Accident and Incident Investigations Divisioncaa.co.za/Accidents and Incidents Reports/ZS-CAR.pdf · 2020-02-24 · Accident and Incident Investigations Division Accident - Preliminary

CA 12-14a 10 October 2018 Page 1 of 31

Section/division Accident and Incident Investigations Division Form Number: CA 12-14a

PRELIMINARY ACCIDENT REPORT

Accident and Incident Investigations Division

Accident

- Preliminary Report - AIID Ref No: CA18/2/3/9855

Aircraft Type

Figure 1: The aircraft, a Citation S550 with registration ZS-CAR. (Source: FlightRadar24)

Description: The aircraft impacted terrain while calibrating the Instrument Landing System (ILS) on Runway 11 at George Aerodrome (FAGG). The aircraft was destroyed on impact and both pilots and the flight inspection officer were fatally injured.


DESCRIPTION OF ACCIDENT DESCRIPTION OF THE ACCIDENT Reference Number : CA18/2/3/9855 Name of Owner : South African Civil Aviation Authority Name of the Operator : South African Civil Aviation Authority3

Manufacturer : Cessna Aircraft Company Model : S550 Nationality : South African Registration Marks : ZS-CAR Place : George Aerodrome (FAGG) Date : 23 January 2020 Time : 0853Z 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. All altitudes in this report are mean sea level unless otherwise indicated. Purpose of the Investigation: In terms of Regulation 12.03.1 of the Civil Aviation Regulations (CAR) 2011, 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 apportion blame or liability.

Ministerial Order regarding Aircraft Accident and Incident Investigation dated 26 May 2016 issued by Minister Dipuo Peters in terms of section 100 (1)(b) of the Civil Aviation Act, 2009 (Act No. 13 of 2009):

“The Aircraft Accident and Incident Investigation unit shall report functionally to the Minister of Transport through the Deputy Director-General: Civil Aviation in so far as it relates to accident and incident investigations and reports. The South African Civil Aviation Authority (SACAA) shall be responsible for managing operational resources (technical, human, financial) to conduct investigations without hindrance”

Any person who has information concerning this accident should contact the Accident and Incident Investigations Division (AIID) on [email protected] Investigation Process: The AIID of the South African Civil Aviation Authority (SACAA) was informed of an aircraft accident involving a Cessna S550, which occurred near George, in the Western Cape Province, on 23 January 2020. The Aeronautical Rescue Co-ordination Centre (ARCC) informed the AIID investigator-on-call that the Cessna S550 ZS-CAR aircraft had disappeared from radar and no radio communication was possible with the aircraft, and that an official search and rescue operation had been activated. The wreckage of the missing aircraft was located later the same day by a rescue helicopter from the South African Air Force. The AIID had appointed an investigator-in-charge with an investigation team. Notifications were sent to the State of Operator and Registry, South Africa; and the State of Manufacture and Design, the United States of America and Canada. Both states have appointed non-travelling accredited representatives to this investigation. The AIID had appointed an independent expert, a former Managing Director of the United States National Transport Safety Board (NTSB) and former NTSB accredited representative to Africa. In terms of the International Civil Aviation Organisation (ICAO) Annex 13 Standard 5.25 and CAR 2011 Part 12, the accredited representatives shall confer entitlement to participate in all aspects of the investigation under the control of the investigator-in-change, in particular to:

a) visit the scene of the accident b) examine the wreckage c) obtain witness information and suggest areas of questioning d) have full access to all relevant evidence as soon as possible e) receive copies of all pertinent documents

mailto:[email protected]


f) participate in read-outs of recorded media (the AIID will lead the investigation and issue the final report) g) participate in off-scene investigative activities such as component examinations, technical briefings, tests and simulations h) participate in investigation progress meetings including deliberations related to analysis, findings, causes, contributing factors and safety recommendations i) make submissions in respect of the various elements of the investigation

However, participation of States other than the State of Registry, the State of the Operator, the State of Design and the State of Manufacture may be limited to those matters which entitle such States to participation under 5.23. Standard 5.23. Any State which on request provides information, facilities or experts to the State conducting the investigation shall be entitled to appoint an accredited representative to participate in the investigation. CAR 2011, Sub-part 12.01.8 Designation of experts

(1) The Executive responsible for aircraft accident and incident investigations may appoint an expert, where a citizen of the Republic of South Africa is fatally injured or has suffered serious injuries in an aircraft accident or incident involving a foreign-registered aircraft in the territory of a contracting or non-contracting State.

(2) The Executive responsible for aircraft accident and incident investigations shall inform the State of Occurrence of the intention to appoint experts to participate in the investigation of the occurrence.

(3) The Executive responsible for aircraft accident and incident investigations may accept the appointment of an expert from any State whose citizens were fatally injured or suffered serious injuries in a South African or a foreign-registered aircraft accident or incident in the territory of the Republic.

(4) The expert referred to in subregulation (3) may, under the control of the investigator-in-charge— (a) visit the scene of the accident (b) have access to the relevant factual information (c) participate in the identification of the victims (d) assist in questioning surviving passengers who are citizens of the expert’s State (e) receive a copy of the final report (5) An expert appointed in terms of subregulation (1) or accepted in terms of subregulation (3) shall not circulate, publish or give access to a draft report or any part thereof, or any documents obtained during an investigation of an accident or incident, without the express consent of the State which conducted the investigation, unless such reports or documents have already been published or released by the State conducting the investigation.

(6) The conditions, requirements, rules, procedures and standards connected with the designation or acceptance of an expert referred to in subregulations (1) and (3), are prescribed in Document SA-CATS 12.

The information contained in this Preliminary report is derived from the factual information gathered during the ongoing investigation into the accident. Later, an Interim report or the Final report may contain altered information if new evidence is found during the ongoing investigation that requires changes to the information contained in this report. The AIID reports are made available to the public at: http://www.caa.co.za/Pages/Accidents%20and%20Incidents/Aircraft-accident-reports.aspx Notes: 1. Whenever the following words are mentioned in this report, they shall mean the following:

• Accident – this investigated accident

• Aircraft – the Cessna S550 involved in this accident

• Investigation – the investigation into the circumstances of this accident

• Pilot – the pilot involved in this accident

• Report – this accident report

http://www.caa.co.za/Pages/Accidents%20and%20Incidents/Aircraft-accident-reports.aspx


2. Photos and figures used in this report were obtained from different sources and may be adjusted from the original for the sole purpose of improving clarity of the report. Modifications to images used in this report are limited to cropping, magnification, file compression; or enhancement of colour, brightness, contrast; or addition of text boxes, arrows or lines.

3. The Flight Inspection Unit (FIU) is a Division within the SACAA responsible for calibration of aerodrome navigation and approach facilities for commercial purposes. In this report, the FIU Division will be regarded as the operator.

Disclaimer: This report is produced without prejudice to the rights of the SACAA, which are reserved.


TABLE OF CONTENTS PAGE NO

Cover Page 1

Purpose of Investigation 2

Investigation Process 2-4

Disclaimer 4

Table of Contents 5

List of Abbreviations 6

1. FACTUAL INFORMATION 7-22

1.1 History of Flight 7-8

1.2 Injuries to Persons 8

1.3 Damage to Aircraft 9

1.4 Other Damage 9

1.5 Personnel Information 9-11

1.6 Aircraft Information 11-12

1.7 Meteorological Information 12-13

1.8 Aids to Navigation 13

1.9 Communication 13

1.10 Aerodrome Information 14-15

1.11 Flight Recorders 15-16

1.12 Wreckage and Impact Information 16-19

1.13 Medical and Pathological Information 18

1.14 Fire 18

1.15 Survival Aspects 19-20

1.16 Test and Research 20

1.17 Organisational Management Information 20

1.18 Additional Information 21-22

1.19 Useful and Effective Investigation Technique 22

2. Findings 22-24

2.1 General 22

2.2 Preliminary Findings 22-24

3. Recommendations 24

4. List of Appendices 25

5. On-going Investigation 25

6. Appendices 26-31


AMM Aircraft Maintenance Manual

AMSL Above Mean Sea Level

ARCC Aeronautical Rescue Coordination Centre

ARFF Aircraft Rescue and Fire-Fighting

ATC Air Traffic Control

ATPL Airline Transport Pilot Licence

BEA Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation Civile

CAVOK Ceiling and Visibility OK

C of A Certificate of Airworthiness

C of R Certificate of Registration

CPL Commercial Pilot Licence

DME Distance Measuring Equipment

ELT Emergency Locator Transmitter

FAGG George Aerodrome, Western Cape

FAPE Port Elizabeth Aerodrome, Eastern Cape

FDR Flight Data Recorder

FIU Flight Inspection Unit

FL Flight Level

FO First Officer

ft Feet

GP Ground Proximity

hPa hectopascal

kt Knot

ICAO International Civil Aviation Organisation

IFR Instrument Flying Rules

IIC Investigator-in-Charge

ILS Instrument Landing System

MSA Minimum Safe Altitude

MHz Megahertz

NM Nautical Mile

PAPI Precision Approach Path Indicator

PIC Pilot-In-Command

QNH Query: Nautical Height

SACAR South African Civil Aviation Regulations, 2011

SACAT South African Civil Aviation Technical Standards, 2011

SAWS South African Weather Service

TMA Terminal Manoeuvring Area

VHF Very High Frequency

VOR VHF omnidirectional range

ABBREVIATION DEFINITION


1. FACTUAL INFORMATION

1.1. History of Flight 1.1.1 On Thursday morning, 23 January 2020, the Cessna S550 with registration ZS-CAR

departed Port Elizabeth Aerodrome (FAPE) on a positioning flight to George Aerodrome (FAGG). On approach to FAGG, the flying crew requested to carry out a calibration flight for the very high frequency omnidirectional range (VOR) beacon at FAGG. Due to inclement weather conditions at the time, they were not cleared to conduct VOR calibration. As a result, they decided to land and refuel the aircraft before commencing with the calibration of the Instrument Landing System (ILS) on Runway (RWY) 11 at FAGG. The flying crew requested take-off from RWY 11 and an early right turn to intercept radial 250°, 17 nautical miles (nm) Distance Measuring Equipment (DME) arc to radial 330° at 3000 feet (ft) climbing to 4000ft. The air traffic control (ATC) granted their request. The flight was conducted in accordance with provisions of Part 135 of the Civil Aviation Regulations (CAR) 2011 as amended.

1.1.2 Radar data indicated that at 0842Z, the aircraft took off from RWY 11 and, once airborne,

made a right-hand turn to intercept radial 250° using the George VOR (GRV VOR). The aircraft climbed to 3000ft. Once the aircraft reached 17nm on the DME from the GRV VOR (DME is co-located with the VOR), it commenced with a right-hand turn to intercept radial 330° while maintaining 17nm DME arc.

1.1.3 At 0846Z, the ATC at FAGG advised the flying crew on frequency 128.2 megahertz (MHz)

that they were now exiting controlled airspace and were advised to broadcast on the special rules frequency 124.2MHz. The crew acknowledged the advisory to change frequency and there was no further communication on frequency 128.2MHz. The aircraft was still being monitored by ATC using secondary surveillance radar.

1.1.4 At 0850Z, radar data showed the aircraft crossing radial 310° and entered a climb from

3000ft, reaching 3900ft. At 0851Z, radar and radio contact were lost with the aircraft. The approach controller attempted to contact the aircraft on frequencies 124.2MHz, 124.8MHz and 121.5MHz which were unsuccessful.

1.1.5 After loss of contact with the aircraft, an emergency was declared and an official search

and rescue operation was instituted. The aircraft wreckage was located at the top of the Outeniqua mountains, near the town of Friemersheim, at Global Positioning System (GPS) co-ordinates 33°55’24” South 022°06’30” East, at an elevation of 2192ft.

1.1.6 The aircraft was operating under Visual Flight Rules (VFR) by day. FAGG was operating

under VFR at the time of the accident. 1.1.7 The aircraft was destroyed on impact and all occupants were fatally injured.


Figure 2: The routing of the aircraft prior to impact, based on radar data. (Source: Google Earth and ATNS)

Figure 3: The wreckage was located north of Friemersheim in the Western Cape. (Source: Google Earth)

1.2. Injuries to Persons

Injuries Pilot Crew Pass. Other

Fatal 2 1 - -

Serious - - - -

Minor - - - -

None - - - -

RWY11 used for departure

Intercept R250 GRV

R330 GRV


1.3. Damage to Aircraft 1.3.1 The aircraft was destroyed. 1.4. Other Damage 1.4.1 No other damage. 1.5. Personnel Information 1.5.1 Pilot-in-command (PIC)

Nationality South African Gender Male Age 49

Licence Type ATPL

Licence Valid Yes Type Endorsed Yes

Ratings Instrument; Instructor Grade 2

Medical Expiry Date 31 October 2020

Restrictions Corrective Lenses

Previous Accidents None

1.5.2 Flying Experience (PIC)

Total Hours 5215.4

Total Past 90 Days 15.4

Total on Type Past 90 Days 15.4

Total on Type 1315.4

1.5.3 The PIC had been issued with a class 1 aviation medical certificate on 23 October

2019 with an expiry date of 31 October 2020. 1.5.4 The PIC had completed approximately 20 hours of flight calibration of navigational aids

at FAGG. 1.5.5 First Officer (FO)

Nationality South African Gender Female Age 33

Licence Type CPL

Licence Valid Yes Type Endorsed Yes

Ratings Instrument

Medical Expiry Date 31 July 2020

Restrictions None


1.5.6 Flying Experience (FO)

Total Hours 1061.8

Total Past 90 Days 15.4

Total on Type Past 90 Days 15.4

Total on Type 265.9

1.5.7 The FO had been issued with a class 1 aviation medical certificate on 26 September

2019 with an expiry date of 30 September 2020.


1.5.8 The FO had completed approximately two hours of flight calibration of navigational aids at FAGG.

1.5.9 As a crew pairing, the PIC and FO had completed approximately 200 hours of flight

calibration of navigational aids. This included 58 VOR and 50 ILS calibrations. 1.5.10 The Flight Inspection Unit (FIU) inspector operated the flight inspection system

(CARNAC-30) on-board the aircraft which was used to calibrate navigational and approach facilities.

1.5.11 Air Traffic Controller (ATC):


Licence Type Aerodrome Control Air Traffic Services

Licence Valid Yes Unit Endorsed Yes

Ratings Instructor Grade 1, Aerodrome Control

Medical Expiry Date 28 February 2020

Restrictions None


1.5.12 The ATC had first been issued a licence on 28 February 2003. The ATC had the following

ratings: AD, Area, Area/SURV/ATSA, ATSA/CLD/ATSA/Coord and FIS. 1.5.13 The ATC had been issued a level 6 language proficiency certificate on 28 March 2007. 1.5.14 The ATC had been issued with a class 3 aviation medical certificate on 19 February 2018

with an expiry date of 28 February 2020. 1.5.15 The ATC’s last aerodrome proficiency checks for FAGG and FAOR were carried out on

14 August 2019 and 8 July 2019, respectively. Both licences were issued with the expiry dates of 13 June 2020 and 7 January 2020, respectively. Her licence for FAGG was valid at the time of the accident however, the FAOR licence had expired as per the dates above.

1.5.16 Approach Controller (AC):


Licence Type Aerodrome Control Air Traffic Services

Licence Valid Yes Unit Endorsed Yes

Ratings Instructor Grade 2, Aerodrome Approach Control Procedures and Approach Control Surveillance.

Medical Expiry Date 31 March 2020

Restrictions None


1.5.17 The AC had first been issued a licence on 24 August 2007. The AC had the following

ratings: AD, APP, APP/SURV/ATSA, ATSA/CLD/ATSA/Coord and ATSA/FIS. 1.5.18 The AC had been issued a level 6 language proficiency certificate on 20 August 2007. 1.5.19 The AC had been issued with a class 1 aviation medical certificate on 12 March 2019

with an expiry date of 31 March 2023.


1.5.20 The AC’s last proficiency check for aerodrome control was carried out at FAGG on 5 December 2019 and the licence was issued on the same day with an expiry date of 4 December 2020. The AC also had the approach control procedure proficiency check carried out on 7 May 2019; and the competency licence was issued on the same day with an expiry date of 6 May 2020. The AC also had the surveillance proficiency check for FAGG carried out on 26 April 2019; and the licence was issued on the same day with an expiry date of 25 April 2020.

1.6 Aircraft Information 1.6.1 The accident aircraft was a Cessna S550 which was manufactured in 1986. The aircraft

was fitted with two Pratt and Whitney Canada JT-15D-4 turbo fan engines. The aircraft was used by the FIU to calibrate navigational and approach facilities. The aircraft was fitted with additional equipment (CARNAC-30) in the passenger compartment to allow the inspector on-board to carry out the calibration function.

1.6.2 Airframe

Type Cessna S550

Serial Number S550-0078

Manufacturer Cessna Aircraft Company

Date of Manufacture 1986

Total Airframe Hours (At time of Accident) 10106.1

Last Inspection (Date & Hours) 13 August 2019 10031.1

Hours since Last Inspection 75

C of A (Issue Date) 28 October 1986

C of A (Expiry Date) 30 October 2020

C of R (Issue Date) (Present owner) 26 August 2010

Operating Categories Part 135 (Flight Calibration of Navigational Aids)

1.6.2.1 The aircraft used JET-A1 fuel and had uplifted 2100 litres on the morning of the flight. 1.6.2.2 The aircraft was first registered in the Republic of South Africa (RSA) on 29 July 1986

and was issued the first Certificate of Airworthiness (C of A) on 28 October 1986. The first owner of the aircraft was with the Department of Transport (DoT) of the Republic of South Africa (RSA). The ownership was then transferred to the SACAA after its establishment on 1 October1998.

1.6.2.3 Major aircraft defects and damages based on the aircraft maintenance records:

a. On 30 March 1988 at 351.20 hours, the aircraft was repaired following and incident which resulted in both wings being wrinkled forward of the main spar and stab wing. b. On 20 October 1993 at 1284.45 hours, the aircraft was damaged by a hail storm whilst on approach for the then Jan Smuts Airport, now O.R. Tambo International Airport.

1.6.2.4 Records of the airframe indicate that on 22 March 1994, the aircraft was fitted with two

Prat & Whitney JT15-4B engines with serial numbers 102187 and 102175. 1.6.2.5 Records of the airframe logbook further indicated that on 13 May 2011 at 7032.6 hours,

the left engine with serial number 102187 was removed for overhaul and replaced with an overhauled engine with serial number 102175, which was originally fitted on the right-hand side of the aircraft.


1.6.2.6 Following the overhaul of the left engine with serial number 102187, the engine was fitted on the right-hand side of the aircraft on 15 September 2011 with a total time of 7032.6.

1.6.3 Engine No.1

Type JT15D-4

Serial Number PCE-102183

Hours since New 9290.5

Hours since Overhaul (modular assembly)

15.4 hours

1.6.3.1 The engine was overhauled on 19 January 2016 at 9275.1 hours since new and it had operated for 15.4 hours since installation on ZS-CAR on 16 January 2020.

1.6.3.2 History of engine No.1 changes:

a. Removal and installation of Engine No 1 (left position):

• Once for hot section inspection (HSI)

• Removed twice and replaced with a loan engine

b. Following the incident of 7 and 8 November 2019, engine No 1 (left engine) with

serial number: PCE-70925 was removed on 15 January 2020 at 10090.7 aircraft airframe hours. Engine No 1 later experienced an internal oil leak and this resulted in the oil smell and smoke in the aircraft’s cockpit. At the time of the engine removal, the engine had been installed and operated on the aircraft for eight (8) months. It was noted that the engine had operated 176.5 hours since the last engine overhaul. The engine had accumulated 8265.9 hours since new.

1.6.4 Engine No.2

Type JT15D-4

Serial Number 102187

Hours since New 9905.1

Hours since Overhaul Modular assembly

1.6.4.1 Following the overhaul of the left engine on 31 August 2011 at 7032.6 hours, the engine

was fitted on the number 2 (right side) engine position on 15 September 2011. 1.6.4.2 History of engine No.2 removal and installation:

a. Engine No 2 (right position) was changed twice following scheduled engine overhaul.

1.7 Meteorological Information 1.7.1 The weather information below was provided by the South African Weather Service

(SAWS) for FAGG at 0900Z. The weather report was obtained on 24 January 2020.

Wind Direction 110° Wind Speed 14kt Visibility 9999m

Temperature 19°C Cloud Cover Broken Cloud Base 2400ft

Dew Point 16°C QNH 1018hPa


1.7.2 According to the SAWS report “Significant clouds below 1500ft above ground level (AGL) were present at the time of the accident as observed in the METARs. There is no indication of drastic wind direction or speed changes as seen on the spot graph. Mountain tops were obscured as seen on the webcam.” Refer to Figure 4. Furthermore, no low-level turbulence was forecasted or observed in the area.

Figure 4: A webcam picture taken on the morning of the accident at FAGG. (Source: SAWS)

1.8 Aids to Navigation

1.8.1 The aircraft was equipped with standard navigational equipment as approved by the

Regulator (SACAA) for the aircraft type. There was no record indicating that the navigation system was unserviceable prior to the flight.

1.8.2 The aircraft was equipped with a Terrain Avoidance Warning System (TAWS) which

provides warning to the flying crew when coming close to terrain. However, due to regulation not requiring the installation of the cockpit voice recorder (CVR) on the accident aircraft, the investigation was unable to determine if TAWS was operational at the time of the accident.

1.9 Communication

1.9.1 The aircraft was equipped with standard communication equipment as per the equipment

list approved by the Regulator. There were no recorded defects prior to the accident.

1.9.2 No emergency calls were made to the FAGG ATC.


1.10 Aerodrome Information

Aerodrome Location George, South Africa

Aerodrome Co-ordinates S34°00’24.13” E022°22’27.41”

Aerodrome Elevation 648ft above mean sea level (AMSL)

Runway Designations 11/29

Runway Dimensions 2000m x 45m

Runway Used 11

Runway Surface Asphalt

Approach Facilities PAPI, VOR, ILS, DME, Runway lights

Aerodrome Status Licensed

Figure 5: FAGG Aerodrome layout. (Source: SACAA)


1.10.1 FAGG was operating under VFR at the time of departure and remained VFR for the remainder of the day.

1.10.2 The aircraft impacted terrain at 2192ft above mean sea level (AMSL) in an uncontrolled

airspace during the ILS calibration whilst on 17nm DME arc and operating at 3000ft, climbing to 4000ft.

1.10.3 According to the available preliminary flight data recorder (FDR) graph (refer to Appendix

C), as the aircraft levelled off at 3900ft (QNH 1018), a rapid descent occurred, and the aircraft lost 1500ft in approximately 9 seconds. Three seconds prior to impact, the aircraft’s nose pitched up before it impacted with terrain at 2192ft.

1.11 Flight Recorders 1.11.1 The aircraft was fitted with a Fairchild F-1000 Flight Data Recorder (FDR) as required by

CAR 2011, Part 135.05.10. According to the documents received from the aircraft maintenance organisation (AMO), the FDR was last tested and downloaded on 8 January 2018 by an approved AMO number 808. The South African Civil Aviation Technical Standards (SA-CATS) Part 135.05.9(4)(2)(a) requires an annual testing and downloading of the FDR to ensure that the recorded data from FDR operates correctly for the nominal duration of the recording. The FDR was supposed to have been tested and downloaded on 8 January 2019 and only the test was conducted and not the download of the recorded data. As such, the operator did not comply with the requirement of SA-CATS Part 135.05.9(4)(2)(a).

SA-CATS 135.05.9(4). Inspections of flight recorders

(2) Annual inspections shall be carried out as follows –

(a) the read-out of the recorded data from the FDR and CVR should confirm that the recorder operates correctly for the nominal duration of the recording;

(b) the analysis of the FDR should evaluate the quality of the recorded data to determine whether the bit error rate is within acceptable limits and to determine the nature and distribution of the errors;

(c) a complete flight from the FDR should be examined in engineering units to evaluate the validity of all recorded parameters. Particular attention should be given to parameters from sensors dedicated to the FDR. Parameters taken from the aircraft’s electrical bus system need not be checked if their serviceability can be detected by other aircraft systems;

(3) The results of the annual inspections shall be recorded and retained for a period of five years calculated from the date of such check.

(4) Flight recorder systems should be considered unserviceable if there is a significant period of poor quality data, unintelligible signals or if one or more of the mandatory parameters is not recorded correctly.

(5) When requested, a report of the annual inspection should be made available to the Director for monitoring purposes.

(6) Calibration of the FDR-system –

(a) the FDR-system shall be recalibrated at least every five years to determine any discrepancies in the engineering conversion routines for the mandatory parameters and to ensure that parameters are being recorded within the calibration tolerances; and


(b) when the parameters of altitude and airspeed are provided by sensors that are dedicated to the FDR system, a recalibration shall be performed as recommended by the sensor manufacturer or at least every two years.

1.11.2 The FDR was sent to Bureau d'Enquêtes et d'Analyses (BEA) in France for download under the supervision of a RSA investigator-in-charge (IIC) and the preliminary FDR analysis of the download are attached to this report as Appendix C. Further analysis of the FDR download, in respect to aircraft performance, will be carried out by Textron Aviation performance engineers in the United States (US) under the supervision of the US NTSB accredited representative.

1.11.3 The aircraft was not fitted with a cockpit voice recorder (CVR) nor was it a requirement

to have one installed according to CAR 2011, Sub-part 135.05.11, read together with SA-CATS 135.05.11. Refer to Appendix A and B.

1.11.4 ICAO Annex 6, Volume 1, Chapter 6, standard 6.3.2.1.4 requires:

All aeroplanes of maximum certified take-off mass of over 5700kg for which the individual certificate of airworthiness is first issued on or after 1 January 1987 shall be equipped with a CVR.

ICAO Annex 6, Volume 1, Chapter 6, Recommendation 6.3.2.1.5 states the following:

All turbine-engined aeroplanes, for which the individual certificate of airworthiness was first issued before 1 January 1987, with a maximum certificated take-off mass of over 5 700 kg up to and including 27 000 kg that are of types of which the prototype was certificated by the appropriate national authority after 30 September 1969 should be equipped with a CVR.

1.12 Wreckage and Impact Information 1.12.1 The aircraft approached the accident site from a southerly direction and impacted the

ridge at an elevation of 2192ft AMSL. According to the wreckage debris, the impact corresponded with the aircraft being at a shallow angle on an upslope terrain. The area surrounding the wreckage consisted of rocks and grassland. The wreckage spread was distributed in a radius of 270m.

1.12.2 The height of the mountain which the aircraft impacted was at 2192ft AMSL at GPS co-

ordinates 33°55’24” South, 22°06’30” East. 1.12.3 According to the available preliminary FDR graph plot, the aircraft impacted the terrain

at an indicated airspeed of approximately 286 knots. Figure 7 indicates the position of all major components found at the accident site.


Figure 7: The layout of the main aircraft components field. (Source: Google Earth)

1.12.4 The investigators divided the accident debris field into three zones. The first zone spans from the point of initial impact to 90m, the second zone from 90m to 180m, and the third zone from 180m to 270m.

1.12.5 Zone one (refer to Figure 8) 1.12.5.1 Debris in this zone consisted of empennage-related items such as the engine fire

extinguisher bottles, the FDR and the high frequency (HF) receiver. The first portion of the rear cabin interior was found approximately 35m from the point of initial impact.

1.12.5.2 The upper left portion of this zone includes debris from engine No 1 nose cowl,

shroud and piping.

Figure 8: First spread of debris. (Source: Google Earth)

Component location


1.12.6 Zone two (refer to Figure 9) 1.12.6.1 This portion of the debris field formed the main area of debris spread and

consisted largely of the fuselage and wing structure. Cabin items such as arm rests and carpets were also located in this area. The left wing remained largely intact and the right wing had severe damage and was highly fragmented. The left-hand elevator was destroyed, and the vertical stabiliser came to rest approximately 125m from the initial point of impact.

1.12.6.2 This portion of debris experienced post-impact fire damage.

Figure 9: Second spread of debris. (Source: Google Earth)

1.12.7 Zone three 1.12.7.1 Debris in this area comprised pieces of wing and fuselage which may have been

distributed by impact forces. 1.13 Medical and Pathological Information 1.13.1 To be discussed in the final report. 1.14 Fire 1.14.1 The aircraft sustained a post-impact fire.

Component location


Figure 10: The red circle indicates the fire damage on the surrounding vegetation.

Figure 11: The close-up view of the red circled area in Figure 10 above.

1.15 Survival Aspects

1.15.1 The accident was considered not survivable because of the damage caused by impact forces which destroyed the aircraft.


1.15.2 The aircraft was fitted with an Emergency Locator Transmitter (ELT) with the description ARTEX ELT C406-2 with part number 453-5000 and serial number 170-07269. The ELT did not transmit a signal following the accident, and it was never located at the accident site. The ELT was last bench-checked on 28 May 2019 and its battery changed on 2 October 2019.

1.15.3 After the aircraft went off the radar, a DETRESFA was declared by ATC and the search

and rescue commenced with emergency helicopter on standby. The aircraft was located approximately an hour after going off radar by the search and rescue helicopter. The emergency helicopter was dispatched to the site and arrived approximately 10 minutes after the wreckage of the aircraft was located.

1.15.4 Due to inclement weather conditions at the time, the search and rescue was suspended

until the next day. 1.16 Tests and Research 1.16.1 To be discussed in the final report. 1.17 Organisational and Management Information 1.17.1 The flight was conducted in accordance with the provisions of Part 135 of the CAR 2011

as amended. 1.17.2 The operator (FIU) had been issued with an air operating certificate (AOC) number:

CAA/N942D by the Regulator (SACAA) on 26 April 2019 with an expiry date of 30 April 2020.

1.17.3 At the time of the accident, the aircraft was calibrating the ILS system for RWY 11 at

FAGG. According to the FIU operations manual, this process requires the aircraft to fly 35° on either side of the runway centreline while maintaining a 17nm DME arc. The height for the operation is 2000ft AGL or obstacle plus 1000ft. Refer to Figure 12.

Figure 12: The ILS procedure. (Source: FIU Operations Manual)

1.17.4 The AMO that carried out the last maintenance inspection on this aircraft prior to the

accident flight had been issued with an AMO approval certificate on 31 October 2019 with an expiry date of 31 October 2020.

1.17.5 The SACAA Audit of FIU dated 12 February 2019, revealed that the operator was not

tracking the replacement of emergency gear air bottle as required by Cessna Citation II approved maintenance schedule (Appendix A issued on 8 April 2016).


1.18 Additional Information 1.18.1 Instrument Landing System (ILS) description 1.18.1.1 The ILS provides precision guidance to an aircraft during the final stages of the approach. The signals can either be interpreted by the pilot from the instruments or be input directly into the autopilot and flight management system. ILS performance is divided into three categories depending on the reliability, integrity and quality of guidance, with Category III having the strictest requirements. An ILS comprises the following elements:

a) the localiser, operating in the frequency band from 108 to 112MHz, providing azimuth guidance to a typical maximum range of 46.3km (25nm) from the runway threshold; b) the glide path, operating in the frequency band from 328 to 336MHz, providing elevation guidance to a typical maximum range of 18.5km (10nm) from the runway threshold; and c) the marker beacons, operating on the frequency of 75MHz, providing position information at specific distances from the runway threshold.

Note — On certain runways, a DME provides the distance information in place of marker beacons. Source: ICAO Doc 8071, Chapter 4, Section 4.1.2 1.18.2 Very High Frequency Omnidirectional Radio Range (VOR) system description

2.1.2 The VOR is a short-range radio navigation aid that produces an infinite number of bearings that may be visualised as lines radiating from the beacon. The number of bearings can be limited to 360, one degree apart, known as radials. A radial is identified by its magnetic bearing from the VOR.

2.1.3 The radials are generated in space by comparing the phase angle of two equal frequencies radiated from the beacon. One signal, called the reference, radiates omnidirectionally so that its phase is equal in all directions. The second signal, called the variable, radiates from a directional array. The phase of the variable signal received at the aircraft is dependent upon the radial on which the receiver lies with respect to magnetic north.

2.1.4 Both signals are in-phase at magnetic north. The phase of the variable signal lags that of the reference signal by an amount equal to the azimuth angle around the beacon.

Source: ICAO Doc 8071, Chapter 2, Section 2.1.2 through 2.1.4 1.18.3 Distance Measuring Equipment (DME) system description

3.1.2 The DME system provides continuous distance information to an aircraft during approach, departure, or en-route procedures according to the location of the DME. The signals can be interpreted either by the pilot from the display or input directly into the flight management system (FMS).

Source: ICAO Doc 8071, Chapter 3, Section 3.1.2

1.18.4 Accident aircraft (ZS-CAR) reported incidents in the past 12 months prior to the accident

1.18.4.1 On 2 March 2019, engine No 1 engine did not respond to throttle movement due

to a damaged cable. The operator, through the AMO, replaced the damaged cable on engine No 1.


1.18.4.2 On 7 November 2019, the aircraft was on approach for Wonderboom Aerodrome (FAWB) when the flying crew experienced an oil smell and smoke in the cockpit; the AMO carried out maintenance to rectify the defect and, following the maintenance, the aircraft was released to service.

1.18.4.3 On 8 November 2019 during the take-off roll, the crew experienced smoke in the

cockpit. The crew decided to abort take-off, and the aircraft was taxied back to the hanger before the engines were shut down. The AMO further investigated the incident and found out that there was a seal leaking in the engine and that resulted in the AMO replacing the defective engine.

1.18.5 ICAO Annex 13, Chapter 5, Standard 5.1

The State of Occurrence shall institute an investigation into the circumstances of the accident and be responsible for the conduct of the investigation, but it may delegate the whole or any part of the conducting of such investigation to another State or a regional accident and incident investigation organization (RAIO) by mutual arrangement and consent. In any event, the State of Occurrence shall use every means to facilitate the investigation.

1.19 Useful or Effective Investigation Techniques 1.19.1 To be discussed in the final report. 2. Findings 2.1. General

Based on the available evidence, the following preliminary findings were made with respect to this accident. These shall not be read as apportioning blame or liability to any particular organisation or individual. To serve the objective of this investigation, the following sections are included in the conclusions heading:

• Findings — are statements of all significant conditions, events or circumstances in this accident. The findings are significant steps in this accident sequence, but they are not always causal or indication of deficiencies.

2.2 Preliminary Findings 2.2.1 The PIC had been initially issued with an Airline Transport Pilot Licence (ATPL) on 20

December 2011. His last skills test was carried out on 24 January 2019 and his licence was issued on the same day with an expiry date of 29 February 2020. He was issued with a class 1 aviation medical certificate on 23 October 2019 with an expiry date of 31 October 2020.

2.2.2 The FO had been initially issued with a Commercial Pilot Licence (CPL) on 16 May 2014.

Her last skills test was carried out on 15 March 2019 and her licence was issued on the same day with an expiry date of 31 March 2020. She was in possession of a class 1 aviation medical certificate issued on 26 September 2019 with an expiry date of 30 September 2020.


2.2.3 The air traffic controller had been initially issued with an Aerodrome Control Air Traffic Services licence on 28 February 2003. His last skills test was carried out on 14 August 2019 and his licence was issued on the same day with an expiry date of 13 June 2020. He was issued with a class 3 aviation medical certificate on 19 February 2018 with an expiry date of 28 February 2020. The aerodrome controller was issued with level 6 language proficiency certificate on 28 March 2007. The aerodrome controller conducted her last proficiency check on her aerodrome control licence for FAGG and FAOR on 14 August 2019 and 8 July 2019, respectively.

2.2.4 The aerodrome approach controller had been initially issued with an Aerodrome Control

Air Traffic Services licence on 24 August 2007. His last skills test was carried out on 5 December 2019 and his licence was issued on the same day with an expiry date of 4 December 2020. He was issued with a class 3 aviation medical certificate on 12 March 2019 with an expiry date of 31 March 2023. The aerodrome approach controller was issued with a level 6 language proficiency certificate on 20 August 2007. The Aerodrome Approach controller also did a proficiency on approach control surveillance for FAGG on 26 April 2019 and had an expiry date of 25 April 2020.

2.2.5 The aircraft had been issued with a certificate of airworthiness with an expiry date of 30

October 2020. The aircraft had been issued with a certificate of registration on 26 August 2010.

2.2.6 The aircraft had been issued with a Certificate of Release to Service on 31 May 2019

with an expiry date of 31 May 2020 or 10227.7 airframe hours, whichever occurs first. 2.2.7 The aircraft was being operated under CAR 2011 Part 135 and was conducting an ILS

calibration at the time of the accident. 2.2.8 The operator had been issued with an air operating certificate (AOC) number:

CAA/N942D on 26 April 2019 with an expiry date of 30 April 2020. 2.2.9 The aircraft experienced three incidents in the past twelve months namely: On 2 March

2019, engine No 1 throttle did not respond due to a damaged throttle cable. In the month of November 2019, the aircraft had two incidents of an oil smell and smoke in the cockpit that resulted in the operator and AMO electing to change engine No 1. Following the incident of 8 November 2019, the aircraft remained on the ground until 17 January 2020.

2.2.10 The ELT did not transmit a signal following the accident and could not be found on-site

after numerous searches. The aircraft was located by search and rescue within an hour after it was reported missing by the George Airport.

2.2.11 According to the FIU operations manual, the ILS calibration process should be carried

out at 35° on either side of the runway centreline while maintaining 17nm DME arc. The height for the operation requires a flight at 2000ft AGL or obstacle plus 1000ft.

2.2.12 The last scheduled phase inspection was Phase 15, which was carried out on 13 August

2019 at 10035.0 airframe hours and there was no unscheduled maintenance during Phase 15 inspection. The aircraft had accumulated an additional 75 airframe hours in operation since the last phase check maintenance.

2.2.13 The AMO that carried out the last maintenance inspection on this aircraft was issued

with an AMO approval certificate on 31 October 2019 with an expiry date of 31 October 2020.

2.2.14 The aircraft was not fitted with a CVR nor was it a requirement according to CAR 2011,

Sub-part 135.05.11 read together with SA-CATS 135.05.11. Refer to Appendix A and B.


2.2.15 The aircraft was fitted with an FDR which was downloaded in France under the supervision of a RSA IIC. According to available preliminary graph FDR results, as the aircraft levelled off at 3900ft (QNH 1018), a rapid descent occurred, and the aircraft lost 1500ft in approximately 9 seconds; three seconds prior to impact, the aircraft nose pitched up before impacting the terrain at 2192ft.

2.2.16 The aircraft was equipped with TAWS, which provides a warning to the flight crew when

coming close to terrain. However, due to the regulation not requiring the fitment of the CVR to this aircraft, the investigation was unable to determine if TAWS was operational at the time of the accident.

2.2.17 Based on the information provided by SAWS, the mountain tops were obscured by

clouds at the time of the accident. 2.2.18 The elevation of the mountain which the aircraft impacted was at 2192ft at GPS co-

ordinates 33°55’24” South, 22°06’30” East. According to the wreckage debris, the impact corresponded with the aircraft being at a shallow angle on an upslope terrain.

2.2.19 FAGG was operating under VFR by day at the time of the accident. 2.2.20 The aircraft was destroyed during the impact sequence and all three occupants were

fatally injured. 3. Recommendations 3.1 The Regulator (SACAA) to review the current CAR 2011, Part 135.05.11 and SA-CATS,

Part 135.05.11 with the view of determining if it is necessary for all aircraft with a maximum certified take-off weight of 5700kg or above and engaged in commercial operations to be fitted with a CVR regardless of their year of manufacture and/or the first date of issue of the certificate of airworthiness, as this recommendation is supported by ICAO Annex 6.

ICAO Annex 6, Volume 1, Chapter 6, Recommendation 6.3.2.1.5 states the following: All turbine-engined aeroplanes, for which the individual certificate of airworthiness was first issued before 1 January 1987, with a maximum certificated take-off mass of over 5 700 kg up to and including 27 000 kg that are of types of which the prototype was certificated by the appropriate national authority after 30 September 1969 should be equipped with a CVR.

3.2 Given the circumstances surrounding this accident, should the Department of Transport

or the Ministry deem it appropriate, to consider delegating this investigation to another Investigation Authority that will be supported in line with ICAO Annex 13, Chapter 5, Standard 5.1, which states the following:

The State of Occurrence shall institute an investigation into the circumstances of the accident and be responsible for the conduct of the investigation, but it may delegate the whole or any part of the conducting of such investigation to another State or a regional accident and incident investigation organization (RAIO) by mutual arrangement and consent. In any event, the State of Occurrence shall use every means to facilitate the investigation.


4. LIST OF APPENDICES 4.1 Appendix A: CVR requirements according to CAR 2011, Part 135. 4.2 Appendix B: CVR requirements according to SACATS, Part 135. 4.3 Appendix C: The preliminary FDR download analysis. 4.4 Appendix D: ATC Transcript 5. On-going Investigation

5.1 The AIID investigation is on-going and will be looking into aspects of this occurrence which

may or may not have safety implications.

This Report is issued by:

Accident and Incident Investigations Division

South African Civil Aviation Authority

Republic of South Africa


Appendix A 1.11.3 The requirement for a CVR is stipulated in the CAR Part 135.05.11: Cockpit voice recorders 135.05.11 (1) An air service operator shall ensure the aeroplanes specified in Document SA-

CATS 135, when operated in terms of this part, are equipped with the CVR specified in Document SA-CATS 135 and that such CVR complies with the specifications prescribed therein.

(2) The CVR shall record, with reference to a time scale— (a) voice communications transmitted from or received on the flight deck or in the cockpit

by radio; (b) the aural environment of the flight deck or cockpit, including without interruption, the

audio signals received from each microphone in use; (c) voice communications of flight crew members on the flight deck or in the cockpit using

the interphone system of the aeroplane, if installed; (d) voice or audio signals identifying navigation or approach aids introduced into a headset

or speaker; and (e) voice communications of flight crew members on the flight deck or crew members in the

cockpit using the public address system of the aeroplane, if installed. (3) The CVR shall— (a) be capable of retaining information recorded during at least the period of time as

prescribed in Document SA-CATS 135; (b) start automatically to record the aeroplane moving under its own power and continue to

record, until the termination of the flight when the aeroplane is no longer capable of moving under its own power; and

(c) if possible, start to record the cockpit checks prior to engine start at the beginning of the

flight, until the cockpit checks immediately following engine shutdown at the end of the flight.

(4) The CVR may be combined with a FDR referred to in regulation 135.05.11.


Appendix B

1.11.4 The requirement for a CVR is stipulated in the SACATS Sub-Part 135.05.11: Cockpit voice recorders The aircraft was not required to be equipped with a CVR because the aircraft was registered in 1986. (Refer to table below)

Group See note

1.

Conditions See note 2.

Maximum Certificated

Take-Off Mass (kg)

Propulsion System

Recording retained for the last 30 minutes of operation

Recording retained for

the last 2 hours of operation

Recording retained for at least the

last 25 hours of operation

1

Application for type certification submitted to

Contracting State on or after 1 January

2016 and required to be operated by more

than one pilot

> 2250 but ≤ 5700

Turbine X

2

Individual certificate of airworthiness first issued on or after 1

January 2003

> 5700 All X

3

Individual certificate of airworthiness first issued on or after 1

January 1987

> 5700 All - X

4

Individual certificate of airworthiness first

issued before 1 January 1987 whose

types of which the prototype was

certificated by the appropriate national

authority after 30 September 1969

> 27000 Turbine - X

5

individual certificate of airworthiness is

first issued on or after 1 January 2021

> 27000 All X


Appendix C The preliminary FDR analysis

00:20:15 - 00:21:00

• The aircraft pitch increased from +5 and decreased to +2 degrees.

• The aircraft altitude increased from 2900 ft to 3900 ft

• The aircraft airspeed increased from about 210 to 245 kts.

• The aircraft magnetic heading was generally constant at 37.5 degrees until about

00:20:45 when it increased to 67.5 degrees

• The aircraft roll was about zero degrees and began to increase to 35 degrees at

00:20:45.

00:21:00 - 00:21:10

• The aircraft pitch decreased from about +2 to -10 degrees from 00:21:02 to 00:21:05

and over the next 5 secs decreased to -32.5 degrees.

• The aircraft altitude decreased from 3900 to 3200 ft between 00:21:00 - 00:21:05 and

the next 5 secs decreased to 2800 ft.

• The aircraft airspeed increased from 245 to 275 kts.

• The aircraft magnetic heading increased from 67.5 to 150 degrees.

• The aircraft roll increased from about 35 to 105 degrees during the period of 0:21:00 -

00:21:07 and then over the next 3 secs decreased to 75 degrees.

00:21:10 - 00:21:13

• The aircraft pitch increased from -32.5 to -17.5 degrees.

• The aircraft altitude decreased from 3200 to 2400 ft.

• The aircraft airspeed increased from 275 to 310kts during the period of 00:21:10 to

00:21:12 and one second later the airspeed was 290kts.

• The aircraft magnetic heading increased from 150 to 177 degrees.

• The aircraft roll decreased from 75 to 10 degrees.


Appendix D

Air Traffic Service Unit AUDIO TRANSCRIPT

Transcript of FAGG TWR voice recordings on 23/01/2020 regarding:

ZSCAR

• The transcript was verified by …..

• Times in HH:MM:SS UTC

• Station refers to any aircraft, ATC position or Vehicle making the transmission

• Text of transmission is the contents of the transmission for that specific time

Time Station Text of transmission

08:24:07 Intercom

Technician phones to advise ATC that they will taking

the ILS (RWY 11) for the calibration.

08:27:48 ZSCAR

George Tower ZSCAR good morning

(no response from ATC).

08:28:06

ZSCAR

George Tower ZSCAR good morning

08:28:15 ATC

Last call to George Tower, report your call sign, go

ahead with your transmission.

08:28:19

ZSCAR

It’s ZSCAR, good morning ma’am.

08:28:21 ATC Morning CAR.

08:28:25

ZSCAR

Ma’am we are 3 on board, 4h30min of endurance,

requesting start for ILS calibrations, 3000 ft.

08:28:32 ATC CAR your start is approved ma’am for RWY11 on a

QNH of 1018. Your transmission is slightly soft, I just

want to verify you want to do the calibration and you

want to intercept did you say 3000ft is that correct?

08:28:44 ZSCAR

Affirm ma’am, we would like to do the ILS calibration

at 3000ft, RWY11 QNH1018, we are cleared start and

we would like to intercept radial 250 and fly a 17 DME

clockwise arc from radial 250 up to radial 330, CAR.

08:29:05 ATC

CAR, ma’am, thanks for that information and I will be

with your shortly for a clearance and a plan.



08:32:00

Composite

TWR Controller then discusses the request with the

APP Controller and advises that ZSCAR is now starting

for the calibration. TWR then discusses the possibility

of declaring VMC as the weather minima is within the

legal limits to do this. VMC is declared at 08:32:25.

They also have a discussion that the 17 DME arc is

going to take the aircraft outside of controlled airspace

and TWR must advise the pilot of this. The TWR

Controller then asks if the APP Controller is happy with

the clearance of RWY track climbing to 3000ft and she

will advise the aircraft about the exiting of controlled

airspace before she gets airborne.

The TWR Controller has a brief discussion with the APP

Controller about keeping the LSA sterile during

calibrations

08:35:47

ZSCAR

TWR, CAR request taxi.

08:35:50 ATC

CAR taxi via A, right on to A to the A1 holding point of

RWY11.

08:35:58

ZSCAR

Right A, A1 holding RWY11, CAR.

08:39:00

ZSCAR

TWR, CAR ready to copy ATC clearance.

08:39:04 ATC Thank you CAR, after departure RWY11 climb maintain

runway track to 3000ft, the approach control on 128.2

passing 2500ft squawk 1545.

08:39:20

ZSCAR

After departure RWY11 climb to 3000ft maintain

runway track and passing 2500ft, approach 128.2

squawk 1545, CAR.

08:39:31 ATC

CAR read back is correct and report ready for

departure.

08:39:35

ZSCAR

Report ready for departure next, CAR.

08:39:37

ZSCAR

And TWR, from CAR.

08:39:39 ATC Go ahead sir.

08:39:41

ZSCAR

Is it at all possible to do an immediate right turn

(pause) after departure

Composite TWR ATC passes on the pilot’s request to APP control –

this is approved by APP

08:39:52

ATC

CAR affirm, then you are re-cleared after departure

RWY11 you can turn immediately right as per your

request and then climbing to 3000ft, I just need to

check are you then going out to intercept that radial as

the lady said.



08:40:04

ZSCAR

Affirm ma’am, 250, 3000, immediate right turn 3000ft,

CAR.

08:40:08

ATC

CAR you’re re-cleared affirm, your read back is correct,

copied your intentions and then just a question with

that 17, 17DME marker just to advise you you’re going

to be in and outside, just in and outside of controlled

airspace for your planning.

08:40:22

ZSCAR

TWR copy that ma’am, CAR we’re fully ready.

08:40:27 ATC

CAR RWY11 surface wind is 120 degrees 15kts you are

cleared for take-off and we’ll chat to you later.

08:42

ZSCAR airborne

Documents

Accident and Incident Investigations Divisioncaa.co.za/Accidents and Incidents Reports/ZS-CAR.pdf · 2020-02-24 · Accident and Incident Investigations Division Accident - Preliminary