The Nigerian Safety Investigation Bureau (NSIB) has hinged the Max Air incident involving its Boeing 737-400 aircraft marked 5N-MBD, on lack of due diligence.
The Director General of NSIB, Engineer Akin Olateru, announced this while delivering the preliminary report on the serious incident which occurred between take off at the Yola Airport Adamawa State and on landing at the Nnamdi Azikiwe International Airport, Abuja, on May 7, 2023.
Presenting the report in Abuja on Thursday, Olateru, attributed the probable cause of the incident to lack of due diligence during the maintenance of the equipment.
In his explanation, the quality control department of the airline failed to supervise the maintenance action of the brake unit and wheel change on the aircraft conducted on May 5, 2023 while the crew did not take adequate measures to confirm the information about the missing wheel assembly.
He said: “There was severe fire damage on the No. 2 main wheel assembly. After the replacement of the wheel brake on the 5th May 2023, an aircraft mechanic crosschecked the work performed by the engineer.
“The Yola air traffic control (ATC) voice recording system (VRS) did not record any communication between the Pilot and the duty controller on the day of the occurrence.”
The NSIB also found that the CVR recording on the plane was found to have been 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 a wrong tech log entry of the serial number of the incident aircraft. The quality control department did not supervise the maintenance action of the brake unit and wheel change on 5N-MBD conducted on 5th May 2023.The crew did not take adequate measures to confirm the information about the missing wheel assembly.
“There was severe fire damage on the No. 2 main wheel assembly. After the replacement of the wheel brake on the 5th May 2023, an aircraft mechanic cross-checked the work performed by the engineer.
“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,” the report said.
However, Olateru said the flight crew of the aircraft was licensed and qualified to conduct the flight and that the aircraft had a valid certificate of airworthiness.
In its recommendations to the airline, the bureau said the quality assurance of the carrier should ensure maintenance activities are supervised and monitored in accordance with the maintenance control manual.
The bureau also charged the Nigeria Civil Aviation Authority (NCAA) to among others *conduct regular safety management system (SMS) assessments to evaluate the capability of Max Air limited to effectively manage safety; *ensure that the 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) and TGM Volume III Flight Operations Inspector’s Handbook Chapter 30 (Continuing Surveillance).
It added: “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.
“NCAA should invoke the 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.”