EXECUTIVE SUMMARY – CAA AIRCRAFT ACCIDENT REPORT
This discussion contains extracts from the SACAA’s accident report. It is compiled in the interest of promoting of aviation safety and not to establish legal liability.
Aircraft Registration: ZS-JGY
Date of Accident: 9 March 2008
Time of Accident: 1330Z
Type of Aircraft: Beech 58
Type of Operation: Domestic Charter Flight
Pilot-in-command Licence Type: Commercial
Licence Valid: Yes
Flying Experience: Total Flying Hours 399.8. Hours on Type 4.8.
Last point of departure: Vilankulo Aerodrome Mozambique
Next point of intended landing: Magaruque Island Aerodrome
Location of the accident site: Runway 23, Magaruque Island, Mozambique
Meteorological Information Surface wind: 110º/5-10 kts; temp 30ºC; visibility: >10 km; cloud cover: 4/8
No. of people on board 2 + 2
No. of people injured 0
No. of people killed 0
The pilot stated that after touchdown he continued down the runway for 100 -150 m. He then retracted the flaps to reduce lift. About 50 m after the flaps were retracted, the starboard wing dropped suddenly. At this point, the pilot realised that his speed had not reduced. He applied power to execute a go-around but then saw that there was not enough runway left to become airborne again. He immediately closed the throttles and applied maximum braking. He then pulled back on the control column to further assist the aircraft to slow down.
The aeroplane left the runway and came to rest approximately 25 m past the end of the runway. The skid marks of the tyres started about 100 m before the end of the runway. The right-hand main gear was ripped off, the left-hand main gear failed outwards and the nose gear folded back into the nose gear well.
The last Mandatory Periodic Inspection (MPI) had been carried out on 20 June 2007 at 3877.7 flying hours. This servicing was performed by AMO 076. The aircraft was operated for a further 53.0 flying hours after this.
[Not stated in the SACAA report.]
I selected this accident because it shows how only two risk factors coming together at the same time can end in disaster
Would I have been happy to sit in the back of that aircraft. No sir, I would not have boarded. And I say that despite the fact that some of the classic risk factors were not there at all. I am thinking of bad weather, mountainous terrain, strong winds, dodgy strips, fuel problems, poor maintenance and so on.
So what exactly is my beef? Basically, too much aeroplane for too little experience. The guy had less than 400 hours total and less than five hours on type – at least half of which would have been the flight from Johannesburg to Vilankulo (Vilancoulos).
Also, he is a young man taking friends or charter passengers on a flight to a holiday destination – there is serious pressure to perform. I am speculating, but this is a learning forum so speculation is fine. Unfortunately there is an increasing culture that believes go-arounds are for poor pilots and pansies. That’s what attracted me to this accident – it gives me an excuse to spread the news that go-arounds are to be admired in any pilot from a 10-hour student to the captain of an A380.
It looks to me as if this guy’s lack of experience on type caused him to cross the fence too fast and his ego really didn’t want to be hammered by the perceived indignity of a go-around.
Let’s try to figure out what was going on in the cockpit. This is not easy because the report is somewhat garbled, but reading between the lines, this is what seems to have happened.
- He must have approached way too fast.
- On the ground he was too fast and applied power for a go-around.
- Then he saw it was too late, throttled back and used maximum braking 100 m before the end of the runway
- He wound up 25 m past the end of the runway.
- At some point the right undercarriage leg collapsed. Sounds like he failed to mention in the report it was a catastrophically hard landing.
Actually it sounds as if the landing was little more than a semi-controlled crash.
Why did this happen? My guess is that there were two main factors: approaching too fast due to a lack of familiarity with the aircraft, and a refusal to do a timely go-around – almost certainly due to pride.
It is interesting to note the flight can’t have take more than a couple of minutes because the two airfields are only 6 nm apart. Hardly worth raising the undercarriage for. I suspect the aircraft got way ahead of the pilot, which is possibly why he wound up too fast. It’s a very common fault with inexperienced pilot – when they arrive at a strange airfield they keep the circuit too tight which puts them too high on final approach.
What Can We Learn?
QUICK CONVERSION. Folks, if you are going to fly a fancy aeroplane please make sure you have plenty of hours and a proper conversion. This guy is a classic example of inadequate training and/or experience. If I was the boss of the CAA I would have this guy’s instructor in my office for tea and cookies. He would leave without his instructor rating and would have to re-do his exams and flight test. He signed out a pilot who was dangerously not up scratch, and under different circumstances would be killing fare-paying passengers.
GO AROUND. A go-around is a gift from God. It’s a get out of jail free card. It’s a Christmas bonus. It’s the best back door in aviation. On every final approach there are two critical things to remember, first that the gear is down and locked, and second that you don’t have to land – you can always go-around.
PEOPLE PRESSURE. People pressure is often an unspoken pressure that makes a pilot want to perform and meet expectations. This frequently causes pilots to take unnecessary risks such as overloading the aircraft or pushing on into bad weather or, as in this case, suffering the perceived indignity of doing a go-around.
I believe that people pressures are the reason behind the reason for a hell of a lot of accidents. When a pilot does something stupid like pushing on into bad weather, trying to stretch their fuel or doing a beat up, it’s often because they are trying to meet someone else’s expectation. They want to get home for their kid’s birthday, they want to get their pax to the match, they don't want their bosses to think they are incompetent or they are just showboating. The secret of avoiding these accidents is to simply ask yourself if you would be doing this if there was no one else involved.