It is 25 years today. But I still feel tears in my eyes reading this graphic, award-winning investigation and report I wrote for Newswatch Magazine on the tragic crash of ADC Flight 086 on November 7, 1996. Once I gained access to the top-secret black box in the fortified dark rooms of the aviation industry, no one was going to stop me from telling it all to Nigerians and the rest of the world. Newswatch put it on its cover. Greater detail is my 2018 book AUDACIOUS JOURNALISM. The lessons for the aviation industry and Nigeria at large are as valid today as they were 25 years ago.
Time: 5.03pm; November 7, 1996. A routine flight from the oil-rich Southern Nigerian city of Port Harcourt disappeared from the control tower radar screen as it was getting ready to land in Lagos. Frantic efforts to spot the aircraft in the hazy evening skies yielded no result. Moments later, Flight 086 plunged head-long into the bottomless lagoon of Ejirin, near Lagos.
The Boeing 727 went down with 143 souls. Internationally-backed massive rescue operations came up with a piece of wing, the size of a reading table and an orange-colored box curiously called the Black Box. That was all rescuers could salvage from the wreckage of Nigeria’s worst air disaster.
Tears flowed. Sorrow and horror gripped the nation. General Sani Abacha, Head of State, made a four-minute nationwide broadcast that graphically expressed the grief of the nation. He described the tragedy as one of the saddest events in the history of Nigeria.
True. So many factors combined to make that horrible November evening a sad day for Nigeria. Onboard Flight 086 were some of the best brains in Nigeria, trusted hands in the oil industry, irreplaceable fathers and breadwinners, newly-wedded couples who were flying off for a blissful honeymoon, and children. There were also 29 foreigners on board.
Besides, Flight 086 was manned by one of the best fliers the country has ever had. Dafe Sama, the captain and folk hero of his people, was not just the trainer of many Nigerian pilots, he was the national president of Nigeria’s Association of Aircraft Pilots and Engineers, NAAPE. What’s more, here was Nigeria’s favorite airline, Aviation Development Company, ADC, reputedly safe, efficient, and reliable. It was the only airline in the country quoted on the stock exchange.
What actually happened to Flight 086? Was ADC sabotaged? Did Flight 086 develop an engine problem? Was it airworthy in the first place? Or was the airplane blown into pieces by bombs as some suggested? Did the crash have something to do with the Ogoni crisis as some intelligence theories speculated? Did secret agents of the Abacha government, hot on the heels of its critics, plant explosives in the airplane to settle scores with one or two of them on board?
For 14 months the search for answers kept the nation in suspense. For the investigation panel set up by the government, mum was the word. The closest the government volunteered to date on the tragedy was given by Ita Udo-Imeh, Air Commodore and Aviation Minister. He said the crash of Flight 086 was caused by “human factors.”
Last November, Jerry Agbeyegbe, pilot and new president of NAAPE, demanded for the report of investigations into the crash. After months of investigation, Newswatch has, at last, unraveled the puzzles of “human factors” that caused the air disaster. The Black Box of Flight 086 which consists of the Cockpit Voice Recorder, CVR, and the Flight Data Recorder, FDR, is in Newswatch possession and has thrown sufficient light on why the ADC flight crashed.
The FDR was taken to the American National Transport Safety Board, NTSB, for transcription. NTSB passed no judgment on the crash but transcribed every conversation and noise in the Black Box. The Black Box, Newswatch can reveal, recorded everything properly. The recordings reveal that nothing was wrong with the ADC aircraft and that the status of the engine was perfect.
The flight ran fully during the three phases of an emergency, suggesting that there was no pre-flight impairment in the aircraft condition. There was also no sign of trouble at all before the crash on the outskirts of Lagos. The transcripts of CVR and the FDR pointedly confirmed that the cause of the crash was a “traffic conflict situation.” Indeed, Newswatch can now reveal that Flight 086 was barely 30 seconds away from colliding with another Boeing 727, called Flight 185 which was wrongly released into the air by air traffic controllers.
Flight 185 belonged to Triax Airline. It was heading for Enugu. Nigeria would have recorded a double tragedy that Thursday evening but for the fact that ADC Flight 086 was equipped with a traffic collision avoidance system, TCAS. With TCAS in Flight 086, the pilot saw Flight 185 flying directly at him. In a sudden manoeuver to avoid collision with Flight 185, the pilot of the ADC aircraft lost control and the plane plunged into the Lagoon.
Said a senior airport official: “Well, I can tell you that somebody fumbled. That evening, we would have lost two Boeing 727s and maybe double the number of casualties but for the TCAS in Flight 086. This is why ADC deserves some commendation.”Newswatch investigations show that the journey for Flight 086 from Port Harcourt began on a beautiful note. Flight 086 called the approach controller, APC, at Lagos Control Tower at 1547.27 hours:
ADK 086: Lagos approach eh good afternoon, (This is) ADK 086
APC: ADK 086, good evening. Go ahead
ADK: A Boeing 727, eh Port Harcourt to Lagos. Flight level 240 degrees on board 144. Crew of 01 eh correction 10 included, endurance take off 0220
APC: Say again, total crew?
ADK 086: 10 Crew included
APC: ADK 086 is cleared, no delay for VOR approach, runway in use 19L.
The summary of that coded conversation was that the captain of Flight 086 informed Lagos Approach Controller of his movement and received clearance and confirmation to proceed accordingly. Six minutes later, Flight 086 called APC again to inform him he was right on course. The reply from APC was “Go ahead.” Then Flight 086 said “next call descent” meaning, “I will call you again when I am ready to descend.”
Flight 086 kept the promise. At 1556.42 hours, about three minutes later, Flight 086 called APC notifying him of his position and requesting for descent. At this point APC was busy with another flight called Flight 645. A few seconds later, he returned to Flight 086 and sought confirmation that it wanted to descend. Flight 086 answered in the affirmative, giving all necessary data. By now, Flight 086 was at 69 nautical miles to Lagos. No tension. No anxiety whatsoever in their conversation. Meanwhile, APC was making efforts to speak with Flight 645 but Flight 645 requested Flight 086 to help. Flight 086 came in and helped APC relay the message:
ADK 086: “QNK 645, Lagos is calling you”
Flight 645: “Ok, Sir, if you can relay (to Lagos I am flying at) eh 56, level 220
The flight continued normally only with banters between the crew that sometimes drew hearty laughter. Again at 50 miles to Lagos, flight 086 notified APC of its descent and its position. The reply from the tower was: “Roger, ADK 086 descend to 160 (meaning O.K. ADC Flight 086, descend to 16000 feet above mean sea level”).
At this point the NTSB – transcribed tape indicates that the radar controller in the control tower took over from the approach controller, as messages moved to the radar frequency. About the same time, Flight 185 to Enugu had been cleared to take off from Lagos opposite Flight 086 which was already descending into Lagos. The tragedy was about to strike. But Flight 185 was completely unaware and uninformed about Flight 086 because, like most aircraft in Nigeria, it was not equipped with TCAS. All the same, a hearty conversation began between the radar controllers and the pilot of Flight 185, at 1553.10 hours.
Flight 185: Radar, good evening. Flight 185 with you on the right turn
Radar: Flight 185, good evening. Radar identified (you) on departure. Verify you are passing 1400.
Flight 185: Charlie, Charlie (Yes, yes)
Radar: You want a left or right turn?
Flight 185: O. K. we’d like a right turn
Radar: No problem, you turn right, heading 330 degrees. I read you continue turning, heading 330.
How wrong! There was a problem. That was certainly a fatal instruction. The ascending Flight 185 was heading directly into the descending Flight 086. Apparently uncomfortable, Flight 185 pilot sought again from the radar controller to confirm the instruction given him.
Flight 185: Radar, eh, Flight 185, eh, again, can we turn further right, sir?
Radar: Flight 185, turn right, heading 360, 360.
Flight 185: Roger (meaning O.K) right 360
Radar: (second later) Flight 185, (you are) 6 miles North West of the field. Turn right; resume (your) own navigation.
That was a big mistake, aviation experts told Newswatch in the course of investigations. It was too early for the radar controller to allow Flight 185 to resume flying on its own, experts agree. The radar controller however put a seal to that at 1558.15 hours.
Radar: “Flight 185 (you are) 10 miles east of the field. Radar service terminated, maintain squawk.
Flight 185: Good night, Sir
As it turned out, it wasn’t going to be a particularly good night. Not for radar controllers, not for the entire nation. And just then, the pilot of the ADC Flight alerted the radar controller of his position. That was at 1600.14 hours!
Flight 086: Lagos approach, eh ADK 086, eh coming out of 210 for 160 44 miles (meaning: Lagos approach controller, eh, this is ADC Flight 086. We are at 21000 feet above mean sea level. We are descending to 16,000 feet above sea level. We are 44 nautical miles to Lagos)
Radar: ADK 086, squawk ident (meaning ADC Flight 086, Identify yourself)
Flight 086: Ident (meaning: I am doing so or I am identifying myself).
Radar: (about a minute later) ADK 086, radar identified at 41 miles southeast of the field, fly heading (hesitating) fly heading eh, 320, vector round traffic, descend maintain FL50 (meaning ADC Flight 086. I have identified you on radar at 41 nautical miles, southeast of the field. Fly heading, fly heading, eh, 320 degrees, Descend and maintain 5000 feet above mean sea level).
Flight 086: Down to 50, heading 320 (meaning: I understand. I have been cleared to descend to 5000 feet above mean sea level and to fly heading 320 degrees).
At this point, it was just 30 seconds to disaster. Then confusion started. The tower controller began to betray anxiety.
Radar (1602.41 hours): ADK 086, what is your actual heading now?
Flight 086: (1602.46 hours): We are heading eh 3 .15, turning 320.
Radar (1602.51): Maintain heading 300, maintain heading 300
Flight 086 (1602.56): Ah, we..
Then the TCAS in Flight 086, came alive.
TCAS 91602.57 hours) Traffic, traffic (meaning hey, you have another aircraft approaching you and may collide with you)
Flight086 (1602.58 hours noticing Flight 185) I have it OK, we have the…
Radar (1603.01 hours): Say again?
Flight 086 (1603.03 hours): I have the traffic and I continue my heading to 330, to avoid him.
Radar (1603.08 approving Flight 086 plans) That’s better.
It was not better. Three seconds later, TCAS in Flight 086 changed from what was initially a traffic information alert to what is called Resolution Advisory: an emergency warning on how to quickly avoid collision with Flight 185 which was now imminent.
TCAS (1603.11): Reduce (descent), reduce, reduce, climb, climb, climb (meaning, you’ve got a serious problem. Reduce descent to avoid collision. Climb up, climb up, climb up).
What was heard next in the black box tapes was a sound similar to a high-speed clacker. That was nine seconds after the TCAS warning. Five seconds later the sound of a horn followed along with sustained screams that apparently came from horrified crew members and passengers. Then a rapid knocking sound followed, similar to the sound of a knocking car engine. The screams continued. A voice believed by experts to be that of Sama was shouting orders: “Power! Power!! Power!!!”
Experts interpret this to mean emergency commands to the pilot flying to “throttle, throttle, throttle” to gain the needed climb. One retired captain said this indicated that Sama was “still conscious and battling to recover that airplane until impact.”
Back at the control tower, Flight 086 had disappeared from the radar. But the controller did not think at first it was anything serious. After his last message (“That’s better”) to the ill-fated aircraft, he had switched attention to guide Flight 645. Returning to Flight 086, 30 seconds later, he called five minutes without any reply. Then an unidentified airplane within the vicinity joined to call Flight 086. “ADC 086, Lagos wants you,” the unidentified aircraft said. No answer.
Now panic began to descend on the control tower with repeated calls to the crashed aircraft. “ADK 086 Lagos, ADK 086, Lagos, how do you read? ADK, ADK ADK.” Then a helping hand came from another aircraft called Flight 615 which was also coming into Lagos.
Flight615, Lagos (radar), what is his destination, we will try and raise him for you. Soon Flight 645 was also brought in to help. “Could you help raise ADK 086?” the radar controller requested. “ADK , ADK, ADK. No response. Worried, Flight 645 asked the radar controller:” Lagos, is he in-bound or out-bound?” The radar controller had no time for interviews.” ADK..ADK..ADK 086 Lagos?” he went on.
With the calls becoming more frantic, other incoming flights began to suggest where ADK 086 could possibly be located: radar scope? radial? Tower frequency? Every frequency? On the tarmac? No dice. One inbound flight was requested to hold on for 15 minutes as the run-way was being cleared for a long possible emergency landing.
Flight615 (to Radar): OK, Lagos, what was the last level you gave him?
Radar: FL 50, sir,
Flight615: And did he respond?
Radar: Ah, he responded and he was even a traffic to (Flight 185) when they crossed I called him. I couldn’t see him again.
As the radar controller, nobody has seen ADK 086 and 143 souls it flew ever since. It seems now the energies of government and aviation authorities are focused on averting a recurrence of the Ejirin experience.
In a paper presented November last year to the Vision 2010 sub-committee on aviation, K.K. Sagoe, the nation’s head of aviation accident investigation bureau, classified the ADC Flight 086 crash among “accidents caused by contributions from the Air Traffic Control.”
Said Sagoe: “Recently, negative contributions by the air traffic controller services are surfacing in the accident scenario in Nigeria. The accident of Boeing 727, registered 5N-BBG near Ejinrin village on 7th of November, 1996, comes to mind. A Boeing 727, (Flight 185) was departing from Lagos to Enugu, while a Boeing 727, which was operated by ADC Airline was about to commence its approach to Lagos on a flight from Port Harcourt. At 16,000 feet above means sea level, both aircraft found themselves on a collision course. The ADC aircraft was equipped with a traffic collision avoidance system and hence was alerted to the danger. In an anti-collision avoidance maneuver, the aircraft plunged into the waters of the lagoon at a speed in excess of 500 knots. The investigators traced the origin of the accident to the fact that the air traffic controller released Flight 185 to fly under its own navigation far too early before the two aircraft were certain to have been positively and vertically separated.”
As a result, aviation authorities have made the acquisition of TCAS a priority for all airlines in Nigeria. Newswatch learned from reliable sources that the government has already given all airlines in Nigeria up to the year 2003 to equip their aircraft with TCAS. That decision was conveyed to them last December. Although they initially resisted the idea, thinking that it was the government’s way of avoiding the repairs and efficiency of traffic equipment, it later agreed to comply with it in the interest of safety.
Said a senior staff of the airworthiness division of FAAN: “The question of installing TCAS is non-negotiable. In fact, the government wanted TCAS installed immediately, because of the sad event of Flight 086 but we had to strike a compromise when some airlines demanded for a time frame of five years.”
Accordingly, training of pilots and air traffic controllers on the operation of TCAS is in the offing. In addition, both aviation authorities and AON have resolved to put pressure on the government to provide functional radar coverage to the whole country. AON appears also to have convinced the government to train air traffic controllers properly because of apparent difficulties they encounter daily in working with them. Government and AON appear also to have agreed to enforce existing regulations concerning compulsory use of transponders. The transponder is a radio device that transmits its own signal on receiving it. Operators may have agreed that the serviceability of their transponders is suspect. Aviation regulations require that all aircraft must not only be equipped with transponders but should also be switched on before takeoff. Monitoring and enforcing this regulation have been lax in the past. Indications are that aircraft without serviceable transponders may not be given clearance to take off in the near future.
Newswatch investigations further show that “human factors” have been blamed for 90 percent of plane crashes in Nigeria. According to records by aviation accident investigators, apart from two accidents namely, the Nigeria Airways Boeing 707 crash of December 1994 and the crash of Falcon 20 operated by Aero Contractors in September 1995, all the other accidents could have been avoided if the human element of the operation had been performed accurately.
For instance, the accident of the Gulfstream aircraft that crashed into a telecommunication mast in Jos in June 1996, killing Mohammed Wase, a colonel and military administrator of Kano State, was traced by investigators to human factors. Investigations show that “the clearance of the aircraft by the air traffic controller was to a navigational aid that was known to be unserviceable with radial error of more than 10 degrees.”
Similarly, the Fokker F-28 aircraft from Lagos to Enugu which crashed in November 1983, three miles to run away, killing 53 persons, was caused by human factors. Newswatch learnt that the pilot of that aircraft may have suffered from “spatial disorientation or dizziness.” The pilot, who did not die in the crash, later died in a road accident, when the car he was driving suddenly veered off the road killing him and his children.
While the tragedy of Flight 086 appears to be keeping aviation authorities on their toes for more than a year now, aviation officials may not have taken visible and adequate steps yet to cater for the well-being and sagging morale of staff charged with the sensitive responsibilities of manning multi-million dollar equipment and guiding hundreds of aircraft a day to safety.
Sagoe identified poor salaries and economic status of air traffic controllers vis-à-vis pilots as one reason for accidents and lack of confidence by air traffic controllers. Said Sagoe: “This lack of confidence of the controllers was clearly evidenced in the ADC accident.”