BAGAIA, Charles Irikefe Erhueh, ISASI 2025, Denver Colorado, aviation safety, air accident investigation, delegated accident investigation, Moderator-Mr. Douglas Zabawa of Pratt & Whitney aviation certificate, at the safe

Commissioner of the Banjul Accord Group Accident Investigation Agency (BAGAIA), Engineer Charles Irikefe Erhueh, has outlined critical lessons learned from the 2017 CAVOK Airlines crash in São Tomé, stressing the importance of cooperation, cultural sensitivity, and professionalism in delegated accident investigations.

Speaking at the International Society of Air Safety Investigators (ISASI) 2025 conference in Denver, Colorado, on October 2, Engineer Erhueh presented a paper titled Delegated Accident Investigation by São Tomé to BAGAIA and the Lessons Learned.

The presentation examined how São Tomé, lacking resources to conduct a full-scale probe, formally delegated the investigation to BAGAIA in line with the International Civil Aviation Organization (ICAO) Annex 13 provisions.

According to him, Annex 13 allows a State of Occurrence to delegate an investigation either wholly or partially to another State or to a Regional Accident Investigation Organization (RAIO) by mutual arrangement.

This, he explained, is designed to guarantee independence and efficiency, especially when a State does not have the technical expertise or resources to carry out a credible inquiry.

The São Tomé Case Study

The accident at the heart of the study involved a CAVOK Airlines AN-74TK-100 aircraft, flight CVK 7087, registered UR-CKC, which crashed on July 29, 2017, during take-off at São Tomé International Airport. The São Toméan civil aviation authority, acknowledging its limitations, wrote to BAGAIA requesting a full delegation of the investigation.

On receiving the request, BAGAIA coordinated with member and non-member states, eventually assigning the Nigeria Accident Investigation Bureau (now Nigerian Safety Investigation Bureau, NSIB) to deploy experienced investigators.

Ukraine, the State of Registry and Operator, also participated through its National Bureau for Aviation Occurrences, while São Tomé’s Instituto Nacional de Aviação Civil (INAC) worked alongside the team.

Engineer Erhueh noted that this collaborative effort marked one of the earliest practical demonstrations of BAGAIA’s role as a regional agency under ICAO Doc. 9946.

Findings and Safety Recommendations

Despite the multi-stakeholder collaboration, the investigation faced challenges. Translation delays, scheduling conflicts, and limited time on-site slowed the process.

However, the final report determined that the crash was caused by a rejected take-off above decision speed (V1) due to birds on the runway, a decision inconsistent with CAVOK Airlines’ Standard Operating Procedures.

The inquiry identified 23 findings and issued nine safety recommendations: six to São Tomé’s regulator, two to the airline, and one to Ukraine’s Civil Aviation Authority. These addressed runway wildlife management, airline operational procedures, and regulatory oversight.

Lessons for Future Investigations

Reflecting on the process, Engineer Irikefe stressed that the São Tomé experience provided lasting lessons for regional accident investigation. Among them, he highlighted the need for patience, teamwork, and respect for cultural differences in a multinational setting.

He cautioned that communication gaps can quickly derail complex investigations, while neutrality and professionalism are essential when managing conflicting claims from stakeholders. For instance, during the São Tomé case, while some parties denied a bird strike, others confirmed it as a contributing factor. BAGAIA’s neutral position ensured fairness and credibility.

“These lessons shaped BAGAIA’s evolution,” Irikefe told participants. “Working together, respecting cultures, and maintaining professionalism are not just ideals but necessities in delegated investigations.”

Strengthening Regional Capacity

Since the 2017 investigation, BAGAIA has consolidated its institutional framework. Its headquarters was formally established in Praia, Cape Verde in 2019. A resident Commissioner was engaged the same year, ending the reliance on external appointments.

By 2021, BAGAIA developed its own Safety Investigation Regulations, followed in 2022 by a detailed Policies and Procedures Manual.

The agency has also built a regional pool of investigators, enabling quicker response and resource-sharing among its seven member states: Cape Verde, Gambia, Ghana, Guinea, Liberia, Nigeria, and Sierra Leone.

Earlier this year, the Banjul Accord Group Council of Ministers assented to an amendment of the BAGAIA Agreement, presented at the 18th BAG Plenary in Abuja. This review strengthens BAGAIA’s mandate and reinforces its independence in conducting accident investigations.

A Model for Regional Cooperation

Engineer Erhueh concluded that São Tomé’s delegation of the CAVOK Airlines investigation proved that smaller states can rely on regional structures to guarantee credible and independent accident investigations.

“The São Tomé accident validated the RAIO concept,” he said. “It showed that when states work together under ICAO provisions, safety investigations can be conducted to the highest standards, no matter the size or capacity of the State of Occurrence.”

BAGAIA, he noted, continues to play a central role in strengthening air safety across West Africa through collaboration, knowledge-sharing, and efficient use of resources, lessons that remain relevant for all regional safety bodies worldwide.

Before his presentation, Jay Graser of Concept Solutions gave a presentation on  Investigating Uncrewed Vehicles:The Continuum and What to Consider while Brian Huh of USC gave his on Trust-Centered Investigations:Integrating Human Factors and Behavioral Science with Al in Aviation

Engineer Erhueh was bestowed a Certificate of Appreciation at the event which held in Denver, Colorado in the United States.