On Saturday 28 January 2012, the pilot and owner of ZS-TVT delivered his aircraft at an Aircraft Maintenance Organization (AMO) at Port Elizabeth International Airport (FAPE) for a regular Mandatory Periodic Inspection (MPI). The AMO commenced with the MPI inspection on 31 January 2012 and released the aircraft to service on 16 February 2012. The aircraft was parked at the AMO’s hangar between 16 February 2012 and 17 April 2012. On 17 April 2012, the pilot arrived at FAPE to fetch his aircraft. This was to be the first flight after the MPI was completed two months earlier.
According to the AMO on 17 April 2012 a normal inspection and ground run were conducted during the presence of the owner/pilot and the aircraft was handed over to him for the flight back to Cape Town. The pilot accepted the aircraft and commenced with the thorough pre-flight inspection before the flight to Cape Town. It appeared that the pilot was happy and he filed a Visual Flight Rules (VFR) flight plan with the FAPE control tower. The flight plan was activated and the aircraft taxied to the runway 26 holding point where the run up checks were carried out. The pilot was cleared for take-off and requested to keep an altitude of 2000 feet above mean sea level (AMSL) and report at Sea View.
According to the air traffic controller who was communicating with the pilot before departure he appeared to be unsure of the location of Sea View, but after some explanation he understood and departed. Take-off and climb out was uneventful. Once ZS-TVT was airborne the approach controller was advised that ZS-TVT was routing towards the right side of the intended track. At 12h17 the approach controller established contact with ZS-TVT and advised him to remain at 2000 feet AMSL or below and standby for further climb. There was IFR traffic overhead ZS-TVT and the controller was waiting for the aircraft to be clear before further climb. The controller cleared the conflicting IFR traffic to descend to 3000 feet.
The controller observed TVT climbing to 2200feet and then 2600feet, still routing towardsthe right side of his intended track. ZS-TVT was advised to remain at 2000feet. The pilot apologised and slowly descended to 2400feet. He then requested to descend to 1000feet without indicating why. His request wasgranted. At 12h21 the controller observed ZS-TVT making a sharp turn to the right before the aircraft disappeared off the radar. The controller attempted to establish contact with the pilot, but there was no response. According to the controller due to the nature ofZS-TVT’s flight path he assumed that the aircraft may have experienced technical problems and landed at Progress airfield. The controller contactedProgress flight school asking whether ZS-TVT has not landed at their airfield andthe answer was negative.
The controller informed the airport pool manager and they started the initial phase of Search and Rescue. At this time, Progress flight school aircraft, call sign, ZSKHOwas in the air on a training flight and its pilot was requested to overfly thesurrounding area to see if they could see anything. They saw aircraft debrisscattered all over the area and was confirmed to be ZS-TVT aircraft. There was nodistress call made by ZS-TVT pilot and the aircraft crashed on a private farm nearthe Draaifontein road, approximately 24 kilometres North West of Port ElizabethInternational Airport. The South African Police Services (SAPS) and the localEmergency Medical Services (EMS) were notified and immediately drove to theaccident site. The aircraft was found to have been destroyed by impact during theaccident sequence and the pilot was fatally injured.
A witness, who is also a pilot, saw the aircraft flying overhead Progress airfieldrouting in the westerly direction at an altitude of approximately 2000feet AMSL. Hestated that he observed the aircraft taking a gradual bank to the left into a cloud.Immediately after the aircraft entered the cloud, the witness heard a high pitched noiseas if the engines were accelerating. A few moments later the witness heard animpact sound as the aircraft impacted the groundat an elevation of 594 feet above meansea level.
Wreckage and Impact Information
The accident site was a livestock grazing field on a private farm and the aircraft impacted blue gum trees before hitting the ground. It would seem like the aircraft impacted the ground at a very high speedand steep attitude. The is evidenced by the fact the initial impact with the ground iswhere one engine was found one metre underground and the second engine wasfound on top of the buried engine. The remainder of the wreckage was scattered over an area the size of a soccer field.
The wreckage distribution was a straight line trail that extended to approximately100 metres from the initial impact point. All control surfaces were accounted for atthe accident site. The cockpit/cabin area was destroyed and all instruments weredestroyed. All flight controls were destroyed by the impact forces and flight controlcable continuity and pre-impact control integrity could not be established. Both fueltanks ruptured during the accident sequence and there was no fuel available foranalysis. Theundercarriage was destroyed after impact. The extent of the damage to the aircraft and wreckage distribution revealed that theaircraft had struck the ground at high speed in a nose down attitude.
Post mortem results revealed that the pilot died as a result of multiple injuries associated with the accident. The pilot’s medical had expired.On-site inspection of the wreckage revealed that all of the structural damages wereconsistent with the impact at high speed in a nose down attitude and nothing wasfound to suggest that there had been any pre-impact failure of the primary structure.
Aircraft engines, serial numbers, 684414 and 684423 were recovered and taken toan approved engine overhaul facility based at Wonderboom (FAWB) aerodrome,Pretoria for further examination and analysis. Before that all relevant aircraftdocumentation e.g. Certificate of Registration (C of R), Certificate of Airworthiness(C of A), Radio Station Licence, Mass and Balance Certificate were inspected andwere found to be valid in accordance with requirements of applicable regulation.
The aircraft maintenance documentation such as airframe logbooks, engineslogbooks and work packages were obtained from the AMO and inspected and all maintenance entries made in thelogbooks were appropriately certified in terms of applicable regulations. A completeengine teardown inspection was conducted in the presence of a SA CAA accidentinvestigating team. It was found that all noted damage on both engines wasconsistent with that of accident damage. Disassembly and examination of bothengines revealed no evidence of any internal mechanical malfunction orcatastrophic failure. There was no evidence of detonation, piston/combustionchamber melting or oil starvation. Both engines’ ignition system components,including the magnetos, the spark plugs and the ignition harnesses were severelydamaged and could not be tested.
The pilot appeared to have entered instrument meteorological conditions (IMC) andin an attempt to remain VFR, he failed to maintain adequate terrain clearanceresulting in the aircraft colliding with the ground.
ANALYSES BY CHARLIE MARAIS
When it comes to losing control of an aircraft it always seems that the pilot has not been paying enough attention to the correct things that would prevent precipitation of such an event.
Before I get into the accident purse, I would first like to do some observations and possible analyses to the factual information.
Firstly it is amazing how the past flying experiences of the pilots are just not available. This is normally very important to make some kind of judgement of currency, or then the recent exposure the pilot had to similar flying conditions. Pilots may fly one hour Instrument Flying prior to the next Instrument Commercial Test and that would be sufficient to ensure a revalidated licence depending on obviously passing the test. They normally do. Does this make you current? Legal yes, but capable? I believe not at all. At least not when it comes to the real thing.
Flying hours is not something to brag with or throw around to impress the ladies. Different flying hours will have different qualities to it. One hour on the autopilot, observing the machines compliance to a set requirement during an ILS, is not the same story as flying a Knife Edge at an air show, or for that matter flying 10 feet above the ground trying to understand the flying lesson a Tsetsibi (a buck species) is busy teaching you.
To have an Instrument rating and not be current and well-rehearsed in the procedures may be one thing, but another would be to fly without auto-pilot or auto-assistance. Show me an Instrument Landing Approach (ILS) assisted by a good auto-pilot such as found in the more sophisticated aircraft and I will show you how one and all struggles to do a CAT I approach without any assistance. We must get real about this; instrument flying is a tough business.
I will never forget the first time I was briefed about this. "If not competent you will lose the aircraft within the first 20 seconds!" What? Is this all the time we have? If this is true then if not trained and not current and very capable, the first few seconds could leave me alive, but theoretically dead until the inevitability of terrain strike.
There is some reading this that actually had the good luck, note not good skill, but luck, to get out. Yes that happens from time to time, but believe me, you were only lucky and should confess this like a man.
Let me say this; to get into an instrument flight situation inadvertently, is not only very surprising, but leads to many different reactions from different pilots.
I have been there. On the climb out to 16500 feet to drop parachutes from an Angel, old Kudu with turbine engine, I became entangled in setting the GPS, listening to the jump master, negotiating traffic entering the immediate area and receiving instructions from Johannesburg Central. There were lots of clouds around, around five eights, with vertical development between 2000 and 10 000 feet above ground. When I all of a sudden out of the corner of my eye I noticed the very pertinent colour grey, I knew I was in the cloud. Not 50 shades of grey guys, just grey! “Attitude, bank, DI, Attitude Bank VSI……”, and so on. I started scanning out loud. My mind was not listening to all the other interfering factors, I knew that with the instruments, a non-instrument rated aircraft and just old fashioned scans drilled into me, I must get into the clear.
I turned left through 90 degrees and hoped to exit, then to the right. During the steady turns I got the absolute sensation that I was flying straight and level, but the instruments did not confirm this. I fought the urge to follow my feelings and followed the instruments in great anticipation and with great effort. I eventually popped out at around 15 000 feet. I did the drop, landed and then faced myself with great honesty in the mirror.
Asshole was all that came to mind. Sorry ladies and sensitive readers, but how else do I describe such a foolish act?
I am current, recent and all the things when it comes to Instrument Flying. It is part of my job to teach and assess these phases of flight. The sheer realisation that I entered into cloud unplanned, unintentional, unprepared and totally by surprise, gave me a very real shock. It took a lot of discipline and I would dare to venture skill, which was thankfully engraved in me, to regain my composure and get out of trouble.
I will not for one moment pretend that there are none better than me, in fact, there are many, but entering into Instrument Conditions by surprise is a surprise that has killed many. There is no immunity clause you can sign.
A few other issues come to mind. A qualified IR pilot aged 57 with only around 736 hours? Sounds like this was not his day job.Coupled to this the aircraft was on the ground over two months. I do not know if he flew in those two months, probably not, but not the baron 58 in question. Therefore the question to recency, currency and all those fancy words that only describe if you are freshly mortised skills competentis very much relevant. If flying is then so much more difficult and so much more complex and so much more cognitively challenging, why is it that we treat it as a weekend or seasonal sport?
In April we get the aeroplane out to take the family to the sea, and then only in December we repeat this. We fly our family twice a year, nothing in between, and we confess that flying is more complex than driving a car. We never fly Instrument Flying and try our best to avoid it, yet when challenged we take to it without a second thought.
In this case it is very evident that the pilot expressed his opinion that he would like to stay clear of cloud. He expressed asked to remain right of track as he would have liked to stay clear of cloud. The met report stated scattered (3 to 4 Octas) and Broken (5 to 7 Octas) cloud. The cloud base veried, but it is clear from the tower tapes that the pilot wanted to stay clear of clouds.
I believe he was distracted due to flying, dodging clouds, adhering to heights and ATC instructions and so on. I then believe that he inadvertently and unintentionally found himself in the cloud.
None of the above is to blame, we as pilots just seem to be like normal people and when the attention is scattered, a slip may occur. I believe in this case the pilot was all aa sudden daced with the constant colour of grey.
The very natural thing that pilots do, and they most of the cases do it and they die in most of the cases, is to get back to where it was clear as quickly as possible. This leads to hard manoeuvring to go back to where we are comfortable and plainly, where we can see. Very natural and instinctive behaviour from us pilots. In this case I believe the pilot did the same.
Now we must bank hard to turn about, height maintenance becomes an immediate problem and power is normally induced to somehow correct what is happening. The result is a steep bank angle, probably running over Vne and with too little sky beneath the cloud to recover, the accident is brutal and final.
Firstly I would like qall of us for just one momemt to reflect on our status as pilots. Not comparing it to others, just to what is actually required and where do we stand. Am I capable to handle the situation? Am I recent and current and legal.
A lapsed medical do not cause any accidents, or at least I have not encountered that one. What is true though is that when the licence is not valid due to a lapsed medical or flight test or for whatever reason, the insurance of the aircraft and the personal insurance of the pilot will not pay out. Your passenger’s families will (not might), sue your estate leaving your family, already devastated because of losing you, penniless.
If you enter to where you are not allowed to such as in weather, night, mountains and so on, you are tempting fate irresponsibly. We all believe that it will never happen to us. We are all wrong. The only truth is that in a world of adversities, only the competent and disciplined will survive, or at least have the chance.
When unintentionally entering cloud he following is some good advice:
- When there are clouds about and you must stay clear due to any reason, beware of being distracted and by surprise find you in an area where you really did not what to be.
- The first thing when in a cloud is to stabilise the aircraft or helicopter. Straight and level controlled flight, if there are no mountains, must be achieved. Without this there is no second step. Get control by applying the scan you were taught. It not taught, get taught.
- If in mountainous terrain the level part must become a climb at 500 feet per minute. Naturally these depend on the rate of climb of the mountain, but get control in the pitch as well as the roll.
- Once initial control has been established and the adrenaline subsided to a level where your cognitive abilities return, go to the next step of turning about. This must be a level turn, or if terrain does not allow, a controlled climbing turn. A level turn is always advisable rather than climbing or descending, but circumstances may dictate.
- The reverse course must now once again be stabilised before a descend or a climb is attempted.
- The last step would be a controlled descend or further climb depending on the situation.
It would be irresponsible to give times and distances in the above, I merely need one to understand that every move must be started from a stable and controlled position. Yes I have procedures I can teach low flying helicopters inclusive of times, but there are so many variables that to fix time to any of the above would be untrue.
I am convinced that our pilot in this case wanted to stay clear of cloud, but was surprised to find himself inside the grey. This reasons that for starters we must all take a step back and always plan and pay attention to the unwanted reality of ending up in the grey.
Whether we intentionally or unintentionally end up inside a situation where we really did not want to be, the end result is normally the same.
To honour those pilots that departed, we must learn from their experiences, mistakes and sometimes just vey unlucky situations.
The greatest honour is to learn from them and then to apply that which we have learned, that is called self-respect.
Johan turned onto heading 330 at three Nm after take-off from Cape Town International to intercept the CTV 354 radial adhering to the OKTED1A Standard Instrument Departure (SID).
After this interception, at 8 Nm, he turned on a heading of 060 to intercept RIV outbound on a radial of 090 degrees.
Everything has gone according to plan so far and although he is slightly tense, as concentration levels are high, I notice that his shoulders are drooping slightly as he starts to relax, as he was clearly flying on the numbers.
At first, he does not notice the left alternator annunciator light lighting up as his attention is fully on the instrument scan. The autopilot is not selected. After approximately thirty seconds he notices the light and immediately scans the Ammeter just to confirm that it is not charging. At that exact moment the left engine fails without warning.
The pronounced left yaw was a tell-tale sign and immediately his attention shifts from the alternator problem to the much more complex problem of the engine cut. Johan sorts it out in no time and contacts Cape Town informing them of the emergency and requests vectors back to CTV, planning for a procedure turn onto the ILS runway 01.
He can now see the front coming in and he elects to select the help of the auto-pilot. He then asks Cape Town for vectors onto the ILS onto runway 01. This is granted and as he enters the frontal system, the visibility quickly becomes zero. He is informed that the visibility on the ground has deteriorated to around 500 meters and that the cloud base is 500 feet AGL.
The autopilot cooperates, but mysteriously disengages just as he is intercepting the localiser. His knuckles become slightly whiter and I can see that his concentration levels have now peaked. With a single engine, very poor weather and no autopilot to help, the situation couldn’t possibly get any worse.
Maintaining the localiser and glide slope proves to be extremely hard work and finally the lead-in lights become visible just to the left of the aircraft nose. As he intercepts the centre line of runway 01, there is a very loud bang as massive birds pound the cockpit, cracking the glass and the remaining engine fails.
With a multi-engine reduced to a super brick glider, Johan struggles to regain control and negotiate the landing. There is no first prize for the landing, but we are safely on the ground. As we come to a stop, he turns to me and says, “sh*t”.
The new FNPT II simulator as built by Simu Flight has performed yet another CPL annual Instrument and General Flying licence revalidation test. This simulation of reality was quite extreme, but then again I was not merely testing the candidate’s ability to fly. Nearly all pilots can fly, but the procedures and emergency decision-making is tested for realities that could not be simulated in real flight, let alone safely.
Westline Aviation, with its fourteen aircraft and three helicopters, does a lot of training. However, my work as DFE has suddenly become more fruitful as testing under IF conditions and Instructor Rating renewals are elevated to the next level.
Westline has expanded over the last eight years to accommodate local as well as international students. With accommodation, housing (same thing??) and personal attention for students struggling with ground subjects, Westline has built a reputation for going that extra mile.
The flying school offers PPL to ATPL, Single to Multi-Engine as well as Basic to Advanced helicopter flying. We also offer specialised training such as: Mountain Flying, Game Ratings, operational command and control, vehicle following, tactical navigations, formation flying as well as helicopter and aircraft turbine ratings.
I regularly lecture on Flight Safety and perform testing as a DFE Aeroplane and Helicopter. Normally in January of each year I also present the fully fledged Aircraft Accident Investigation Course over a four week period in Pretoria for the SAAF.
Fuel supply, fuel distribution and fuel placing are to name but a few of the extra services rendered at Westline. When you visit Tempe Airport, you will meet the friendly staff of Westline, with coffee and burgers on order. And with landing fees at half the normal rate, competitively priced fuel and no passenger tax, where else would you choose to stop on your way across South Africa?
Westline Aviation, where we help your flight dreams become a reality!
What should have been a routine flight to reposition a relatively new Cessna 206, from Krugersdorp airfield to Wonderboom airport for the purposes of a 50 hour oil change, resulted in tragedy when the aircraft flying in IMC conditions impacted the Magaliesberg Mountains close to the red and white radio masts east of Hartebeespoort Dam.
On 3 February 2010, the pilot accompanied by an instructor pilot departed from Krugersdorp airfield (FAKR) on a private flight to Wonderboom Airport (FAWB) when the aircraft collided with the Magaliesberg Mountains and the post-accident fire destroyed the aircraft. The weather conditions reported in the area were instrument metrological conditions (IMC) and from the information provided by witnesses, it appears that the aircraft was flying in adverse weather conditions at the time of the accident. According to another witness the mountain was covered in mist and fog. The mist reached down to the tree line of the mountain. Both occupants were fatally injured.
Owner/operator: Marshall Fowler (South Africa)(Pty) Ltd
Manufacturer: Cessna Aircraft Company Cessna T206H ZS PNM
Weather conditions at the departure airport were reported as acceptable for VFR flights. However, en route to FAWB, the aircraft flew into Instrument Meteorological Conditions (IMC). Clearly the pilots were flying far too low as they impacted terrain in the Magaliesberg Mountain range three nautical miles east of the red and white radio mast, at an elevation of 5 169 feet AMSL. A post-impact fire erupted that destroyed the aircraft and both occupants were fatally injured. The aircraft impacted the mountainside at an angle with a left wing tip impacting first, then the nose section and right wing. The maximum elevation of the Magaliesberg Mountains in the area of the accident is 5 319 feet and the aircraft should have been at least 1 000 feet higher to clear all obstacles including the very tall radio beacons close to the impact site.
Information received from the witness’s statement at the time of the accident suggest that the aircraft was flying in adverse IMC conditions prior to the accident. According a witnesses (who is also a pilot) who lives in the area, the mountain was covered in mist and fog and the mist reached down to the tree line of the mountain. The witness said he heard an aircraft passing over his house around 06h20 local time. He stated that he heard an aircraft with a constant RPM engine sound but about two seconds later heard an increase in RPM followed by the sound of an impact. He stated that prior to the increase in RPM sound, the engine sounded perfectly normal and it did not sound as if there were any problems. He called FAWB ATC, but there was no contact as the station is only manned from 07h00. He then called Johannesburg ATC to report the accident.
Maybe CFS Dunnottar needs a little more details revealed. The first few weeks at Dunnies, as we called the place, things were tuff. We were pupes, short for pupil pilot and there were very few rules, well, if there were actually any the instructors were to follow, we certainly did not know of them. We on the other hand was young, stupid, invulnerable and brave. We obviously had many rules and normal screaming, shouting and physical punishment sorted the rules out quickly. Soon we learned that when the instructor shouted AGABAKEN, we had to run like hell to the beacon about 500 meters away from the crew rooms and training cubicles. When tuned to this frequency a ladies voice would tell you the direction to steer to get back to the facility. This omni-directional voice assistant was commonly referred to as the “whore in the box”, and she needed to see us regularly for any good or invalid or even no reason at all.
It is not every day that one has to give account of who you really are. Like many of us, I also do not necessarily think that my experiences are that special that everyone needs to know about them. On the contrary, I find it a bit intimidating to talk about what I have done and where I have been. On the other hand, some are of the opinion that it might be interesting or even inspiring.
So my kids and their spouses convinced me that my own Blog, (what the hell is that?!), is what I must have. To be honest at the possibility of being classified as technologically challenged, I still confess that the new generation communication skills and methods are quite “cool”. OK, so still not knowing what it is, here is where my story begins.
Born and bred in the little town Piketberg in the Cape Province, I matriculated at Paul Roos Gymnasium, Stellenbosch. We lived there, and I must confess that I had no idea what a beautiful and history rich environment this was and still is, until I left. When I joined the SAAF directly after school, and the train pulled into the Pretoria train station, my first time there, the realisation of where I came from hit home hard and with absolute clarity. Then I knew that I would never stay in Stellenbosch again, my destiny would take me other places and all I would have is the memory of my formative years.