AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY and Incidents Reports/9024.pdf · AIRCRAFT ACCIDENT...

CA 12-12a 20 NOVEMBER 2015 of 16

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

AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY

Reference: CA18/2/3/9024

Aircraft Registration

ZU-EUT Date of Accident

31 March 2012 Time of Accident

0730Z

Type of Aircraft Jihlavan KP5-ASA (Aeroplane) Type of Operation

Training (Part 141)

Pilot-in-command Licence Type Commercial Age 23 Licence Valid

Yes

Pilot-in-command Flying Experience

Total Flying Hours

329,4 Hours on Type

90

Last point of departure Tedderfield Airpark (FATA), Gauteng

Next point of intended landing

Tedderfield Airpark (FATA), Gauteng

Location of the accident site with reference to easily defined geographical points (GPS readings if possible)

Poortje, an informal settlement, at the coordinates S26° 27.245’ E027° 46.400’

Meteorological Information

Temperature: 12 ˚C; wind: 30° from TN at 1 kt; dew point: 10 °C; cloud cover: Nil; cloud base: N/A; visibility: >1 000 m

Number of people on board

2 + 0 No. of people injured

0 No. of people killed

2

Synopsis

The pilot, accompanied by a student, took off from Tedderfield Airpark for a training flight in the general flying area (FAD # 184) in the Poortje area, under the auspices of MT Naval Trading 509CC. Approximately 10 minutes after take-off the engine failed and the pilot lost control of the aircraft. At 0730Z, the aircraft crashed into a parameter fence of a house in an informal settlement. Both occupants sustained fatal injuries during the sequence of the accident. The pilot opted to turn to the right in an attempt to clear the build-up area. The aircraft was pitched up in an attempt to avoid crashing into the houses. The investigation revealed that the cause of the engine failure was as a result of carburettor icing. The reason for unsuccessful forced landing was due to the confined space within the area where the aircraft was flying, due to the build-up area it was impossible for a successful forced landing.

Probable Cause

Following an engine failure, the aircraft collided with the tree and the pilot lost control after the wing clipped the tree. Contributory factor(s) The engine failed due to carburettor icing.

RSP Date Release Date


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

AIRCRAFT ACCIDENT REPORT

Name of Owner : MT Naval Trading 509CC

Name of Operator : MT Naval Trading 509CC

Manufacturer : Jihlavan Airplanes SRO

Model : KP-2U-Rapid 200

Nationality : South African

Registration Marks : ZU-EUT

Place : Poortje, Gauteng

Date : 31 March 2012

Time : 0730Z 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.

Purpose of the Investigation In terms of Regulation 12.03.1 of the Civil Aviation Regulations (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 establish legal liability.

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

1. FACTUAL INFORMATION 1.1 History of Flight 1.1.1 On 31 March 2012, at approximately 0720Z, the pilot, accompanied by a student,

took off from Tedderfield Airpark for a training flight in the general flying area (FAD #

184) in the Poortje area.

1.1.2 Approximately 10 minutes after take-off the engine failed to produce power. It would appear that the pilot was unable to restore the engine power and the aircraft started losing height which resulted in failing to produce power

1.1.3 A witness in the informal settlement of Poortje reported that at about 0730Z, while standing in front of his shop, he saw the aircraft flying very low, pitching up and down and yawing from side to side, as though the pilot were performing manoeuvres for fun. The aeroplane then clipped the upper branches of a black wattle tree, struck high-tension conductors with its tail assembly, collided with a stationary vehicle parked in front of a house and finally crashed into the ground next to another house.

1.1.4 The witness immediately contacted the emergency services and proceeded to the

accident site. There he found the two occupants, who had both been killed, still strapped to their seats with the aircraft’s safety harnesses. The pilot was in the right-hand seat and the student in the left-hand seat. The witness removed their bodies from the wreckage.


1.1.5 An occupant in the stationary vehicle confirmed that the aircraft had struck his car.

He had also seen the aeroplane pitch up and down, yaw from side to side, made contact with the high-tension conductors with its tail assembly and finally crash next to the house.

1.1.6 There were no recorded radio transmissions from the crew. 1.1.7 The accident occurred at the coordinates S26°27.245’ E027°46.400’ at an elevation

of approximately 3 800 ft AMSL in an informal settlement (Poortje). 1.2 Injuries to Persons

Injuries Pilot Crew Pass. Other

Fatal 1 1 - -

Serious - - - -

Minor - - - -

None - - - -

1.3 Damage to Aircraft 1.3.1 The aircraft was destroyed by the impact sequence.

Figure 1: The wreckage after the accident.


1.4 Other Damage

1.4.1 Other damage included minor damage to a black wattle tree, high-tension electrical conductors, a vehicle, a house and the perimeter fence around the house.

Figure 2: ZU-EUT clipped this black wattle tree approximately 8 m from the ground.

Figure 3(a) and (b): The aircraft’s empennage struck these electrical power lines.


1.4.2 The high-tension conductors did not break, but the attachment points failed on the posts and the cables had to be cut off by the local municipality to avoid electrocution of bystanders.

Figure 4: The aircraft collided with this vehicle before crashing into the ground.

Aircraft direction of travel


1.4.3 The vehicle sustained damage to the left front fender, the bonnet and the front bumper, which was broken from its mounting points during the accident sequence.

Figure 5: The damage to the house and fence

1.4.4 The wire fence in front of the house was flattened and broken by the impact of the

aircraft. The roof sustained structural damage from the impact. A window frame and a mirror inside the house were broken. No-one in or near the house sustained any injury.

1.5 Personnel Information

Pilot-in-Command

Nationality South African Gender Male Age 23

Licence Number 0272242686 Licence Type Commercial

Licence valid Yes Type Endorsed Yes

Ratings Instructor Gr 3 – 28 July 2011 to 31 July 2012 Instrument – 26 Sept 2011 to 30 Sept 2012 Night

Medical Expiry Date 31 March 2012

Restrictions Corrective lenses

Previous Accidents Nil


Flying Experience

Total Hours 329,4

Total Past 90 Days 13,4

Total on Type Past 90 Days 13,4

Total on Type 90

Student Pilot Note 1: According to the applicable CARS (Civil Aviation Regulations) at the

time (Part 61.01.2 (1)): No person may act as a pilot of a South African registered aircraft, except in the case of dual instruction with an appropriately rated flight instructor.

Note 2: According to the applicable CATS (Civil Aviation Technical Standards) at the time (Part 61.01.9 (3), a student pilot may be credited in full with all solo and dual instruction flight time towards the total flight time requirement for the initial issue of a pilot license.

Nationality South African Gender Female Age 15

Licence Number No licence Licence Type N/A

Licence valid N/A Type Endorsed N/A

Ratings Nil

Medical Expiry Date N/A

Restrictions N/A

Previous Accidents Nil

Flying Experience

Total Hours 11,7

Total Past 90 Days 4,5

Total on Type Past 90 Days 4,5

Total on Type 11,7

1.6 Aircraft Information 1.6.1 The aircraft was refuelled to maximum capacity (90 litres) two days before the

accident. It had been flown for a total of 1 hour 20 minutes after this, consuming 36,2 ℓ of fuel. With full tanks, the endurance of the Jihlavan KP5-ASA is 3 hours 45 minutes. With a consumption of 27,2 ℓ/hour, it can be calculated that approximately 54 ℓ remained in the tanks of ZU-EUT at the time of the accident. This equates to approximately two hours’ flying time remaining.

1.6.2 The airplane has a basic weight of 1008 lb. and an authorised maximum gross weight of 1600 lb. The loading of this airplane was as follows:


Basic empty weight 1008 lbs Consisting of empty weight 973 lbs Oil 15 lbs Extra equipment 20 lbs

Useful load (max 592 lbs) 393 lbs Consisting of pilot 143 lbs Fuel 85 lbs Payload: passenger 165 lbs Baggage 0 lbs

Gross weight at take-off (max 1600 lb.) 1400 lbs The above calculation shows that the take-off weight was within the approved limitations and therefore was not a contributing factor to this accident.

Airframe

Type KP 2U-Rapid 200

Serial Number 5139164M

Manufacturer Jihlaven Airplanes SRO

Date of Manufacture 2007

Total Airframe Hours (At time of Accident) 1 191,9

Last Annual Inspection (Date & Hours) 17 January 2012 1 101,1

Hours since Last Annual Inspection 90,8

Authority to Fly (Issue Date) 18 July 2011

C of R (Issue Date) (Present Owner) 15 September 2009

Operating Categories Part 141

Engine

Type Rotax 912 ULS

Serial Number 5649286

Hours since New 1 191,6

Hours since Overhaul TBO not reached

Propeller

Type Woodcomp SR 3000/2W/1750

Serial Number 4177

Hours since New 1 191,9

Hours since Overhaul TBO not reached


1.7 Meteorological Information 1.7.1 According to the official weather report received from the SA Weather Service, the

following conditions prevailed in the vicinity of the accident site at the time of the accident:

Wind direction 30° from TN Wind speed 1 kt Visibility 1 000 m

Temperature 12 °C Cloud cover Nil Cloud base N/A

Dew point 10 °C

A plot of the official temperature and dew point values on a carburettor icing probability chart indicates a serious probability of carburettor icing at any power setting. See paragraph 1.16.1 for details.

1.7.2 Natural daylight conditions prevailed at the time and place of the accident. 1.8 Aids to Navigation 1.8.1 The aircraft was equipped with standard navigation equipment as approved by the

regulator for the aircraft type. No defects were reported prior to the flight. 1.9 Communications 1.9.1 The aircraft was equipped with standard communication equipment as approved by

the regulator for the aircraft type. No defects were reported prior to the flight. 1.10 Aerodrome Information 1.10.1 The accident occurred in a built-up area (Poortje) at GPS coordinates determined

as S26°27.245’ E027°46.400’ at an elevation of approximately 3 800 ft AMSL. 1.11 Flight Recorders 1.11.1 The aircraft was not equipped with a flight data recorder or a cockpit voice recorder.

Neither was required by the relevant aviation regulations. 1.12 Wreckage and Impact Information 1.12.1 During the descent, the aircraft’s left wing tip clipped the upper branches of a black

wattle tree, resulting in the aircraft rolling to the left. After this the bottom of the tail assembly struck high-tension wires with the nose slightly up. This resulted in the aircraft rolling to the left, hitting a vehicle before impacting the ground with the nose section followed by the left wing. The right wing and belly hit the parameter fence and house.

1.12.2 The on-site investigations revealed no anomalies with the control surfaces, control

cables or control rods, and the landing gear and flaps were retracted at the time of the accident.


1.12.3 The aircraft was fitted with an electronic flight instrument system (EFIS), but it was not possible to download the information due to the damage caused by the impact.

Figure 6: Aerial view of flight path and crash site

1.13 Medical and Pathological Information 1.13.1 The post-mortem report attributed the death of both occupants to multiple injuries

sustained during impact.

1.13.2 No toxicology report was available at the time of compiling this report. Should the

results, once received, change the cause of the accident, the investigation will be

reopened and revised.

1.14 Fire 1.14.1 There was no evidence of a pre or post-impact fire. 1.15 Survival Aspects 1.15.1 The accident was not survivable due to the high impact forces. The cockpit area

was destroyed during the impact. 1.15.2 Both occupants were properly restrained with the aircraft-equipped, four-point

safety harnesses.

Direction of flight as

per witness accounts

Direction of impact

determined as 268° M Power lines

Black wattle tree


1.15.3 The safety harnesses were cut off by the witness who removed the deceased from

the wreckage. 1.16 Tests and Research

1.16.1 A plot of the official temperature and dew point values on a carburettor icing

probability chart indicates a serious probability of carburettor icing at any power setting.

Figure 7: Carburettor icing probability chart

1.16.2 Carburettor Icing is an icing condition which can affect any carburettor under certain

atmospheric conditions. It occurs when there is humid air and the temperature drop in the venturi causes the water vapour to freeze, which gradually blocks the venturi (Figure 8). This upsets the fuel/air ratio, causing a progressive smooth loss of power, and can “strangle” the engine, which can cause the engine to fail if no corrective action is taken or if corrective action is taken too late.


Figure 8: Build-up of icing in induction system

1.17 Organisational and Management Information 1.17.1 Operator The operator was in possession of a valid training approval certificate issued by the

SA Civil Aviation Authority on 28 July 2011 and valid until 7 July 2012. The certificate authorises the operator to conduct training under Part 141 of the Civil Aviation Regulations of 1997. The flight was therefore authorised.

1.17.2 Maintenance

The approved person who certified the last annual inspection on the aircraft prior to the accident was in possession of a valid approved person accreditation issued by the Aero Club of South Africa.

1.18 Additional Information 1.18.1 Fuel selector

Due to accident-related damage, it was not possible to determine the position of the fuel selector at the time of impact. Both fuel tanks ruptured on impact and a strong smell of fuel was present at the accident site.


1.18.2 Flaps The Fowler flaps were retracted. Both flaps and their mechanisms were still intact.

1.18.3 Rudder

Rudder controls, i.e. rudder cables, bell cranks, pushrods, fork ends, bolts, castle nuts and cotter pins were all intact. At the cable to bell crank attach point, turnbuckles, wire locking and fork ends were all in good order.

1.18.4 Elevators

The two pushrods connecting the control sticks to the machined yoke at the rear of the fuselage were broken at mid-span due to the impact. The yoke and bell crank driving the dog-type connection to the elevators were intact. All attachment points, bolts, castle nuts, cotter pins and floating bearings were in good condition. The right-hand elevator had jumped out of its dog clutch drive due to the tail plane (empennage) moving forward by about 50 mm.

1.18.5 Ailerons

The connection of the push rods in the area and the root ends of the wings, and all the fork ends, bolts, nuts and cotter pins were still intact. The outboard aileron attachment points were intact.

1.18.6 Wings

All the wing bolts were still in place at their attachment points. All the hoses connecting the standard tanks to the outboard auxiliary tanks were still connected. The fuel cock was on and selected to the left tank position. Fuel could not be checked as the tanks were ruptured.

1.18.7 Propeller

Both propeller blades sheared at the root of the propeller hub. The propeller blades showed no signs of rotation. This indicated that the engine was producing no power at the time of impact with the ground. Evidence on the propeller blades also revealed that the engine was not running at the time of accident. On ground impact, the both blades failed and the spinner dug into the ground.

Figures 9 (a) & (b): Both blades sheared at the root of the hub and showed no sign of rotation during impact with the terrain.


1.18.7 Fuel filter

The fuel filter was inspected for cleanliness on site. It was found to be clean, without visible contamination and containing approximately 25 ml of fuel.

1.18.8 Engine

The spark plugs were removed and inspected for condition on site. All the spark plugs and related high-tension wiring appeared to be in good condition. The engine turned freely and no signs of overheating or possible seizure were evident. On-site investigation revealed that the engine was not running on impact. The engine most probably failed as a result of carburettor icing while practising stalls and recovery techniques authorised by the training organisation.

1.19 Useful or Effective Investigation Techniques 1.19.1 Two separate witnesses reported that at about 0730Z they saw the aircraft flying

very low, pitching up and down and yawing from side to side. This is indicative of a low flying speed where the aircraft is close to a stall or probably stalled already. That would explain the rocking of the wings and the pilot’s apparent loss of control.

2. ANALYSIS

2.1 Man 2.1.1 The pilot (instructor) was properly licensed and rated on the aircraft type and held a

valid medical certificate at the time of the accident.

2.1.2 It was also determined that they were flying low in the area while possibly practising stalls and recovery.

2.1.3 The student was a low-hour student with no licence and no medical. Note 1: According to the applicable CARS (Civil Aviation Regulations) at the time

(Part 61.01.2 (1): No person may act as a pilot of a South African registered aircraft, except in the case of dual instruction with an appropriately rated flight instructor. The student pilot was not the holder of any licence. However, she was under dual instruction with an appropriately rated flight instructor.

2.2 Machine 2.2.1 Examination of the wreckage revealed no deficiencies of the engine or airframe

system that could have occurred prior to impact. The aircraft was destroyed. The aircraft was properly maintained, and according to available documentation the aircraft did not have any defect or malfunction that could have contributed to or have caused the accident. The investigation revealed that the engine was not running at the time of the accident. The engine most probably failed as a result of carburettor icing while practising stalls and recovery techniques authorised by the training organisation.


2.2.2 The pilot opted to turn to the right in an attempt to clear the build-up area. The aircraft was

pitched up in an attempt to avoid crashing into the houses. The investigation revealed that the cause of the engine failure was as a results of carburettor icing. The reason for unsuccessful forced landing was due the confine space within the area where the aircraft was flying, due to the build-up area it was impossible for a successful forced landing.

2.3 Environment 2.3.1 The available information indicates that fine weather conditions prevailed in the

area at the time of the flight and subsequent accident. The temperature was 12°C and the dew point was 10 °C. This is indicative of a serious possibility of engine carburettor icing, which can result in engine power loss or even engine failure. A plot of the official temperature and dew point values on a carburettor icing probability chart indicates a serious probability of carburettor icing at any power setting. It was therefore concluded the weather was probably a contributory factor to the accident.

2.4 Witnesses 2.4.1 Two separate witnesses reported that at about 0730Z they saw the aircraft flying

very low, pitching up and down, and yawing from side to side. This is indicative of a low flying speed where the aircraft is close to a stall or probably stalled already. That would explain the rocking of the wings and the pilot’s apparent loss of control.

3. CONCLUSION 3.1 Findings 3.1.1 The pilot-in-command was licensed and qualified for the flight in accordance with

existing regulations. 3.1.2 The maintenance records indicated that the aircraft was equipped and maintained

in accordance with existing regulations and approved procedures. 3.1.3 The operator was in possession of a valid training certificate. 3.1.4 The on-site investigation revealed no anomalies of the airframe or the engine. 3.1.5 The investigation revealed that the cause of the engine failure was as a result of carburettor

icing. 3.2 Probable Cause/s 3.2.1 Following an engine failure, the aircraft collided with the tree and the pilot lost control after

the wing clipped the tree.

3.3 Contributory factor(s): 3.3.1 The engine failed due to carburettor icing.


4. SAFETY RECOMMENDATIONS 4.1 None

5. APPENDICES 5.1 None …END…

AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY and Incidents Reports/9024.pdf · AIRCRAFT ACCIDENT...

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