NCAT Incident: NSIB Wants NCAA To Ensure FAAN Completes Control Tower

“Nigeria Civil Aviation Authority should ensure that the Federal Airports Authority of

Nigeria (FAAN) completes the construction of the Control Tower at General Hassan Usman Katsina international Airport Kaduna to permit seamless operation in accordance with section 14.1.19 (a), (b), (c) and (d) of the Nig. CARs 2015 and now 14.1.26.2 of the Nig CARs 2023.”

This is one of the safety recommendations in the report from Nigeria Safety Investigation Bureau (NSIB) on the Serious Incident involving Beech Baron 58 aircraft operated by Nigerian College of Aviation Technology (NCAT), Zaria with nationality and registration marks 5N-CAG which occurred on runway 05 at General Hassan Usman Katsina international Airport, Kaduna Nigeria on 31 December, 2022.

Other safety recommendations are that the “Nigerian College of Aviation Technology (NCAT), Zaria should ensure that its flight crew strictly adhere to the use of Emergency/non-normal checklist during flight training,” “Nigeria Civil Aviation Authority should ensure that the Nigerian College of Aviation Technology (NCAT), Zaria strictly adhere to the Flight Instructor’s refresher courses in accordance with the NCAT Flying School Procedure Manual Chapter 4 subsection 4.4.1 and section 3.2.1.14 (d) (1) of Nig. CARs 2015 and 2023 respectively,” and “Nigeria Civil Aviation Authority should ensure that the Nigerian College of Aviation Technology (NCAT), Zaria strictly adhere to the Flight Maintenance Engineer’s refresher course, in accordance with the NCAT Maintenance Management Exposition Part 3 Subsection 3.4.0 and section 3.2.1.14 (d) (1) Nig. CARs 2015 and 2023 respectively.”

Causal factor of the incident was “the decision to land the aircraft within the remaining runway available during the initial climb instead of continuing with the flight using the appropriate procedure to land normally” and contributory factors are “the opening of the cockpit door during the initial climb” and “failure to execute the door unlatch checklist emergency procedures.”

On 31 December, 2022 a Beech Baron 58 aircraft operated by Nigerian College of Aviation Technology (NCAT) Zaria with nationality and registration marks 5N-CAG, was schedule for Airline Transport Pilot Licence (ATPL) training on instrument approach procedures in General Hassan Usman Katsina International Airport (DNKA) Kaduna.

Four persons were onboard including the Flight Instructor (FI), the Student Pilot (SP) and two additional student pilots seated at the rear with fuel endurance of 6 hours. The SP was the Pilot Flying (PF) on the left seat and the FI was the Pilot Monitoring (PM) on the right seat.

The ATPL training was initially scheduled to be conducted at Mallam Aminu Kano International Airport (DNKN) Kano with Diamond 42 (5N-CZA and 5N-BZE) where jet A1 fuel was readily available. The Service Bulletins (SB’s) with reference number MSB 42-143/1 and MSB 42NG-086/1 requiring inspection of a hole position and condition in the rudder steering bracket rendered the DA-42 aircraft unserviceable. NCAT decided to continue the training at DNKA with a Beech Baron 58 (5N-CAG) that uses AVGAS which was available in Kaduna.

At 09:20 h, the FI briefed the SP on the training and the SP carried out preflight inspection in accordance with the Baron 58 (B 58) NORMAL PROCEDURES Checklist. At 09:56 h, 5N-CAG requested for engine start-up for a non-precision VOR/DME instrument approach exercise for Runway 05 from Tower which was granted. At 10:00 h, 5N-CAG requested for taxi and it was granted. According to the SP, during taxi the throttle levers were stiff and the engine RPM were not synchronized. The FI confirmed the indication as normal when asked.

The flight crew stated that, at the holding point before take-off the checklist was completed and all parameters were found in the green.At 10:15 h, 5N-CAG requested for take-off runway 05 which was granted. The crew confirmed that they were on runway centerline and advanced the throttles for take-off. Immediately after lift-off, the cockpit door on the right side opened. The SP continued with the take-off while the FI attempted to close the door. As the FI tried to close the door, the SP reduced the throttle lever to 300 RPM. With the door still open, the flight crew decided to land the aircraft straight ahead on the remaining runway. The FI took control of the aircraft, closed the throttle levers and confirmed with the SP whether the landing gears were down. The SP replied landing gears down with three greens.

On landing, the left main wheel touched the runway first followed by the right main wheel. The aircraft veered to the right and FI applied left rudder to keep the aircraft on the runway. The torque link sheared off and inner cylinder of the right main landing gear pulls out and separated from the outer cylinder. The right wing impacted the runway.

The aircraft veered to the right and finally stop at the edge of runway 05 with the right wing dripping fuel. The flight crew notified Tower of the occurrence and requested the assistance of the Emergency services followed by the complete shutdown of the aircraft. At 10:19 h the Aerodrome Rescue and Fire Fighting Service (ARFFS) arrived the scene of the occurrence.

All the occupants disembarked unhurt. The incident occurred at 10:16 h, day time in Visual Meteorological Conditions (VMC). The aircraft was substantially damaged.

NSIB findings was that the flight crew were licensed and qualified to conduct the flight. Also, the aircraft had a valid Certificate of Airworthiness. The flight was an Airline Transport Pilot License (ATPL) training on instrument approach procedures. The SP was the Pilot Flying (PF) and the FI was the Pilot Monitoring (PM). The ATPL training was initially scheduled to be conducted at Mallam Aminu Kano International Airport with Diamond 42 (5N-CZA and 5N-BZE). The two DA-42 were unserviceable due to the Service Bulletin (SB) with reference number MSB 42-143/1 and MSB 42NG-086/1.  NCAT decided to continue the training at General Hassan Usman Katsina international Airport with Beech Baron 58 that uses AVGAS which was available in Kaduna. Immediately after lift-off, the cockpit door on the right side opened. The SP continued with the take-off while the FI attempted to close the door. The FI tried to close the door, the SP reduced the throttle lever to 300 RPM. With the door still open, the crew landed the aircraft straight ahead on the remaining runway 1440 m from the of runway 05.

On the safety investigators’ arrival to the scene of the occurrence, it was discovered that the aircraft was moved away from its final position to another location 713 m along the runway after the occurrence. On landing, the left main wheel touched the runway first followed by the right main wheel. The right main wheel sheared off from its attachment point. The right wing impacted the runway and the aircraft veered to right of the runway. The aircraft came to stop at the edge of the runway with the right wing dripping fuel. The aircraft was moved to another location along the runway at about 713 m before the safety investigators arrived The investigation identified that there were previous instances of the door opening in flight.

There were no technical logbook entries regarding the previous incidences of door opening in flight. There was no maintenance carried out on the main landing gear in the last four months preceding the occurrence. During the site inspection, the Bureau observed that with the cockpit door closed and locked from the inside, indicating LOCKED, the door handle outside did not latch. The control tower in DNKA is temporarily located at the ARFFS watch room at the time of occurrence. The watch room provides limited view of the maneuvering area, active runway, departing and landing aircraft at the beginning of runway 05 or end of runway. The Duty Air Traffic Controller (DATCO) reported that permission to remove the aircraft from the incident site was not granted. The Bureau did not grant permission for the aircraft to be removed from incident site. NCAT Flight Instructors refresher course, Multi Crew Coordination (MCC) refresher were not consistent with in accordance with Nig. CARs.