WHAT CAN WE LEARN: How to add up known threats
CAA ACCIDENT REPORT SUMMARY: Beechcraft Baron B58
Date of accident: 23.10.08
Time of accident: 1647 Z (1847 local time)
Aircraft registration: ZS-NAB
Type of aircraft: Beechcraft Baron B58
Pilot’s age: 42
Licence type: CPL with Instrument Rating
Pilot-in-command flying experience: Total flying hours: 1140
Hours on type: 15
Last point of departure: Phalaborwa Airport (FAKN)
Next point of intended landing: Lanseria Airport (FALA) (Johannesburg)
Location of the accident site: Phalaborwa - Silongo (S23º54.354 E31º09.235)
Meteorological information: Wind: 160/07, Viz. 10km. cloud base 3000ft. SCT 2000ft
No. of people on board: 1 + 0
No. of people injured: nil
No. of people killed: 1
The pilot, accompanied by four passengers, departed Lanseria Aerodrome (FALA) at approximately 1430Z on a private flight under Instrument Flight Rules (IFR) to Kruger Gateway Phalaborwa Aerodrome (FAPH) as per the filed flight plan. The pilot landed on Runway 19 at FAPH, taxied to the apron and the passengers disembarked from the aircraft.
At approximately 1645Z, in night-time conditions, the pilot started the engines of the aircraft and taxied to the threshold of Runway 19 for the return flight back to FALA. The aircraft took off in a southerly direction and during the climb made a right turn and proceeded with a right-hand circuit. During the latter part of the downwind sector of the right-hand turn circuit, at an altitude of approximately 2500ft the aircraft started to descend at a fairly high rate. At an altitude of approximately 2200ft the aircraft entered into a right-hand turn and impacted with the ground in a nose-down attitude.
The aircraft was destroyed on impact and by the post-impact fire. The pilot, who was the sole occupant on board, was fatally injured. During the onsite investigation of the wreckage there was proof found indicating that the right side propeller was feathered. This was an indication that the right side engine had stopped prior to the aircraft impacting the ground.
The pilot lost situational awareness whilst positioning the aircraft to return for landing on Runway 19 and the aircraft entered into a spiral dive from which a recovery could not be affected within the height remaining.
There were numerous problems with the paperwork relating to maintenance, including an expired C of A, an illegally fitted autopilot, test flights signed out but not done, repeated autopilot snags, repeated oil leaks and the possibility of mandatory replacement engine-overhaul parts not being fitted.
The report contradicts itself on whether a right or left-hand circuit should have been flown. However, it appears as if it should have been a left-hand turn out. In this case the pilot turned out right, possibly due to the right engine failing.
The investigation was unable to ascertain whether the runway lights were on at the time of the accident. It seems the staff were in a hurry to get home and switched the flarepath off immediately after the aircraft left the ground.
The report runs to 33 pages, so I can’t give you the full story here, but it looks as if this poor guy was the victim of circumstances largely beyond his control. The report’s contributory factors are, at best, vague and misleading. The ‘unknown emergency’ was presumably an engine failure –
the pilot feathered that engine.
The ‘improper circuit’ was surely a result of the engine failure, disorientation and lack of airfield lighting, and could hardly be considered contributory to the accident.
The outbound flight was seriously delayed while the owner arranged insurance for this pilot to fly his aircraft. This meant that the return flight was in the dark and outside the normal duty times of the airport staff, who switched off the flarepath immediately after he was airborne, thus giving him no visual reference and no place to land following the engine failure. The engine failure appears to have been the final straw in a history of incredibly poor maintenance. The pilot is unlikely to have been aware of this.
Here’s my reconstruction of what probably happened. But first, let’s see how the odds were stacked against the pilot:
- He was relatively inexperienced on the Baron.
- He had possibly never flown one at night, or in instrument conditions.
- He had had a long day with frustrating delays.
- He had a wife and family waiting for him to get home.
- He had just been fined by airport management for landing without prior permission, and keeping them outside normal duty hours.
- It was a black hole take-off away from the town lights and with an overcast and no moon.
- The aircraft was in far from prime condition.
- It still suffered from at least two known recurrent faults – an oil leak in the left engine and an unreliable autopilot.
- It seems that the right engine failed at some point soon after take-off, and the pilot feathered it. He would then have wanted to land back on 19, the runway he had just left. In turning to look for the runway, which was now invisible, because the lights had been turned off, he drifted far too close to the runway for a normal approach. He became disorientated and entered a classic graveyard spiral towards the failed engine.
What can we learn?
The main lesson here is to recognise when events are ganging up on you, and then do something minimise them. In this case, if the pilot had taken the time to add up the known threats and stayed the night in Phalaborwa he would have been in a far better position to handle the engine failure in daylight the next morning. It is possible the pilot was not blameless. He should have had a take-off alternate.
This would normally be the take-off airfield, however that was denied him when the lights were switched off. This is a reminder that when things start going wrong, adrenalin/fear narrows your attention, often to the extent that vital duties are ignored. With a graveyard spiral, a pilot of his experience would know that his first duty is to level the wings. Yet he fell into the known trap of ignoring this and only focusing on the horrifying loss of height. His whole world narrows down to hauling on the stick as hard as he can.
30 years ago I chickened out of a charter in an Aztec because, as I taxied out, I counted the things I didn’t feel comfortable about. I invented a mag-drop, told the pax sorry, and flew them the next day. I believe there are times when that is the sensible thing to do.
Jim Davis has 15,000 hours of immensely varied flying experience, including 10,000 hours civil and military flying instruction. He is an established author, his current projects being an instructors’ manual and a collection of Air Accident analyses, called Choose Not To Crash. Visit Jim's website by clicking here.
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