Max Air EMB-135BJ Incident: Apron Congestion Identified As Hazzard To Aircraft Operation

One of the findings of the Nigeria Safety Investigation Bureau (NSIB) in its final report on the ground collision incident involving an EMB-135BJ aircraft operated by Max Air Limited with nationality and registration marks 5N-BXK and a parked ATR 42 aircraft operated by Nigerian Air Force registered NAF 930, which occurred on the apron of the General Aviation Terminal of Nnamdi Azikiwe International Airport Abuja on April 26, 2022 was that “Apron Congestion was identified as a HAZARD to operation of aircraft at the aprons of the airport and the associated high risk level was in the unacceptable region.”

The report says “the incident occurred at daytime in visual meteorological conditions (VMC). The flight crew were certified to operate the aircraft. The Pilot was the Pilot flying. Inadequate Marshallers to provide guidance on the three aprons of NAIA. The airport had a total of 18 Marshallers on a 6-hourly shift regime, six of whom were deployed to the General Aviation Terminal (GAT)/Cargo Apron. Just one Marshaller was scheduled to marshalling duty per shift at GAT/Cargo Apron.

The FAAN Marshaller on duty at the GAT/Cargo Apron was attending to another aircraft at the time 5N-BXK commenced taxi out. No Max Air ground handling agents available for marshalling and wing clear guidance to 5N-BXK. No Briefing was conducted on taxiing in a congested apron prior to commencing the taxi. However, the flight crew were heard on Cockpit Voice Recorder (CVR) discussing manner aircraft were parked on the GAT/Cargo Apron. The flight crew were heard on the CVR during the taxi expressing concern that some people were just watching them without rendering any assistance even though the military personnel stated during post occurrence interview that they passed signals to the flight crew to stop taxi but there was no response.

The 307 Executive Air Group (EAG) of the Nigerian Airforce (NAF) parks some of its aircraft at the GAT Apron from time to time.  EAG deploys military personnel to provide marshalling service to its aircraft at the GAT/Cargo Apron and also mount guard on the parked aircraft to ensure clearance with any taxiing aircraft.

At 08:30 h, ATR 42 NAF930 landed Abuja and was marshalled to park at the GAT/Cargo Apron by military personnel. The ATR 42 NAF930 parked at an unmarked spot on the GAT/Cargo Apron, its right wing extended beyond the active apron edge line and its Tail Section protruded into the Apron Taxi Lane in use by 5N-BXK.  The ATR 42 was not properly parked in accordance with the lateral and longitudinal parking alignment relative to the other parked aircraft at the apron. The protrusion of NAF930 constituted a safety hazard that was readily discernible.

The ATR 42 was on that spot for approximately forty minutes before the collision took place. A more frequent inspection of the apron condition would have afforded the opportunity to timely detect that ATR 42 as parked had constituted a safety hazard to other traffic on the apron. The military personnel that provided marshalling services to ATR 42 NAF930 prior to the occurrence did not have any formal training on aircraft marshalling.

At 09:07:08 h, 5N-BXK commenced taxi to the Holding Point RWY 22 from its unmarked parking spot at a bay on the GAT/Cargo Apron. The condition of the GAT/Cargo Apron was such that it was impracticable to park aircraft at the few marked parking positions only. Therefore, FAAN Marshallers guided all civil aircraft to park at both marked and unmarked spots while maintaining the required wingtip clearance of 7.5 meters and properly aligned laterally and longitudinally with one another.  As the 5N-BXK taxi progresses, Air Traffic Control advised the flight crew to exercise caution as the GAT/Cargo Apron was congested and the flight crew acknowledged.

As at the time of the occurrence, Link A2 which would have been normally used to taxi out of the GAT/Cargo Apron to runway 22 was blocked by a large body aircraft (Airbus 350) on a Special Parking provisions. A construction work for the expansion of the GAT/Cargo Apron was going on at the time of the occurrence.  The NAIA has established and implements a safety Management System (SMS) to ensure safety of operations at the airport. However, the Safety Policy was not signed in the SMS Manual Version 1 dated 28 April 2017 made available to the investigation.”

“The three important risk controls (apron expansion, Pilot compliance with parking instruction from Marshallers and adequate Marshallers) envisaged through the airport’s proactive safety risk management process, to reduce the assessed UNACCEPTABLE LEVEL of safety risk associated with apron congestion to an ACCEPTABLE LEVEL of safety risk have not been realized.”

The causal factor was “the decision to embark on taxi in the congested GAT/Cargo Apron without recourse to the services of FAAN Marshallers and/or Wing-Walkers.” Contributory Factors are “continuing the taxi of 5N-BXK even when the flight crew were in desperate need of ground assistance to proceed; Non-conduct of flight crew BRIEFING on Taxiing in a congested apron prior to commencing the taxi; The inappropriate parking of the military aircraft NAF 930 with its tail section protruding into the Taxi Lane used by 5N-BXK on the congested apron; The use of non-standard marshalling techniques together with the deployment of untrained personnel to marshal the NAF930 to that parking spot on the congested GAT/Cargo Apron; Inadequate number of FAAN Marshallers to provide the required taxi and parking guidance to all traffic on the congested GAT/Cargo Apron” and “Inability of the continual improvement process enshrined in the safety management system of the airport to timely detect as a safety hazard to other traffic, the inappropriate parking of the ATR 42 (NAF930) on the GAT/Cargo apron.”

Safety recommendations were that “Max Air Limited should ensure its flight crew limits communication to only authorized ground crew while on flight duty in line with Section 8.3.3.4(a) of the Max Air Ltd Operations Manual Part A to avoid expecting guidance from unknown persons or entities.

Max Air Limited should develop procedures requiring the flight crew to conduct BRIEFING, including requirement to ensure the use of the services of authorized Marshallers or ground staff/agent prior to commencing taxi in a congested apron. Max Air Limited should ensure that its flight crew adhere to the requirements of Section. 6.2.6.2 of the Airfield Operations Manual of Nnamdi Azikiwe International Airport by using the services of authorized Marshallers and/or the airline’s trained ground staff/handling agent to ensure appropriate wing tip clearance is maintained during push-backs and any subsequent pull forward of the aircraft.

Federal Airport Authority of Nigeria (FAAN) should provide adequate resources to ensure effective implementation of its safety management system, including the immediate recruitment, subsequent training and deployment of adequate number of Marshallers to provide guidance to aircraft for safe operation at the Nnamdi Azikiwe International Airport.

Federal Airport Authority of Nigeria (FAAN) should adhere to Section 3.6 of Nnamdi Azikiwe International Airport Safety Management System Manual to ensure the implementation of all the outstanding Risk Control measures contained in its Hazard and Risk Register, including the timely completion of the GAT/Cargo Apron expansion project to ensure additional parking space is made available to reduce the congestion of the apron.

Federal Airport Authority of Nigeria (FAAN) should adhere to Section 4.3 of Nnamdi Azikiwe International Airport safety management system manual to ensure the continual improvement measures, such as periodic audits and frequent inspections of Movement/Safety Areas of the airport are implemented to ensure early detection of hazards to safe operations in the airport, including inappropriately parked aircraft on the GAT/Cargo apron.

Federal Airport Authority of Nigeria (FAAN) should Carry out sensitization of all airport users, including the military, on the procedures, instructions, safety rules and guidance contained in the relevant manuals of the airport to ensure the users understand their safety responsibilities when operating in the airport in line with Chapter 1 of the Airfield Operations Manual of Nnamdi Azikiwe International Airport to ensure improvement of safety of operations.

Nigerian Air Force should adhere to the procedures, instructions, safety rules and guidance established by the airport authority in its relevant manuals, including Section 6.5 of the Airfield Operations Manual of Nnamdi Azikiwe International Airport for appropriate guidance and allocation of parking bay in the congested GAT/Cargo Apron to avoid safety hazards and to make the most efficient use of the limited parking space.

Nigerian Air Force should ensure that all its personnel deployed to perform duties at the GAT/Cargo Apron of Nnamdi Azikiwe International Airport are provided with the required training, tools and equipment to enable them perform the assigned duties in line with the procedures, instructions, safety rules and guidance established by the airport authority to ensure safety of operations.

Nigerian Civil Aviation Authority should ensure through its safety oversight activities that, the airport operator and all users of the airport adhere to the established procedures, instructions, safety rules and guidance contained in the relevant documents of Nnamdi Azikiwe International Airport to ensure safety of operations.

Nigerian Civil Aviation Authority should facilitate cooperation between the Federal Airports Authority of Nigeria and the military authorities, in particular, the Nigerian Air Force to ensure coordination and harmony is achieved in order to improve safety of operations at the Nnamdi Azikiwe International Airport.”