NIGERIA – On May 7, 2023, Max Air (VM) Boeing 737 aircraft experienced a serious incident in Abuja, Nigeria. Prompting the Nigerian Safety Investigation Bureau (NSIB) to launch an investigation.
The incident brought up concerns about the airline’s compliance with safety protocols and the broader safety standards within the aviation industry.
According to the preliminary report by the Nigerian Safety Investigation Bureau (NSIB) on Max Air. The Airline actively implicated itself in overwriting the Cockpit Voice Recorder (CVR).
Pertaining to the significant incident that took place on May 7, 2023, during landing at Abuja’s Nnamdi Azikiwe International Airport (NAIA) [ABV].
The report additionally leveled accusations against the airline. Further, Stating that it actively pretended to be unaware of the Nigeria Civil Aviation Authority’s (NCAA) All Operators Letter (AOL) (NCAA/FSG/AOL/19/03). Regarding the continuous overwriting of CVR data.
Max Air Boeing 737 Incident
The Nigerian Safety Investigation Bureau (NSIB) explained that a significant incident occurred in Abuja on May 7, 2023. Involving Max Air’s Boeing 737-400 aircraft registered as 5N-MBD.
The incident occurred during the landing phase at Nnamdi Azikiwe International Airport (ABV) in Abuja. Having a total of 143 passengers on board.
On Thursday, the Director General of NSIB, Akin Olateru, released a preliminary report on the serious incident in Abuja. The report stated that the aircraft left Abuja at 12:10 p.m. under the flight designation NGL1648, bound for Yola.
It arrived in Yola at 1:25 p.m. on the same day. According to the report, the aircraft remained on the ground in Yola for about 30 minutes before initiating its return journey to Abuja.
The report disclosed that the aircraft kept the landing gear extended for three minutes following takeoff to facilitate cooling due to high ground temperatures at Yola Airport (YOL).
Furthermore, at 2:08 p.m., Nigerian Air Force personnel near runway 35, in proximity to the Air Force Hangar, reported to the Yola Control Tower that an object resembling a tire fell off from the departing NGL1649 aircraft.
The control tower promptly relayed this information to the pilot, as well as to Kano Area Control (ACC) and the Abuja tower.
Findings of The Investigation
According to the report, the flight purser (L1) and another cabin crew member (L2) notified the pilot. A passenger in seat row 24 had informed them about witnessing a wheel falling off the aircraft.
However, the pilot responded by stating that the instruments and landing gear indications were normal.
The pilot described the landing as normal. After the airplane began to decelerate, he observed that the port side wing was dropping lower than usual. The pilot applied full aileron control to prevent further dropping until the lift diminished.
The pilots utilized thrust reversers and minimal braking to bring the aircraft to a stop on the runway. At 2:57 p.m., Abuja Air Traffic Control (ATC) notified NGL1649, saying, “Be advised, it appears there is smoke around your aircraft. We have called the fire watch room.”
Leading to the activation of the Aerodrome Rescue and Fire Fighting Services (ARFF) and the alerting of emergency services.
“The aircraft halted its motion between Link A5 and A6, approximately 2900 meters from the runway 22 threshold. Federal Airports Authority of Nigeria (FAAN) personnel discovered the port wheel assembly on May 8th, 2023.
It was roughly 1000 meters from the runway 35 threshold at Yola airport. They determined that someone had overwritten the CVR recording.”
Communication Breakdown and Maintenance Oversight
According to the report, Max Air Limited claimed to be unaware of the NCAA All Operators Letter (AOL) (NCAA/FSG/AOL/19/03). Regarding the continuous overwriting of Cockpit Voice Recorder (CVR) information.
The NSIB’s report also uncovered that the airline made an incorrect tech-log entry. Regarding the serial number of the aircraft involved in the incident.
Furthermore, the quality control department failed to supervise the maintenance activities carried out on May 5, 2023. Involving the brake unit and wheel change for 5N-MBD.
The report emphasized that the crew did not take sufficient measures. Not verifying the information concerning the missing wheel assembly. This negligence resulted in significant fire damage to the aircraft’s Number 2 main wheel assembly.
On the day of the incident, the Yola Air Traffic Control (ATC) Voice Recording System (VRS) did not capture any communication between the pilot and the duty controller.
Additionally, the report highlighted that following the wheel brake replacement on May 5, 2023, an aircraft mechanic crosschecked the work performed by the engineer.
Report on Max Air 737 Incident
The report called upon the Nigerian Civil Aviation Authority (NCAA) to enforce the applicable sections of the Nigeria Civil Aviation Regulations (Nig.CARs) 2015.
Outlined in IS 1.3.3 Legal Enforcement Actions against airlines that fail to comply with the AOL (NCAA/FSG/AOL/19/03). Regarding the continuous overwriting of CVR information.
NSIB emphasized the need for Max Air Limited’s Quality Assurance department to ensure that they adequately supervise and monitor maintenance activities.
Adhering to the guidelines specified in the Maintenance Control Manual. Further, this recommendation aims to ensure immediate safety measures.
Furthermore, stating that the Nigerian Civil Aviation Authority (NCAA) should regularly conduct assessments of the Safety Management System (SMS). Assessing the capability of Max Air Limited in effectively managing safety.
Also, urging the Performance Monitoring Inspector (PMI) and Principal Operations Inspector (POI) of Max Air Limited to enhance surveillance and oversight.
Ensuring full compliance with Chapter 23 (Continuing Surveillance) of the NCAA Technical Guidance Material (TGM) Volume IV (Airworthiness Inspector’s Handbook) for maintenance and flight operations.
NSIB highlighted that Max Air Limited must ensure that the flight crew consistently demonstrates excellent situational awareness. Further, the airmanship throughout all flight operations. Further follow the guidelines outlined in the Max Air operations manual.
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