ZS-CAR Prelimary Accident Report
After reading the preliminary report AIID Ref No: CA18/2/3/9855 on the SACAA’s Cessna Citation tragic accident near George in the Western Cape, my immediate assessment was that this was a well-prepared 35-page interim report that was compiled in a very short time – one month.
My next comment is that if the SACAA can do this for its own accident, why cannot the same attention be applied to all accident reports?
Another glaring issue, that has been a problem for many years, is the fact that the Accident Investigation Division of the SACAA resides within the regulator and the salaries are paid by the regulator. The burning question is how the SACAA can continue to investigate its own accident? However, on Friday 21 February 2020 the Minister of Transport, Fikile Mbalula moved to assure the public that his office is overseeing the probe into the circumstances around the plane crash involving the SACAA’s Cessna Citation In a statement, Mbalula said he had noted concerns that the investigation may be tainted if it were to be handled by the SACAA. “The minister wishes to place on the record that the Accident and Incident Investigation Division (AIID) is accountable to the Department of Transport (DoT) and not to the SACAA,” Mbalula’s office said in a statement. “As per a ministerial order issued in May 2016, AIID in so far as it relates to accident and incident investigations and reports shall report to the minister of transport,” the statement continued.
Experts, including the makers of the aircraft, would be brought into the investigation. Once the report was finalised, it would be evaluated by the safety review panel. “I wish to assure the public and the aviation community that the investigation will not be compromised in any way and that we owe it to the bereaved families and the public to establish the real facts on what might have led to this tragic accident,” said Mbalula.
What is suggested from this interim report, is that the crew flew from Visual Flight Rules (VFR) into Instrument Meteorological Conditions (IMC) and subsequently lost control of the jet. This is a classic case of the pilot’s Loss OF Control (LOC), followed by Controlled Flight into Terrain (CFiT). From the report it appears that the aircraft’s roll increased from 35 to 105 degrees, which means the wings were not generating any substantial lift. In turn this caused the nose to drop and the aircraft headed into a spiral dive, from which a recovery is not possible. Once a bank angle gets to 60 degrees there is only half of the vertical lift vector and the nose drops rapidly. The instinctive tendency for the pilot is to pull back on the stick, hence the graveyard spiral. It then appears that the pilots came out of the clouds and their first visual reference was the ground coming at them at considerable speed. They instinctively tried to pull out of the spiral dive, but there was far too little height remaining for the plane to recover.
Of course, the first question to be asked is: “why was the crew conducting calibration flights in known IMC when George airport is located very close to a significant mountain range?” The weather METARS (METAR is a format for reporting weather information) on the day indicated clear weather to the south and east of George airfield, but that the adjacent mountains were covered in cloud. The crew was performing a specialist task and therefore the second question to be asked is: “did the operator ensure that the crew was adequately trained for this specialist task over and above the regular proficiency training requirements?” Although there have been suggestions of some sort of mechanical failure of the aircraft, this scenario is unlikely, because although catastrophically damaged, all major components of the aircraft were found at the accident site as indicated in the overview picture provided within the report. However, the experience of the crew flying airport calibration tasks in IMC conditions needs to be questioned. Having spoken to three different Designated Flight Instructors (DFEs), about calibration flights, the indication is that conditions were not suitable for this flight to take place, meaning that the aircraft should not have taken off in the first place!
Notes from the preliminary accident report
The aircraft was fitted with a Flight Data Recorder (FDR), which was downloaded in France under the supervision of an RSA IIC. According to available preliminary graph FDR results, as the aircraft levelled off at 3 900 feet (QNH 1018), a rapid descent occurred and the aircraft lost 1 500 feet in approximately nine seconds. Three seconds prior to impact, the aircraft’s nose pitched up and the aircraft impacted the mountainous terrain at 2 192 feet.
The preliminary FDR analysis
00:20:15 - 00:21:00
• The aircraft’s pitch increased from plus 5 and decreased to plus 2 degrees.
• The aircraft’s altitude increased from 2 900 feet to 3 900 feet
• The aircraft’s airspeed increased from about 210 to 245 knots.
• The aircraft’s magnetic heading was generally constant at 37.5 degrees until about 00:20:45 when it increased to 67.5 degrees
• The aircraft’s roll was about zero degrees and began to increase to 35 degrees at 00:20:45.
00:21:00 - 00:21:10
• The aircraft’s pitch decreased from about plus 2 to minus 10 degrees from 00:21:02 to 00:21:05 and over the next five seconds decreased to minus 32.5 degrees.
• The aircraft’s altitude decreased from 3 900 to 3 200 feet between 00:21:00 - 00:21:05 and the next five seconds decreased to 2 800 feet.
• The aircraft’s airspeed increased from 245 to 275 knots.
• The aircraft’s magnetic heading increased from 67.5 to 150 degrees.
• The aircraft’s roll increased from about 35 to 105 degrees during the period of 0:21:00 - 00:21:07 and then over the next three seconds decreased to 75 degrees. 00:21:10 - 00:21:13
• The aircraft’s pitch increased from minus 32.5 to minus 17.5 degrees.
• The aircraft’s altitude decreased from 3 200 to 2 400 feet.
• The aircraft’s airspeed increased from 275 to 310 knots during the period of 00:21:10 to 00:21:12 and one second later the airspeed was 290 knots.
• The aircraft’s magnetic heading increased from 150 to 177 degrees.
• The aircraft’s roll decreased from 75 to 10 degrees.
Editor’s notes:
Of course, readers will have to wait for the final accident report to fully understand this tragedy, but the information contained in the premilitary report certainly paints a clear picture of why this accident happened. My feeling is that had the crew been flying the Citation Jet in good weather, this tragic loss of three lives would not have happened.
Reply from the SACAA
The South African Civil Aviation Authority has noted the release of the Preliminary Report on the Flight Inspection Unit aircraft accident. The report serves as the initial step towards providing the much-needed clarity on what might have led to the accident on that fateful day, the 23 January 2020. Although the report is not final, the SACAA duly notes its contents and will continue to provide the necessary co-operation and space needed by the investigation team to conduct a thorough probe and to issue a final accident investigation report.