Preliminary
Accident Report; Fatal Aircraft Crash - Johannesburg International Airport,
November 3, 2001
Wednesday, May 29,
2002
A Cessna F406 twin turbo propeller aircraft, registration ZS – OIG, crashed
shortly after takeoff at 3:19am, on Saturday 03 November 2001, at Johannesburg
International Airport. The aircraft was on route to Eros Airport, Windhoek,
Namibia.
Two
crewmembers and one passenger on board were killed. They were the pilots,
Eduard Davey (29) from Gauteng, Wesley Hampton – Cole (22) from Gauteng and the
passenger Johannes Heinrich Janik (37), a Namibian
citizen.
In
addition to the crewmembers and passenger there were a substantial amount of
cargo, consisting mainly of express freight parcels and two heavy steel bars,
each approximately 3m in length, onboard the aircraft
The Commissioner for Civil Aviation, Trevor Abrahams and the
investigator – in – charge, Jacques Grobelaar, have
briefed the families of the deceased on the content of the preliminary accident
report. This meeting took place this morning (Wednesday) at the CAA office in
Brooklyn, Pretoria
“The objective of any aviation accident investigation is not to
attribute blame or liability to any individual or organisation but rather to
learn from an accident in order to prevent similar occurrences in the future.
However, where criminal actions or flagrant violations of the Civil Aviation
Regulations occur, the South African Police Service or CAA Enforcement
Committee will be activated.
In an accident investigation, it is necessary to consider not only the
unsafe act performed by an employee but also the circumstances which may have
encouraged the individual to act, including the nature of the systemic and
environmental factors which permitted their action to have such serious and
immediate consequences” said Trevor Abrahams
On this flight there were no passenger seats installed in the cabin
area. The people responsible for the
loading of the aircraft reported that they were instructed by the cargo agents
to load the heavy boxes/parcels first in front of the cabin area and the
lighter boxes in the centre and rear.
They were also instructed to load the two heavy steel bars on the left side
of the aircraft, untied, on top of the boxes.
After the loading process was completed they had to re-arrange a few
boxes in order for the passenger to obtain space. He was positioned in the rear of the
aircraft. The cargo was loaded from
behind the pilot seats from floor level to the roof of the aircraft all the way
to the rear. There was no cargo net to secure the cargo as required according
to Civil Aviation Regulations.
Shortly after take-off, the ATC attempted to establish contact with the
aircraft without any response. An
emergency vehicle was requested to drive along the runway in an attempt to
search for the aircraft, as there was no communication with the aircraft. The emergency vehicle was unable to locate
the aircraft on the aerodrome premises.
According
to an eyewitness, he observed the aircraft flying just above the runway when it
suddenly pitched up and rolled left (dropping the left wing). The aircraft impacted the ground in the left
wing low attitude approximately 400m from where he was standing. He immediately phoned his supervisor and
advised him of the accident.
The aircraft was destroyed during impact. There was no post-impact fire.
The aircraft crashed in an open marshy area approximately 700m from the
threshold of runway 03R (right) at Johannesburg International Airport.
The
preliminary accident report revealed significant findings with regards to the
ill-fated flight;
·
It was calculated that the aircraft was operated approximately 1 837.57
pounds (833.51 kg) in excess of its maximum certified take-off
mass.
·
The pilot-in-command was the
holder of a valid pilot’s license and had the aircraft type endorsed in his
logbook. There was no indication that
incapacitation or physiological or psychological factors affected his
performance.
·
According to the co-pilots logbook
he was not rated on the aircraft and had no experience on turbo prop/ turbine
driven engine aircraft.
·
No evidence could be found that
POH (Pilot’s Operating Handbook) was onboard the aircraft.
·
The cargo was not secured.
·
There was no seat or
safety-restraining device for the passenger.
·
The Operator’s GJ Air, AOC
(Air Operating Certificate) expired on 30 October 2001 and at the time of the
flight was still awaiting the renewal approval from the CAA.
·
GJ Air’s pilot, training, aircraft
and operational records were incomplete and not in accordance with the
requirements of parts of the Civil Aviation Regulations.
·
The AMO (Aircraft Maintenance
Organisation) responsible for the maintenance of the aircraft did not comply
with the Civil Aviation Regulations – no records of last few MPI’s in the engine logbooks.
·
The use of ZS-OIG by GJ Air
appears to be based on a questionable lease agreement, which the owner of the
aircraft claims to be fraudulent.
·
An Aircraft Maintenance
Organisation did not attend to certain defects on ZS-OIG, which were reported
on two occasions, by previous pilots of ZS - OIG, to a director of New Heights.
·
New Heights personnel appear to be
responsible for accessing the aircraft, flight crew and loading of the
aircraft. It was unclear how GJ Air
ensured compliance with its operations manual in the conduct of this
flight.
·
Modifications were installed on
the aircraft (lead acid battery, wheel brake assemblies and leading edge paint
coating) without the manufacturers or CAA approval including the replacement of
the outer wing leading edge de-ice boots by an unapproved wing leading edge
harsh anti-erosion rubber paint.
·
The aircraft appears to have been
released to service despite the engines having exceeded their TBO limits. The maintenance records of engine changes to
ZS-OIG also appear to be incomplete.
The Preliminary Accident Report states the following interim
recommendations:
·
It is recommended that the CAA
airworthiness department review the system of weighing and reweighing of
aircraft on the South African register, in particularly the case of F406
aircraft. (The accident aircraft was
manufactured in 1989 and the basic empty weight was calculated by the
manufacturer as 5 479.09 pounds. The aircraft was re-weighed in South Africa on
12 October 1998 and the basic empty weight was calculated as 5 210
pounds).
·
The CAA Legal Department
investigates and reports on the operational discrepancies relating to the lease
of ZS-OIG from the owner to GJ Air.
·
The CAA Operations and Legal
Departments review the role and function of GJ Air with regard to the
compliance with Civil Aviation Regulations and GJ Air’s operations manual,
given the findings.
·
The CAA Operations and Legal
Departments review the role and function of the operator New Heights throughout
the course of this operation to determine what this operator’s effective role
was in this accident.
·
The CAA Airworthiness and Legal
Department review the states of the engines on the accident aircraft and the AMO’s, which were responsible for servicing and installing
these engines.
·
The CAA Airworthiness Department
to ensure that AMO’s conduct sound practices with
regard to maintenance by not certifying maintenance release certificates,
logbooks or Inspections Reports (TV2/72) if they are aware of a non compliance
or excess in the TBO (Time Between
Overall) time of any major component including engines.
·
The CAA Airworthiness and Legal
Department review the unauthorised modifications found on the accident aircraft
and determine the circumstances and which AMO’s were
responsible for effecting these modifications.
The operator undertook this fatal
flight with the full knowledge that the existing AOC expired on the October 31,
2001. This, after a notice from the CAA, have been received by the operator in
June 2001, reminding the owners of GJ Air that their AOC will lapsed at the end
of October in the same year.
After
careful consideration of the application, the Commissioner decided against the
renewal of the operating certificate as GJ Air have failed to operate a safe
operation and non - compliance with the Civil Aviation Regulations.
For Further
Information, contact
Trevor Davids
083 635 0068