A01 - 131 / 7426

SOUTH AFRICAN CIVIL AVIATION AUTHORITY

 

PRELIMINARY ACCIDENT REPORT

Aircraft Registration

ZS-OIG

Date of Accident

3/11/2001

Time of Accident

0120Z

Type of Aircraft

Reims F406

Type of Operation

Commercial

Pilot-in-command Licence Type

ATPL

Age

29

Licence Valid

Yes

Pilot-in-command Flying Experience

Total Flying Hours

1 962.7

Hours on Type

1 007.6

Last point of departure

Johannesburg International Airport (FAJS)

Next point of intended landing

Eros - Windhoek - Namibia

Location of the accident site with reference to easily defined geographical points (GPS readings if possible)

700m South of the threshold of Runway 03R – FAJS (26° 10.220’ South 028° 14.852’ East – elevation ± 5 380ft)

Meteorological Information

Fine  –  Wind 030° / 4kt, Temperature +13°C,  Visibility +10km

Number of people on board

2 + 1

No. of people injured

None

No. of people killed

3
Synopsis
 

The aircraft departed Johannesburg International Airport at 0119Z on an international cargo flight to Eros an aerodrome located just outside Windhoek the capital of Namibia.  There were two pilots, a passenger onboard the aircraft and a substantial amount of cargo, consisting mainly of express freight parcels and two heavy steel bars approximately 3m in length each.    

 

The aircraft crashed approximately 106 seconds after commencing its take-off roll, impacting the ground in a left wing low attitude approximately 700m South of the threshold of runway 03R at Johannesburg International Airport. 

Probable Cause

To be determined.

 

PRELIMINARY ACCIDENT REPORT

 

Name of Owner                       : Transafrican Aviation Sales (PTY) LTD

Name of Operator                    : GJ Air (Pty) Ltd     (As per Flight Plan)

Manufacturer               : Reims Aviation

Model                                      : F406   (Caravan II)

Nationality                               : South African

Registration Marks       : ZS-OIG

Place                                       : South of Johannesburg International Airport

Date                                         : 3 November 2001

Time                                        : 0120Z

 

 

All times given in this report are Co-ordinated Universal Time (UTC) and will be denoted by (Z). South African Standard Time is UTC plus 2 hours.

 

Purpose of the Investigation:

 

In terms of Regulation 12.03.1 of the Civil Aviation Regulations (1997) this report was compiled in the interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and not to establish legal liability. 

 

Disclaimer:

 

This report is given without prejudice to the rights of the CAA, which are reserved.

 

1.                   FACTUAL INFORMATION

1.1        History of Flight

 

1.1.1          The aircraft departed Johannesburg International Airport at 0119Z on an international cargo flight to Eros an aerodrome located just outside Windhoek the capital of Namibia.  There were two pilots, a passenger onboard the aircraft and a substantial amount of cargo, consisting mainly of express freight parcels and two heavy steel bars approximately 3m in length each.    

 

1.1.2     There was 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.            

   

1.1.3     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.  Once the passenger was seated on the floor, the loading agents informed them that they no longer needed their services, where upon the aircraft doors were closed. The aircraft taxied out after they had vacated the parking bay.  There was no cargo net to secure the cargo as required by Part 91.02.7(1)(e) of the Civil Aviation Regulations (CAR’s).        

1.1.4          Taxi clearance was obtained and the aircraft was cleared to taxi to the holding point of Runway 21L(Left).  Take-off clearance was requested and the aircraft was cleared for take-off, Runway 21L with the surface wind being 030°/5 knots.

Shortly after take-off ATC made several attempts 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. 

 

1.1.5          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.     

   

1.1.6     The accident occurred at night at a geographical position determined as 26° 10. 220’ South and 028° 14. 852’ East, at an elevation of approximately 5 380 feet AMSL.   700m South of the threshold of Runway 03R, and left of the extended centreline of Runway 21L.   

 

1.2               Injuries to Persons:

 

Injuries

Pilot

Crew

Pass.

Other

Fatal

2

-

1

-

Serious

-

-

-

-

Minor

-

-

-

-

None

-

-

-

-

 

1.3        Damage to Aircraft:

 

1.3.1     The aircraft was destroyed during impact.  There was no post-impact fire.

 

 

 

1.4        Other Damage:

 

1.4.1          The aircraft crashed in an open marshy area approximately 700m from the threshold of runway 03R (right) at Johannesburg International Airport. 

 

1.4.2          The aircraft was fuelled to capacity prior to take-off containing approximately 3200 pounds of fuel (Jet A1).  During impact the fuel tanks rapture and the fuel, engine oil and hydraulic fluid was spilt at the initial point of impact. 

 

1.4.3          With the area being marshy the environmental damage to the area was considered substantial.  A Company specialising in spill recovery was notified. They responded quickly and the cleaning up process proceeded a few hours after the accident occurred.         

 

1.5               Personnel Information:

 

1.5.1     Pilot-in-command:      

 

The pilot-in-command was a male aged 29 years.  He held an appropriately type rated Airline Transport Pilot’s License No. TA 43224, valid until 30 April 2002.

Also endorsed in his license was a Night Rating and Instrument Rating.  

 

1.5.2     The pilot was certified and qualified for the flight in accordance with existing regulations and was found in the left-hand seat.  The pilot had a valid medical certificate at the time of the accident.  His medical examination for the renewal of his license was conducted on 24 April 2001, when he was declared fit from 24 April 2001 to 30 April 2002 as an Airline Transport Pilot with no restrictions.

           

1.5.3     Flying History:  

 

The pilot applied for his student pilot’s license on 9 April 1997.  On 11 August 1997 he applied for his Private Pilot’s License.  During this period he had accumulated a total of 40.0 flying hours.  All his flying training was conducted on the Cessna 172 type aircraft.    

 

During the period 5 September 1997 and 2 December 1997 the pilot wrote several theoretical exam subjects in order to obtain his Commercial Pilot’s License. 

 

On 15 December 1998 the pilot obtained his night rating as a private pilot.

 

On 14 April 1999 he obtained his Commercial Pilot’s License.

 

On 30 August 1999 the pilot completed his conversion training onto the Reims F406 type aircraft.  During this period he had flown a total of 18 hours dual training.  

 

1.5.4     According to CAA records this was the first accident in which the pilot was involved.

 

1.5.5          The last entry in the pilot’s logbook was on 30 October 2001.  It was established that the pilot conducted another two flights since the entry on 30 October 2001. A flight was conducted on 1 November 2001.  The flight was from Johannesburg (FAJS) – Windhoek, Eros (FYWE) – FAJS, with a total duration of 6.3 hours.  Another flight was conducted the following day being 2 November 2001 from Johannesburg (FAJS) – Vilankulo, Mozambique (FQVL) – FAJS, with a total duration of 4.4 hours. 

 

1.5.6          According to an interview with the wife of the deceased he left the house that morning at approximately 0530Z (07h30) and arrived back at home that afternoon at approximately 1630Z (18h30).  They went out for an early supper that evening where after they went to bed.  She recalls that he left the house at approximately 2330Z (01h30), the following morning for the flight to Windhoek, which was scheduled to depart at approximately 0100Z.  His total flying experience since he started flying on 20 March 1997 until 2 November 2001 comprised the following:        

 

1.5.7     Flying Experience:

 

Total Hours

  1 956.4

Total Past 90 days

     255.2

Total on Type Past 90 days

         6.3

Total on Type

  1 001.3

 

 

            Co-Pilot:

 

1.5.8     The co-pilot was a male aged 22 years.  He held a Commercial Pilot’s Licence No. CA 45124, valid until 31 December 2001.  Also endorsed in his licence were a Night Rating and an Instrument Rating.     

 

1.5.9          His medical examination for the renewal of his licence was conducted on 4 December 2000, when he was declared fit from 4 December 2000 until 31 December 2001 as a Commercial Pilot with no restrictions.

 

1.5.10      Flying History:

 

The pilot applied for his student pilot’s license on 1 June 1998.  On 24 July 1998 he applied for his Private Pilot’s License.  During this period he had accumulated a total of 71.6 flying hours.  All his flying training was conducted on the Piper PA28 140/160/180 type aircraft.    

 

During the period 2 December 1998 and 25 August 1999 the pilot wrote several theoretical exam subjects in order to obtain his Commercial Pilot’s License. 

 

On 8 December 1999 he obtained his Commercial Pilot’s License.

 

During the period 6-10 March 1999 the pilot wrote two theoretical exams subjects in order to obtain his Airline Transport Pilot’s License.

 

According to the pilot’s logbook and CAA records the pilot was not type rated on the aircraft, neither was the aircraft type endorsed in his logbook at the time of the accident.  There was no entry in the co-pilot’s logbook indicating that he had previously flown this type of aircraft or any turbine/turbo-propeller driven type aircraft.  

 

The last entry in the co-pilot’s logbook was on 30 October 2001.  His total flying experience since he started flying until 4 February 1999 comprised the following:                

           

1.5.11   Flying Experience:

 

Total Hours

498.2

Total Past 90 Days

  39.5

Total on Type Past 90 Days

None

Total on Type

None

 

 

            Passenger:

 

1.5.12   The passenger on the ill-fatal flight was a male aged 37 years.  He was also a pilot, although a Namibian citizen he was the holder of a South African Airline Transport Pilot’s License No. TA 16963, which was valid until 11 April 2002.  Also endorsed in his license were an Instructor Rating Grade 1, Instrument Rating and Night Rating. 

 

1.5.13   According to CAA records he was also a Designated Examiner (DE) in terms of the Aviation Act, Section 5.4 to perform the duties as A1A Designated Examiner (restricted) as per AIC 30.11 while holding a valid Pilot License for period 1 January 2001 until 31 December 2001. 

 

The pilot obtained his type conversion training onto the Reims F406 type aircraft on 19 July 1999. 

 

The body of the passenger was located in a sleeping bag in the rear cabin area of the wreckage.  There was no seat or safety-restraining device available for the passenger.     

 

The ill-fated passenger pilot logbook was recovered on the accident site.  The last entry in the logbook was dated September 30, 2001.  His total flying experience, according to his logbook comprised of the following:               

  

1.5.13   Flying Experience:

 

Total Flying Hours as on 30/9/2001

12 233.30

 

 

1.6        Aircraft Information:

 

1.6.1     The aircraft serial No. F406-0041 was manufactured in France by Reims Aviation and was delivered from the factory on 6 October 1989 to a company in Holland.  The aircraft was imported into South Africa from the United States of America in October 1998.  The Certificate of Registration No. 207/ZS-OIG/3, was issued on 4 October 2001.  The Certificate of Airworthiness that was current at the time of the accident was issued on 21 October 1998, in the Standard category. 

 

1.6.2     According to the airframe logbook, the last Mandatory Periodic Inspection (MPI) prior to the accident flight was certified on 30 May 2001, at 4 353.1 airframe hours.  According to the Flight Folio that was recovered on the accident site the aircraft had flown an additional 38.1 hours during the period September 2001 until 2 November 2001.   

 

1.6.3          The aircraft was fitted with two Pratt & Whitney PT6A-112 engines, serial No’s PCE 12568 and PCE 12569.  According to the MPI Record Inspection Form (TV2/72) obtained for these engines dated 20 June 2001 the total hours since overhaul was recorded as 3 725.8, thereby exceeding the approved TBO time of 3 600 hours, by 125.8 hours.      

 

1.6.4     The aircraft was fitted with two McCauley type 3GFR34C-701F propellers, serial No’s. 816048 and 960713.

 

1.6.5     The following is a summary of the aircraft components and the recorded hours

according to the aircraft logbooks and Flight Folio that was recovered on the accident site.  The last entry in the Flight Folio was dated 2 November 2001.

            The hours outstanding in the column below needs still to be confirm.

 

Sub-Assembly

Part No.

Serial No.

Hours

Airframe

F406

F406-0041

 

Engine  No. 1

PT6A-112

12569

 

Engine  No. 2

PT6A-112

12568

 

Propeller  No. 1

3GFR34C-701F

816048

 

Propeller  No. 2

3GFR34C-701F

960713

 

 

1.6.6     Mass and Balance Calculation

 

1.6.6.1                            The cargo was recovered to the CAA hangar where it was sorted and packed into smaller manageable containers.  Some of the cardboard packaging material was ruptured and not collected for the purpose of weighing the cargo.  The weigh bill indicated a total cargo weight of 1,081 kg.  The recovered cargo was however also weighed by the SABS for verification purposes 10 days after the accident and amounted to 997.88 kg.

 

1.6.6.2                            Due to the fact that the two weights did not differ significantly from one another, it was decided to use the SABS weight of 997.88 kg as the total cargo weight as this was the only weight that could be verified.  The SABS figure is therefore the lowest possible cargo weight and it is possible that the total cargo weight was in excess of this figure.

 

1.6.6.3                            The total aircraft mass was calculated as follows:

 

The weight of the pilot, co-pilot and passenger was obtained from the last flying medical examination records of each individual.

 

According to the Pilot’s Operating Handbook, Section 1, Page 1-5, the total fuel capacity of the aircraft is 481.5 US Gallons.  At 6.74 lbs/US Gallon for Jet A-1 type fuel, this amounts to 3 245.31 pounds of fuel.

 

 

Item

[kg]

[lbs.]

Aircraft empty mass

2 363.00

5 210.00

Fuel mass

1 472.06

3 245.31

Cargo mass

   997.88

2 199.93

Pilot

     74.00

   163.14

Co-pilot

     90.00

   198.41

Rear passenger

     82.00

   180.78
Total T/O Weight

           5 078.94

11 197.57

 

1.6.6.4                            The maximum certified mass of this aircraft is stipulated as follows:

 

Maximum Ramp Weight:                        9435 lbs.

4279 kg.

 

Maximum Take-off Weight:                     9360 lbs.

4245 kg.

 

1.6.6.5                            It is therefore calculated that the aircraft’s actual mass exceeded the Maximum Ramp Mass by 1 762.57lbs (799.94 kg) and exceeded the Maximum Take-off Mass by 1 837.57lbs (833.94 kg).  This translates into an overload condition of approximately 19.64%.

 

1.6.6.6                            At this stage it is not possible to calculate whether the aircraft was loaded within the fore and aft CG (Centre of Gravity) envelope.  This is due to the fact there is no known record of the weight and location of cargo loaded in the aircraft and the fact that a large discrepancy exists between the empty weight CG position of ZS-OIG and other South African registered F-406 aircraft when compared to the empty weight CG position data given by the manufacturer. 

 

1.6.6.7                            The CAA Airworthiness section will investigate this discrepancy further before any further comment on the CG position of the aircraft will be made.   

 

 

1.7        Meteorological Information:

 

1.7.1          Surface Observation:

 

A high-pressure system was present over the interior causing fine weather over Gauteng.

 

1.7.2          The weather observations at Johannesburg International Airport on 3 November 2001 at 0100Z and 0200Z were as follows:

 

Time                                        0100Z                                       0200Z

Wind                                         030°/4 knots                              020°/5 knots

Visibility                                    10km +                                     10km +

Cloud cover                               No cloud                                   No cloud

Temperature                              +13°C                                       +12°C

Dew point                                  +10°C                                       +10°C

Pressure Altitude                       1021 hPa                                  1021 hPa (hectoPascal)

 

1.7.3          Satellite Image:

 

Clear weather conditions prevailed over the Gauteng area.

 

 

 

1.8        Aids to Navigation:

 

1.8.1     Not relevant to this accident.

 

1.9        Communications:

 

1.9.1     The following is a transcript of recorded communication between the aircraft and ATC (air traffic control) Johannesburg tower on the frequency 121.90 MHz. 

 

            The accident aircraft call sign was Jolly Rogers 070 abbreviated as JRG070.  

            FROM   TO                                            MESSAGE

 

            JRG070 ATC                  Joburg ground, good morning JRG065 

 

ATC                  JRG070 JRG069 morning activating your Flight Plan call

                                                you back.

 

            JRG070 ATC                  Thank you sir, I think it is actually the JRG070. 

 

            ATC                  JRG070 Thanks copy JRG070 activating calling you back

shortly.   

 

            JRG070 ATC                  Thanks 070.

 

            ATC                  JRG070 JRG070 go-ahead with your details.

 

            JRG070 ATC                  JRG070 parked at Delta 1, we are three crew

members onboard, we have got 4 hours endurance

requested level 100 for Windhoek, Eros. 

 

            ATC                  JRG070 JRG070 your registration?

 

            JRG070 ATC                  Ok that’s Oscar India Golf (OIG).

 

ATC                  JRG070 JRG070 the wind is 030° at 5 knots runway 21L (left)

                                                or 03R (right)? 

 

            JRG070 ATC                  21L (left) will do thanks 070.

                                               

            ATC                  JRG070 JRG070 runway 21L, Lanseria 3B (bravo), radar

124.5, squawk 2411. 

 

JRG070 ATC                  21L, Lanseria 3B departure, airborne 124.5, squawk

241 - double transmission.   

 

ATC                  JRG070 JRG070 sorry double transmission confirm airborne

                                                frequency and squawk.

 

            JRG070 ATC                  Airborne 124.5, squawk 2411.

 

            ATC                  JRG070 JRG070 confirm ready for start?

 

            JRG070 ATC                  Afirm

           

            ATC                  JRG070 JRG070 start approved.

 

            JRG070 ATC                  Start approved call you back for taxi.

 

            ATC                  COX006            Confirm Compion006 is ready.

 

            COX006            ATC                  Sorry about that double transmission we are ready

21L.

           

            ATC                  COX006            Comp006 your new squawk is 2436, your are cleared

take-off runway 21L the wind 030° / 8 knots, cheers.

 

            COX006            ATC                  2416 Confirm for Compion006.

 

            ATC                  COX006            2436.

 

            COX006            ATC                  2436 and we are cleared for take-off 21L,

Compion006.

 

            ATC                  COX006            Confirm 006.

 

            JRG070 ATC                  And JRG070 is ready for taxi.

 

            ATC                  JRG070 JRG070 taxi Alpha, Hotel, holding point runway 21L

                                                            cross 21R.  

 

            JRG070 ATC                  Alpha, Hotel 21L and cleared to cross 21R, JRG070.

 

            JRG070 ATC                  JRG070 is ready at holding point 21L. 

 

            ATC                  JRG070 JRG070 cleared take-off runway 21L the wind is 030°

                                                            / 5 knots, bye bye.

 

            JRG070 ATC                  Cleared take-off Zero, ag correction 21L, JRG070,

good day.

 

ATC                  JRG070 JRG070 on tower 118.1 do you read …., correction

on 121.9 do you read. 

 

            ATC                  JRG070 JRG070 tower.

 

            FTLead ATC                  Tower, Foxtrot Tango Lead

 

            ATC                  FTLead FT Lead your position?

 

            FTLead ATC                  Sir we are east of the new complex.

 

            ATC                  FTLead FT Lead enter Runway 21L proceed down the runway

                                                            to the threshold of runway 03R, when you get to the

threshold if you can just proceed as far as you can,

just have a look, an aircraft departed approximately 6 minutes ago and after that we had no contact with him.  If you can just have a look and see if you can see something. 

 

            FTLead ATC                  Ground - FT Lead copy.

 

            ATC                  JRG070 JRG070, Joburg tower.

 

            ATC                  JRG070 JRG070, Joburg.

 

            ATC                  JRG070 JRG070, Joburg on 121.9 do you read.

 

            ATC                  JRG070 JRG070, Joburg.

 

            There was no further communication.                  

 

 

1.10            Aerodrome Information:

 

1.10.1      The following aerodrome information is applicable:

 

The aircraft departed off Runway 21L at Johannesburg International Airport.  The airport is serviced by two asphalt parallel runways, with the main runway being 03L/21R, which is 4 418m (14 580 feet) long and 60m (198 feet) wide.  Airport elevation is 5 558 feet above mean sea level (AMSL).

     

Aerodrome Location

FAJS

Aerodrome Co-ordinates

S26°08,01’  E028°14,32’

Runway Elevation

5510 feet

Runway Designations

03Right/21Left

Runway Dimensions

03R – 3400m x 60m

Runway Used

21L

Runway Surface

Asphalt

Approach Facilities

NDB, VOR, ILS, PAPI

 

 

1.11      Flight Recorders:

 

1.11.1   The aircraft was not equipped with a flight data recorder (FDR) or cockpit voice recorder (CVR), nor was either required by regulation. 

 

1.12      Wreckage and Impact Information:

 

 

1.12.1   Examination of the accident site suggested that the aircraft impacted in marshy terrain in a left wing low attitude on a heading of 210°(M).  The aircraft left an approximately one meter deep depression of about 25 metres in length at the point of impact before “bouncing” a further 20-30 metres before impaling the right wing on a fence post.  The forward inertia resulted in wrapping around this and another fence post, breaking along the longitudinal axis in the region of the pilot’s seat and the aft door.     

 

1.12.2      The overall length of the wreckage trail was approximately 50 metres (165 feet).  Due to the considerable amount of energy on impact the left wing assembly, left main landing gear assembly and the left-hand propeller and engine assembly separated at the initial point of impact.  The nose section and cockpit area was also destroyed during the impact sequence with the right-hand propeller hub assembly being found approximately 5m from the left-hand propeller down the wreckage trail.    

 

1.12.3      The rest of the fuselage came to rest against the fence post upon, which the right wing assembly had impaled itself.  The fuselage essentially wrapped around this and second post with two major breaks at the location of the pilot’s seats and rear door.  The right engine and main gear was recovered under this wreckage.

 

1.12.4      The wreckage were recovered and taken to the CAA hangar located at Johannesburg International Airport late on the afternoon of the accident.   

 

 

1.13      Medical and Pathological Information:

 

1.13.1      All three occupants probably died on impact.  The forensic pathologist concluded that cause of death to be multiple injuries for the pilots and head and chest injuries in the case of the passenger.

 

The major post mortem findings were multiple fractures, extensive contusions, lacerations and heamorrhage.

 

No indications of previous disease could be found on the macroscopic examination.  However, in view of comprehensive examination, tissue samples were submitted for histological examination.

 

In all three instances the blood alcohol level was found to be 0,00g/100ml.  Routine drug screen tested negative for any toxicological substances.  The concentration of carboxyheamoglobin in the blood of the pilot was found to be 4,6 mg/%, which is of no significance.

 

No medical factor could be found that could have contributed to the cause of the accident.      

 

1.14      Fire:

 

1.14.1   There was no pre or post impact fire.

 

1.15            Survival Aspects:

 

1.15.1   Due to the impact forces associate with this kind of accident, the accident is not considered survivable.  During the removal of the bodies it was noted that both pilot’s were restrained by the use of their safety harnesses.  The passenger who was in a sleeping bag in the rear of the aircraft was not restrained, there was no passenger seat installed in the aircraft and he was positioned between the cargo.      

 

1.16      Tests and Research:

 

1.16.1      The aircraft was fitted with two Pratt & Whitney PT6A-112 engines, serial No’s. PCE 12568 and PCE 12569.  The engines were recovered to Pratt & Whitney Customer Service Centre at Lanseria Airport.  The assistance of a Pratt & Whitney Safety Investigator from Canada were made available and the engines were dismantled and inspected during the period 9 & 10 November 2001 in South Africa.  Selected engine components were identified for further investigation and were forwarded to Canada for analysis.

 

1.16.2      Summary of Findings:

 

The left-hand engine (Serial No. 12569) displayed moderate impact damage including structural separation of the accessory gearbox.  The compressor impeller, impeller shroud, compressor turbine guide vane ring, compressor turbine, power turbine guide vane ring, and power turbine displayed severe circumferential rubbing due to their making axial contact with their adjacent components under impact loads and housing deformation.  The compressor shrouds, compressor turbine shroud, and power turbine shroud displayed heavy circumferential scoring due to their making radial contact with their adjacent blades under impact loads and housing deformation.  The compressor 1st stage blades, power turbine blades, and power turbine shaft coupling were impact fractured.

 

The right-hand engine (Serial No. 12568) displayed moderate impact damage including structural separation of the accessory gearbox.  The compressor impeller, impeller shroud, compressor turbine guide vane ring, compressor turbine, power turbine guide vane ring, and power turbine displayed severe circumferential rubbing due to their makinf axial contact with their adjacent components under impact loads and housing deformation.  The compressor shrouds, compressor turbine shroud, and the power turbine shroud displayed heavy circumferential scoring due to radial contact with their adjacent blades.  Several power turbine blades were impact fractured.

 

There were no indications of any operational dysfunction to any of the engine components, controls, or accessories examined.

 

 

1.16.3      Conclusion:

 

Both the left and right hand engines displayed contact signatures to their internal components characteristic or the engines developing power at the time of impact, likely in high power range.  There were no indications of any significant power asymmetry between the two engines, or of any pre-impact anomalies that would have precluded normal engine operation.   

 

               

1.17            Organisational and Management Information:

 

1.17.1        The organisation that operated the aircraft (GJ Air trading as Fleetair) was not the same organisation (Transafrican Aviation Sales (Pty) Ltd) that owned the aircraft.  GJ Air appears to have leased the aircraft from a director of New Heights.  An employee of New Heights organised the flight crew for this fateful flight.  The owner of the organisation who owned the aircraft was according to the CAA records also a director, the Chief Executive Officer and the Responsible Person: Flight Operations of New Heights 291.  When the owner of the aircraft was interviewed however he indicated that he had resigned from his posts in New Heights with the effect of August 2001.

 

1.17.2        The CAA has also received correspondence, which suggested that an employee of New Heights, has subsequently been held responsible and fired from New Heights for improperly supervising the loading of the aircraft on the night of the fatal flight.  The different organisations will be discussed in this section of the report.    

 

 

1.17.3        GJ Air Trading as Fleetair

 

GJ Air trading as Fleetair was issued a Class I (Scheduled) International Air Services Licence (I/S054) valid for S2 type of international air services (transport of cargo and mail), on 13 April 2000. The aircraft categories indicated on this licence were A3 and A4 (Aircraft, excluding helicopters, with maximum certified mass of 5700 kg and less).

 

G.J. Air trading as Fleetair was issued a Class II (Non-scheduled) International Air Services Licence (I/N117) valid for N1 and N4 type of international air services (transport of cargo, mail, passengers), on 14 February 2001. The aircraft categories indicated on this licence were A2, A3 and A4 (Aircraft, excluding helicopters, with maximum certified mass of 20 000 kg and less).

 

G.J. Air trading as Fleetair was issued a Class II (Non-scheduled) Air Services Licence (N634D) valid for N1, N2 type domestic air services (cargo, mail, passengers), on 11 October 2000.  The aircraft categories indicated on this licence were A2, A3 and A4 (Aircraft, excluding helicopters, with maximum certified mass of 20 000 kg and less).

 

They were also the holder of a Class 3 air services licence (domestic G613D and International I/G109) with the type service indicated as G7 (emergency medical services) under the name G.J. Air trading as Medijet. The aircraft categories indicated on both these licences were A2, A3 and A4 (Aircraft, excluding helicopters, with maximum certified mass of 20 000 kg and less).

 

The operator had operated as an air charter company since 1996, in which company business seemed to have been reasonable and there were periods where the volume of freight had reduced and the company had difficulty in surviving.  On 17 July 2001 the company was put under provisional liquidation and according to the Air Service Safety Officer of the time they flew the last flight on 14 September 2001 on the Johannesburg to Eros route.  According to the air traffic movements’ records there were two flights under the operators call sign on 22 September 2001 and they started regular flights under their call sign again from 22 October 2001.  It was reported that another aircraft owner had invested funds in the operator to be able to lift the provisional liquidation status of the operator on 27 September 2001.  This enabled the operator to start operations again in October 2001.

 

G.J Air suffered two accidents in the past.  On 26 January 1996 a Piper Chieftain of the operator crashed due to fuel exhaustion near Johannesburg International Airport and on 21 October 1998 a Piper Chieftain of the operator overrun the end of the runway at Rand Airport and was destroyed by fire.  The pilot reported an engine problem during the take-off run, and during the accident investigation it was determined that the aircraft was overloaded.

 

During ramp inspections and a follow-up inspection conducted by the CAA Operations Department on 8 December 2000 the operator was found to overload their aircraft and that various non-compliances were identified with their documentation.  During an inspection of the operator’s aircraft at Eros Airport on 25 January 2001, by the Namibian Authorities they also calculated that the aircraft were overloaded.  These incidents resulted in the suspension of G.J. Air’s AOC on 26 January 2001. 

 

G.J. Air trading as Fleetair’s Operating Certificate had expired on 30 October 2001.  Thus at the time of the accident on 3 November 2001 they were operating without a valid Operating Certificate.  The operator was notified in advance by a CAA letter, dated 5 June 2001, about the renewal of their operating certificate.  In this letter their attention was drawn to the Civil Aviation Regulation (135.06.4 (2)) that state the application should be submitted 30 days before the expiry of the current operating certificate.  A similar letter, dated 8 October 2001, was dispatched to the operator relating to the renewal of their operating certificate.

 

On 24 October 2001 an application was received for the renewal of their operating certificate.  There were errors on the application with relation to the aircraft indicated on the application and it was communicated with the consultant of the operator.  A revised application was received on 25 October 2001, but name changes on the operator’s license were still outstanding from the Licensing Council.  The CAA received a fax on 29 October 2001 from an Aviation Consulting company, indicating that the operator was urgently seeking the changes on their operator’s license as the CAA could not issue their new operating certificate before these changes were in place.

 

1.17.3.1       Operational Documentation

 

On 3 November 2001, on the morning of the accident one of the investigators was tasked to obtain the relevant documentation from the operator’s offices. After several hours of waiting the investigator gained access to the offices.  The offices were in a process of being re-arranged and documents were in boxes on the floors.

 

No records of the pilots signing in or out for duty was available for the accident flight or for the flights since October 2001.  The only evidence of such signing was a book of “Flight Authorisation Sheets” with the last record being 28 August 2001.

 

No weight and balance documentation for the accident flight or any of the flights since October 2001 was available.

 

An employer of the operator was able to locate the pilot file of the pilot-in-command of the accident flight and the pilot file of the passenger.  The records of the pilot-in-command consisted only of copies of his pilot’s license and a Certificate of Attendance of a CRM course.  The records of the passenger (pilot) were outdated.  No records of the co-pilot were available.

 

An aircraft file was located for ZS-OIG, which seemed to be up to date, but it was later determined that:

 

-             The Certificate of Release to Service on the file indicated that the aircraft was released for service on 30 May 2001 after maintenance was carried out.  It was determined that further Mandatory Periodic Inspections was carried out, but the Certificate of Release to Service was not updated in the file.

 

-             When the Aircraft Lease Agreement was presented to the owner of the aircraft he indicated that it was fraudulently signed in his name by one of the directors of New Heights 291 (Pty) Ltd without his knowledge.

 

-             The Aircraft Mass and Balance Report on the file indicated that aircraft was weighed on 21 December 2000 and the empty mass was determined as 4 767 lbs.  This is much less than when the aircraft was previously weighed on 12 October 1998 at 5 210 lbs. or when it was released from the factory at 5 479.09 lbs. 

 

-             Aircraft are required to be weighed every 5 years in terms of Part 91.07.11(2) of the Civil Aviation Regulation of 1997.  It is unclear, why ZS-OIG was reweighed in December 2000 (2 years and 2 months after its last weight was recorded) nor, how this significant weight loss was accomplished.   

 

 

1.17.4        New Heights

 

New Heights 291 (PTY) LTD was issued a Class II (Non-Scheduled Public Air Transport) Domestic Air Services Licence (N664D) valid for N1 and N2 type of domestic air services (transport of passengers, cargo and mail), on 28 March 2001. The aircraft categories indicated on this license were A3 and A4 (Aircraft, excluding helicopters, with maximum certified mass of 5700 kg and less).

 

The initial application for the issuance of an Operating Certificate was dated 6 April 2001.  An audit was carried out at the operator on 22 May 2001 and the Operating Certificate was issued in 29 May 2001 with an expiry date as 29 May 2002.  The Operations Manual of New Heights was approved and was effective 1 April 2001.  The page with the office bearers was amended and effective from 1 August 2001.  On this page the Chief Executive Officer and the Responsible Person: Flight Operations was indicated as the same person as the owner of ZS-OIG.  He was also indicated as one of the directors of the operator.  He indicated to the investigators that he had resigned from his posts in the operator with effect from August 2001.  The person indicated as the Air Service Safety Officer in the Operations Manual was also a director of the operator.  This person organised the aircraft and the aircrew for the accident flight.

 

The Responsible Person: Aircraft indicated in the Operations Manual of New Heights is also an Accountable Manager of an Aircraft Maintenance Organisation.  When this person was interviewed it came to light that he had very little contact with the aircraft of the operator during the months preceding the accident. 

 

During interviews with some of the pilots it became clear that New Heights organised and paid the pilots for the flights on ZS-OIG to fly the Johannesburg – Eros route.  It was also asserted that they had reported the defects relating to the performance of one of the engines of the aircraft to one of the directors New Heights on two occasions.  This director does not appear as a office bearer or responsible person in this operator’s Operations Manual.

 

It was also noticed that this operator flew the Johannesburg – Eros route on 20, 21 and 22 September 2001 under a private call sign, at the same times that the cargo flights usually flew to Namibia.

 

1.18      Additional Information:

 

 1.18.1 Radar Trajectories of the last three flights including the accident flight.

 

1.18.2   Modifications Not Approved by Reims Aviation

 

During the investigation the aircraft manufacturer were invited to participate.  The following three modifications were noted by the Reims investigators, which did not have a manufacturer’s approval.

 

(i)                   Nickel-Cadmium aircraft battery replaced by a Lead-Acid battery.

(ii)                 Main landing gear wheel brake assemblies identified as Cleveland type (STC approved for Cessna 404 Titan).  According to the manufacturer the aircraft was approved with either the Goodyear or Goodrich type brake assembly.

(iii)                The outer wing leading edges de-ice boots were replaced by a harsh anti-erosion rubber paint.  It was the opinion of the manufacturer that this type of coating would disturb the airflow along the leading edges, inducing a higher stall speed and change the stall characteristics of the aircraft.  

 

 

2.         ANALYSIS

 

2.1        Analysis of the factual information will be included in the final report.

 

 

3.         CONCLUSION

a)         Findings

 

            PILOTS

 

(i)         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. 

 

(ii)         The co-pilot was the holder of a valid pilot’s license, the aircraft type was not endorsed in his logbook and no records could be found indicating that he had completed his conversion onto type. There was no indication that incapacitation or physiological or psychological factors affected his performance. 

 

(iii)        According to the co-pilots logbook he had no experience on turbo prop/ turbine driven engine aircraft.           

 

METEOROLOGICAL CONDITIONS         

 

(iv)        Weather conditions were fine and were not considered to be a factor in       this accident.

 

            FLIGHT OPERATIONS

 

(v)         The duration of the flight from commencing the take-off roll until the aircraft disappeared off radar was calculated at approximately 106 seconds, the aircraft was airborne for approximately 45 seconds.

 

(vi)        According to ATC, the pilot did not declare an emergency.  The aircraft disappeared from radar shortly after take-off (rotation).

 

(vii)       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.

 

(viii)             The cargo was not secured.

 

(ix)        There was no seat or safety-restraining device for the passenger.

 

(x)        No evidence could be found that POH (Pilot’s Operating Handbook) was onboard the aircraft.

 

OPERATOR

 

(xi)        The Operator’s GJ Air, AOC (Air Operating Certificate) expired on 30 October 2001 and is still awaiting the outcome of an application for the renewal of their AOC.

 

(xii)              GJ Air’s pilot, training, aircraft and operational records were incomplete and not in accordance with the requirements of Part 135.04.6, 135.04.8 and 135.04.9 of the CARs.

 

(xiii)            The AMO (Aircraft Maintenance Organisation) responsible for the maintenance of the aircraft did not comply with Part 43.02.13(1) of the CAR’s – no records of last few MPI’s in the engine logbooks.

 

(xiv)             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.

 

(xv)              Certain defects on ZS-OIG, which were reported to a director of New Heights were not attended to by an AMO.

 

(xvi)             New Heights personnel appear to be responsible for accessing the aircraft, flight crew and loading of the aircraft.  It is unclear how GJ Air ensured compliance with its operations manual in the conduct of this flight.            

 

MAINTENANCE

 

(xvii)           The weighing record of the aircraft as reported by an AMO conducted on 21 December 2000 reflects an unusual decrease in the empty weight from its factory weight of 5 476.09 pounds dated 30 August 1989.  The aircraft was weighed in South Africa on 12 October 1998 and the weight was calculated at 5 210 pounds and later again on 21 December 2000 when the empty weight was calculated at 4 767 pounds, a decrease in empty weight of 709.09 pounds from the factory weight to when it was reweighed on 21 December 2000.   

 

(xviii)          The AMO (Aircraft Maintenance Organisation) responsible for the maintenance of the aircraft did not comply with Part 43.02.13(1) of the CAR’s – no recorders of last few MPI’s in the engine logbooks.

 

(xix)            The modifications mentioned in 1.18.2 above (lead acid battery, wheel brake assemblies and leading edge paint coating) were installed without the manufacturers or CAA approval.

 

(xx)             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.

 

(xxi)            The outer wing leading edge de-ice boots were replaced by an unapproved wing leading edge harsh anti-erosion rubber paint.         

 

 

b)         Probable Cause/s

 

            (i)         To be determined.

 

4.         INTERIM SAFETY RECOMMENDATIONS

 

4.1        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). 

    

4.2        The CAA Legal Department investigates and reports on the operational discrepancies relating to the lease of ZS-OIG from the owner to GJ Air.

 

4.3        The CAA Operations and Legal Departments review the role and function of GJ Air with regard to the compliance with CARs and GJ Air’s operations manual, given the findings noted in (ii), (iii), (vii), (viii), (ix), (x), (xiii), (xiv), (xv) and (xvii) above.

 

4.4        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.   

 

4.5        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.

 

4.6        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 an exceedance in the TBO (Time Between Overall) time of any major component including engines.       

 

4.7               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.

 

 

5.         APPENDICES

 

Compiled by:

 

J.P. Grobbelaar                                                                               Date: 16 May 2002

for Commissioner for Civil Aviation

 

 

Investigator-in-charge      : J.P. Grobbelaar

Co-Investigator               : Dr. A.L. de Kock

Co-Investigator               : F.P. de Bruyn

Co-Investigator               : J.J. du Plessis

Co-Investigator               : K.E. Schwerdtfeger

Medical Examiner                      : Dr. A. Jordaan