AIRCRAFT ACCIDENT REPORT CHL/2019/02/02/F Accident Investigation Bureau Report on the accident involving AgustaWestland AW139 helicopter operated by Caverton Helicopters Limited with nationality and registration marks 5N- CML, which occurred at Kabba, Kogi State on 2nd February, 2019. Aircraft Accident Report CHL/2019/02/02/F 5N-CML This report was produced by the Accident Investigation Bureau (AIB), Murtala Muhammed Airport Ikeja, Lagos. The report was based upon the investigation carried out by AIB, in accordance with Annex 13 to the Convention on International Civil Aviation, Nigerian Civil Aviation Act 2006 and Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 2016. In accordance with Annex 13 to the Convention on International Civil Aviation, it is not the purpose of aircraft accident/serious incident investigations to apportion blame or liability. Readers are advised that AIB investigates for the sole purpose of enhancing aviation safety. Consequently, AIB reports are confined to matters of safety significance and should not be used for any other purpose. The AIB believes that safety information is of great value if it is passed on for the use of others. Hence, readers are encouraged to copy or reprint reports for further distribution, acknowledging the AIB as the source. Safety Recommendations in this report are addressed to the Regulatory Authority of the State, as well as other stakeholders, as appropriate. The Regulatory Authority is the authority that ensures implementation and enforcement. ©Accident Investigation Bureau, Nigeria – March, 2020. Printed in Nigeria for the Accident Investigation Bureau (AIB) Aircraft Accident Report CHL/2019/02/02/F 5N-CML TABLE OF CONTENT TABLE OF CONTENT ............................................................................................... I TABLE OF FIGURES .............................................................................................. IV GLOSSARY OF ABBREVIATIONS USED IN THIS REPORT .................................................. V SYNOPSIS .......................................................................................................... 1 1.0 FACTUAL INFORMATION ........................................................................... 4 1.1 History of the flight ............................................................................... 4 1.2 Injuries to persons ................................................................................ 6 1.3 Damage to aircraft ................................................................................ 6 1.4 Other damage ....................................................................................... 6 1.5 Personnel information ............................................................................ 8 1.5.1 Pilot (Pilot flying) .......................................................................... 8 1.5.2 Co-pilot (Pilot monitoring) ............................................................. 8 1.5.3 Engineer ...................................................................................... 9 1.6 Aircraft information ............................................................................... 9 1.6.2 Power plant .............................................................................. 11 1.7 Meteorological information ................................................................... 11 1.8 Aids to navigation ................................................................................ 11 1.9 Communications .................................................................................. 11 1.10 Aerodrome information ........................................................................ 12 i Aircraft Accident Report CHL/2019/02/02/F 5N-CML 1.11 Flight recorders ................................................................................... 12 1.12 Wreckage and impact information ........................................................ 15 1.13 Medical and pathological information .................................................... 20 1.14 Fire .................................................................................................... 20 1.15 Survival aspects .................................................................................. 20 1.16 Test and research ............................................................................... 20 1.17 Organizational and management information ........................................ 21 1.17.1 Caverton Helicopters Limited ................................................... 21 1.17.2 Excerpts from the Caverton Operations Manual Part A (OMA) .... 21 1.17.3 Caverton Helicopters Safety Management System Manual ......... 29 1.17.4 The Presidential Air Fleet (PAF) ................................................ 34 1.18 Additional information ........................................................................ 35 1.18.4 Risks management strategies to counter brownout ................... 38 2.0 ANALYSIS ................................................................................................... 40 2.1 General............................................................................................... 40 2.2 Coordination and preparation of the flight ............................................. 40 2.3 Conduct of the flight ............................................................................ 41 2.4 Risk assessment by Caverton Helicopters .............................................. 42 2.5 The Brownout phenomenon in this accident .......................................... 43 2.6 Training in brownout conditions ........................................................... 44 ii Aircraft Accident Report CHL/2019/02/02/F 5N-CML 2.7 The flight crew performance during approach and landing ..................... 45 2.8 Safety management system (SMS) ....................................................... 46 3.0 CONCLUSION ........................................................................................... 48 3.1 Findings .............................................................................................. 48 3.2 Causal factor ....................................................................................... 49 3.3 Contributory factors ............................................................................. 49 4.0 SAFETY RECOMMENDATIONS ....................................................................... 51 4.2.1 Safety Recommendation 2020-001 ..................................................... 53 4.2.2 Safety Recommendation 2020-002 ..................................................... 54 APPENDICES ..................................................................................................... 56 Appendix 1: Satellite Weather Imagery ........................................................... 56 Appendix 2: NCAA All Operators Letter (FSG 002) ........................................... 57 Appendix 3: NCAA letter dated 12th March 2019 to the AIB .............................. 59 iii Aircraft Accident Report CHL/2019/02/02/F 5N-CML TABLE OF FIGURES Figure 1: Damaged parked car relative to the helicopter ........................................... 7 Figure 2: Damage to a parked car from flying debris ................................................ 7 Figure 3: Profile of the flight ................................................................................ 14 Figure 4: Approach and landing phase .................................................................. 14 Figure 5: Wreckage distribution diagram ............................................................... 16 Figure 6: The underside of the helicopter .............................................................. 17 Figure 7: The helicopter ....................................................................................... 17 Figure 8: Damaged right main landing gear ........................................................... 18 Figure 9: Damaged right horizontal stabilizer ......................................................... 18 Figure 10: Deployed life raft ................................................................................. 19 Figure 11: Damaged tail rotor blades .................................................................... 19 iv Aircraft Accident Report CHL/2019/02/02/F 5N-CML GLOSSARY OF ABBREVIATIONS USED IN THIS REPORT AIB Accident Investigation Bureau, Nigeria AMO Approved Maintenance Organisation AOC Air Operator Certificate ATC Air Traffic Control ATPL Airline Transport Pilot Licence ATS Air Traffic Services AW AgustaWestland C of A Certificate of Airworthiness CPL Commercial Pilot Licence CVR Cockpit Voice Recorder FDM Flight Data Monitoring FDR Flight Data Recorder IAS Indicated Airspeed ICAO International Civil Aviation Organization IMC Instrument Meteorological Conditions IVSI Instantaneous Vertical Speed Indicator LDP Landing Decision Point MEL Minimum Equipment List MPRF Multi-Purpose Flight Recorder NAF Nigerian Air Force NAMA Nigerian Airspace Management Agency NCAA Nigerian Civil Aviation Authority v Aircraft Accident Report CHL/2019/02/02/F 5N-CML NiMet Nigerian Meteorological Agency Nig. CARs Nigeria Civil Aviation Regulations NPF Nigeria Police Force OM Operation Manuals PAF Presidential Air Fleet PF Pilot Flying PIC Pilot in Command PM Pilot Monitoring QAR Quick Access Recorder QRH Quick Reference Handbook RAD ALT Radio Altimeter SMS Safety Management System SOPs Standard Operating Procedures T/O Take-off VFR Visual