A devastating air crash in Lagos, Nigeria killed all on board and at least 10 on the ground. This was the first major commercial air disaster since 2006. Safety efforts since that disaster resulted in the US Federal Aviation Administration ( FAA) granting Nigerian airlines its top air-safety rating. Now concerns about air safety in Nigeria have resurfaced. As a result of the crash, according to Harold Demuren, head of Nigerian civil aviation body: “We have suspended the entire Dana fleet. They will be grounded as long as it takes to carry out the necessary investigations into whether they are airworthy.”
We can examine this incident in a Cause Map, or a visual root cause analysis. We begin with the goals that were impacted. In this case, the safety goal was impacted due to the deaths of people on the plane and on the ground. We begin by asking “Why” questions to put together a very simple cause-and-effect relationship. In this case, after losing both engines, Dana Air flight 992 crashed into a residential building in a highly populated suburb of Lagos, Nigeria, killing all 153 people on board and at least 10 on the ground.
The investigation of the plane crash is still ongoing. However, it is known that both engines of the plane lost power, causing the plane to rapidly lose altitude and crash into a highly populated area. Some of the areas being investigated that may have contributed to the crash are:
1) a bird strike (bird remains were found in one engine),
2) poor maintenance (although the plane was regularly inspected, there were also reports of leaking hydraulics and a history of poor airline safety in Nigeria, which appeared to have been remedied in recent years as indicated by the US FAA’s granting of its top air-safety rating,
3) overworked planes, likely due to financial considerations (the plane that crashed was on its fourth trip of the day), and/or
4) the age of the airplane (at 22 years old, it was technically not permitted to fly in Nigeria, which bans the use of planes over 20 years old).
As more information is revealed during the investigation it can be added to the Cause Map. As the investigation is concluded, there will likely be more changes to Nigerian requirements and oversight for air safety.
To view the Outline and Cause Map, please click “Download PDF” above.