist, it should have been examined and

discussed in the report.• If an SMS did not exist, it should have been made a

Recommendation at the end of the report.




• Dana Airlines Safety Culture-• Interestingly, SMS is not mentioned in the AIB

report whatsoever, even though “SMS” appears in its Glossary of Abbreviations section.



Related reading:

The Four Pillars of Safety Management (SMS)

A Just Culture

A Poisoned Safety Culture

Us and Them

The Human Factors Funnel Model (HFFM): Another Window on Error Causation


https://www.tacgworldwide.com/Portals/23/pdf/The-Four-Pillars-of-Safety-Management.pdf

https://www.tacgworldwide.com/Portals/23/pdf/A-Just-Culture.pdf

https://www.tacgworldwide.com/Portals/23/pdf/A-Poisoned-Safety-Culture.pdf

https://www.tacgworldwide.com/Portals/23/pdf/Us-and-Them.pdf

https://www.tacgworldwide.com/Portals/23/pdf/HFFM.pdf

• Captain’s Conduct on Accident Flight-• Capt. was clearly a threat to flight safety.• The threat should have been identified, and acted on,

before approval to fly the line-• If NCAA and Dana Airlines had utilized the defenses that were

already in place, the Capt. most likely would not have been hired by the Airline.

• This Capt. typology is not uncommon. Attitudes and perceptions include-• Risk-taking.• Cavalier attitude toward safety.• “Rules don’t apply to me.”• “CRM is useless.”• “The Captain is always right.”• “Checklists and SOPs are for weak pilots.”




• Captain’s Conduct on Accident Flight-• The Capt. lacked, among other things-

• Professionalism. • Overall discipline.• Checklist and SOP discipline.• CRM adherence. • Decision making skills.

• During a NORMAL, UNEVENTFUL flight, these issues can be dangerous.

• During an in-flight EMERGENCY, lacking the above skills can be the difference between successfully handling the problem, or the flight ending in an accident-• That is unfortunately what happened to Flight 0992.




• Captain’s Conduct on Accident Flight-



Related reading:

Failure to Follow Procedures

The Toxic Captain

Flight Pathogens

Cockpit Discipline


https://www.tacgworldwide.com/Failure-to-Follow-Procedures

https://www.tacgworldwide.com/Portals/23/pdf/Toxic-Captain.pdf

https://www.tacgworldwide.com/Portals/23/pdf/flight-path-ogens.pdf

https://www.tacgworldwide.com/Portals/23/pdf/asw_dec07_p47-48.pdf

• Safety Recommendations-• Safety Recommendations (SRs) speak for

themselves; however, this brings us back to SMS, and specifically its safety risk management (SRM) component-• SRM is a proactive method used to identify hazards and

their associated risks, and to reduce those risks to an acceptable level.

• The intention is to prevent an incident or accident from occurring in the first place.

• This contrasts a reactive method whereby the incident or accident has already taken place.



Related reading: Looking Forward to Your Next Accident


https://www.tacgworldwide.com/Portals/23/pdf/Looking-Forward-to-Your-Next-Accident.pdf

• Safety Recommendations-• After a careful review of the SRs, you will notice

that if the Airline were doing what it was obligated to do in the first place, there would have been no need for these reactive SRs—or for the accident to have occurred, for that matter.

• All of the procedures were in place; they were just not being used as required, if at all—they probably are now—but practical drift will likely occur in the near future.



Related reading: The Safety Space and Practical Drift


https://www.tacgworldwide.com/Portals/23/pdf/Safety_Space.pdf


Official AIB Accident Report


https://www.tacgworldwide.com/Portals/23/pdf/Dana-Airlines-MD83-5N-RAM.pdf?ver=2017-03-17-173834-980&timestamp=1490026065528

Thank You!



The Crash of Dana Airlines Flight 0992

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