Bureau releases preliminary report on Max Air aircraft incident

The Nigerian Safety Investigation Bureau (NSIB), on Thursday in Abuja, released preliminary report on the serious incident involving a Boeing 737-400 aircraft operated by Max Air Limited with Nationality and registration marks 5N-MBD

NSIB Director-General, Mr Akin Olateru stated that the incident occurred between take off at Yola, Airport Adamawa and on landing at the Nnamdi Azikiwe International Airport, Abuja Nigeria on May 7.

He said the initial findings show that the flight crew are licenced and qualified to conduct the flight and the aircraft has a valid Certificate of Airworthiness.

“At 12:10 h 5N-MBD departed Nnamdi Azikiwe International Airport (DNAA) for Yola (DNYO) as NGL1648 and arrived Yola at 13:25 h.

“The aircraft was on ground Yola for about 30 minutes before turning around for Abuja. According to flight crew, after takeoff, landing gear was left extended for 3 minutes to allow cooling due high temperature on ground Yola.

“At 14:08 h, the Nigerian Air Force personnel from the Air Force Hanger close to runway 35, reported to Yola Control Tower that an object appearing like a tyre fell off from the departing NGL1649.

“Yola DATCO promptly informed the Pilot of NGL1649 as well as Kano Area Control (ACC) and Abuja Tower,” he said.

Olateru said the flight purser (L1) and another cabin crew (L2) informed the Pilot that a passenger at seat row 24 informed them about seeing a wheel fall off from the airplane.

The NISB boss said that the pilot mentioned instruments and landing gear indications were normal.

He said Yola ATC informed Abuja Tower and NGL1649 that nothing was found after the runway inspection at 12.51h.

“According to the pilot, the landing was normal but after the airplane started decelerating he noticed the port side wing was dropping lower than normal.

“He applied full aileron control to keep the wing from dropping until the lift decayed. Thrust reverser and minimal braking was used to stop the aircraft on the runway.

“At 14:57 h, Abuja ATC informed NGL1649 pilot that should be advised it appeared he had smoke around his aircraft that fire watch room had been called. Aerodrome Rescue and Fire Fighting Services (ARFF) and emergency services were alerted.”

The director-general said the aircraft came to a stop between Link A5 and A6 about 2900 m from the threshold of runway 22.

According to him, the port wheel assembly was located by personnel of the Federal Airports Authority of Nigeria (FAAN) about 1000 m from threshold of Runway 35 Yola airport on May 8.

He stated that the roller bearings on the wheel assembly of No. 1 main wheel had discoloration and was burnt out.

“The CVR recording was found to be overwritten. Max Air Limited stated that they were unaware of the NCAA All Operators Letter (AOL) (NCAA/FSG/AOL/19/03) in respect of continuous overwriting of Cockpit Voice Recorder (CVR) Information.

“There was wrong tech log entry of serial number of incident aircraft. The quality control department did not supervise maintenance action of the brake unit and wheel change on 5N-MBD conducted on May 5.

“The crew did not take adequate measures to confirm the information about the missing wheel assembly,” he said.

The director-general affirmed that there was severe fire damage on the No. 2 main wheel assembly.

According to him, after the replacement of the wheel brake on May 5, an aircraft mechanic crosschecked the work performed by the engineer.

He said the Yola ATC Voice Recording System (VRS) did not record any communication between the pilot and the duty controller on the day of the occurrence.

He said that the Max Air Limited Quality Assurance ought to ensure maintenance activities were supervised and monitored in accordance with Maintenance Control Manual for immediate safety recommendation.

According to him, Nigerian Civil Aviation Authority (NCAA) should conduct regular Safety Management System (SMS) assessments to evaluate the capability of Max Air limited to effectively manage safety.

“Ensure that PMI and POI of Max Air Limited increase surveillance and oversight to ensure maintenance and flight operations are carried out in accordance with NCAA Technical Guidance Material (TGM) Volume IV (Airworthiness Inspector’s Handbook) Chapter 23 (Continuing Surveillance).

“Also, TGM Volume III Flight Operations Inspector’s Handbook Chapter 30 (Continuing Surveillance).

“Max Air Limited should ensure that flight crew display good situational awareness and airmanship at all times during conduct of flight operations in accordance with Max Air ops manual.,” he said.

According to him, NCAA should invoke relevant sections of Nig.CARs 2015 in accordance with IS 1.3.3 Legal Enforcement Actions to non-compliant operators with the AOL (NCAA/FSG/AOL/19/03) on continuous overwriting of Cockpit Voice Recorder (CVR) Information.

He advised the NCAA to ensure FAAN and Nigerian Airspace Management Agency (NAMA) provided uninterrupted power supply in order to avoid vulnerability of their operational equipment.

“Further investigations inspection of the roller bearing and other accessories, retrieval of pertinent document from Max Air limited and other stakeholder and pertinent factors leading to drafting of the final report,” he said.