Moremi Air van down
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We are still awaiting an answer to this whole issue. Does anyone know if any legal action has been taken by the families of the deceased passengers? If so the insurance companies must be screaming for information.
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Ngami Times 19th October
What caused the Moremi Air plane crash a year ago?
By Bright Kholi
Sunday October 14, marked exactly a year since a Moremi Air plane crashed in the Moremi Game Reserve just after take off from Xakanaxa airstrip, killing 8 passengers including the pilot. While it's been a year since the incident, the aviation sector, the tourism sector, families of the deceased and the general public are yet to know what really caused the accident as the report on the incident is still being finalised.
On October 14, 2011, the Cessna 208 registered A2 AKD took off from Maun airport to do its regular trips in and out of the Delta camps transporting tourists. At the controls of A2 AKD was Martin Gresswell, then Moremi Air's most experienced pilot and general manager for flight operations with a staggering 12 000 flying hours. At about 1.55pm it crashed just after take off from Xakanaxa airstrip, which is about 25 flying minutes from Maun, destined for Pom Pom. Aboard the aircraft were 12 passengers, of whom four survived while 7 tourists and Gresswell died.
From there on the investigations on to the cause were initiated by the Ministry of Transport and Communications and to date, it is yet to release the report. Many questions have been asked as to what could have gone wrong with the aircraft, more so that the pilot was one of the finest in the industry.
In response to questions from The Ngami Times this week, Aron Kitunga, the investigator in charge at the ministry, said “investigations are a process”, adding that they are currently at the report writing stage of the investigations.
“The draft final report has been completed and circulated to affected parties. Only one has not submitted representations, but we have started working on other representations which were submitted,” he said.
Of the affected parties - two are known to be Moremi Air Services in Maun and engine makers Pratt and Whitney, Canada - two have submitted their representations which are now being taken into consideration before submitting the final report. Questioned on the preliminary findings, Kitunga said the investigations revealed that the aircraft engine had failed during take-off. He could not go into detail as to what could have led to the engine to fail. A2 AKD was fitted with a powerful Pratt and Whitney Canada PT6A-114A turbo prop engine. There have been allegations that the engine could have been altered in a way which made it susceptible to failure but Kitunga said “we are not aware of such rumours, and in any case, the investigations are normally based on factual information.” On whether the final report will be made public, Kitunga said regulations require that the final report be submitted to the Minister of Transport and Communications who will then determine if the report or part of it is to be published.
Asked why it took so long for the investigations to be concluded, Kitunga said, “accident investigations are always complex and are required to determine not only the root cause of the accident, but also other systemic shortcomings that could be potential cause of accidents. Therefore, a thorough investigation is carried out before determination of the conclusions and any lessons that might be learnt from the accident. Normally this takes not less than one year and could go as far as two or three years for a large commercial aircraft.”
Moremi Air Services in Maun did not respond to a set of questions sent to them by The Ngami Times this week.
By Bright Kholi
Sunday October 14, marked exactly a year since a Moremi Air plane crashed in the Moremi Game Reserve just after take off from Xakanaxa airstrip, killing 8 passengers including the pilot. While it's been a year since the incident, the aviation sector, the tourism sector, families of the deceased and the general public are yet to know what really caused the accident as the report on the incident is still being finalised.
On October 14, 2011, the Cessna 208 registered A2 AKD took off from Maun airport to do its regular trips in and out of the Delta camps transporting tourists. At the controls of A2 AKD was Martin Gresswell, then Moremi Air's most experienced pilot and general manager for flight operations with a staggering 12 000 flying hours. At about 1.55pm it crashed just after take off from Xakanaxa airstrip, which is about 25 flying minutes from Maun, destined for Pom Pom. Aboard the aircraft were 12 passengers, of whom four survived while 7 tourists and Gresswell died.
From there on the investigations on to the cause were initiated by the Ministry of Transport and Communications and to date, it is yet to release the report. Many questions have been asked as to what could have gone wrong with the aircraft, more so that the pilot was one of the finest in the industry.
In response to questions from The Ngami Times this week, Aron Kitunga, the investigator in charge at the ministry, said “investigations are a process”, adding that they are currently at the report writing stage of the investigations.
“The draft final report has been completed and circulated to affected parties. Only one has not submitted representations, but we have started working on other representations which were submitted,” he said.
Of the affected parties - two are known to be Moremi Air Services in Maun and engine makers Pratt and Whitney, Canada - two have submitted their representations which are now being taken into consideration before submitting the final report. Questioned on the preliminary findings, Kitunga said the investigations revealed that the aircraft engine had failed during take-off. He could not go into detail as to what could have led to the engine to fail. A2 AKD was fitted with a powerful Pratt and Whitney Canada PT6A-114A turbo prop engine. There have been allegations that the engine could have been altered in a way which made it susceptible to failure but Kitunga said “we are not aware of such rumours, and in any case, the investigations are normally based on factual information.” On whether the final report will be made public, Kitunga said regulations require that the final report be submitted to the Minister of Transport and Communications who will then determine if the report or part of it is to be published.
Asked why it took so long for the investigations to be concluded, Kitunga said, “accident investigations are always complex and are required to determine not only the root cause of the accident, but also other systemic shortcomings that could be potential cause of accidents. Therefore, a thorough investigation is carried out before determination of the conclusions and any lessons that might be learnt from the accident. Normally this takes not less than one year and could go as far as two or three years for a large commercial aircraft.”
Moremi Air Services in Maun did not respond to a set of questions sent to them by The Ngami Times this week.
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Although there was never any doubt by the people in Maun, and those who knew him, at least this article looks like the blame is pointed away from Martin with stupid rumours of being overloaded etc etc.
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Indeed, it is a very rare occurance with the PT6 but if your only engine granades just after takeoff your only chance is a suitable cabbage patch. If all you have is trees it is not going to end well.
Sometimes fate deals you a bum hand and there is nothing that the best pilot in the world can do about it.
The interesting part, when the full report is released, will be P&W's analysis of why the engine failed so disastrously.
Sometimes fate deals you a bum hand and there is nothing that the best pilot in the world can do about it.
The interesting part, when the full report is released, will be P&W's analysis of why the engine failed so disastrously.
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Gee....
Did the hot section shell or the gearbox explode? Over-TQ comes to mind. Poor maintenance a likely reason too. Operators on the pinch like to run PT6 engines way past the maint. sched. Sure it wasn't just an FCU shaft fail?
Design fail in this engine, in all likelyhood, is out of the question. All but impossible, but still possible. Could be FOD through the compressor. Nine chances out of ten it's poor maintenance or pilot engine control error or abuse.
I am interested in knowing when info becomes available.
Design fail in this engine, in all likelyhood, is out of the question. All but impossible, but still possible. Could be FOD through the compressor. Nine chances out of ten it's poor maintenance or pilot engine control error or abuse.
I am interested in knowing when info becomes available.
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Temp spike. Have you flown in Botswana or are you assuming that it is poor maintenance because it is Africa?
Because engine failures on PT6's never happen in the states right?
I had my first PT6 failure in Canada. Not in Africa.
An FCU failure is pretty easy to recognise in a van. The emergency power lever is there for such an occasion.
Is a turbine disk letting go so far fetched?
Because engine failures on PT6's never happen in the states right?
I had my first PT6 failure in Canada. Not in Africa.
An FCU failure is pretty easy to recognise in a van. The emergency power lever is there for such an occasion.
Is a turbine disk letting go so far fetched?
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Moremi Air van down
While the content and nature of the report has not yet been released, it has been confirmed that it was engine failure due to the compressor blades that sheared off due to corrosion. So no, Temp spike in this instance it was not pilot engine control or abuse but the standard of the maintenance needs to be considered as corrosion of that nature doesnt happen overnight.
Last edited by Golf Romeo Mike; 6th Nov 2012 at 17:15.
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....it has been confirmed that it was engine failure due to the compressor blades that sheared off due to corrosion.
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Moremi Air van down
While i can't tell you how i know, I can confirm that this is not another rumour. I know for a fact that P&W have verified that it was engine failure which was as a result of corrosion on the compressor blades.
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So, finally some aspects of the report have come to light:
Sunday Standard - Online Edition
Some interesting points to note are that, while everything from the trees, to the training and even lack of documentation is blamed, no mention is ever made to the primary issue, which is that the Engine essentially blew up and caught fire on take off, which would be a maintenance issue. It should also be noted, that while not mentioned in this article, P&W had issued all AOM's an Airworthiness Directive advising of a potential issue of corrosion build up in the PT6 engine 1 year before the crash. As per P&W's analysis AKD's engine, the engine failed due to a turbine blade shearing off as a result of severe sulphurdation build up which caused massive corrosion.
It is quite amusing that the GM of MA states that she has not received or read the pre-liminary or the final report which was issued to all involved parties months ago. Is she lying or does our favourite CEO not think it pertinent for the GM of the Air Charter company to know why one of their air craft crashed, killing 9 people (including their former GM)
Sunday Standard - Online Edition
Some interesting points to note are that, while everything from the trees, to the training and even lack of documentation is blamed, no mention is ever made to the primary issue, which is that the Engine essentially blew up and caught fire on take off, which would be a maintenance issue. It should also be noted, that while not mentioned in this article, P&W had issued all AOM's an Airworthiness Directive advising of a potential issue of corrosion build up in the PT6 engine 1 year before the crash. As per P&W's analysis AKD's engine, the engine failed due to a turbine blade shearing off as a result of severe sulphurdation build up which caused massive corrosion.
It is quite amusing that the GM of MA states that she has not received or read the pre-liminary or the final report which was issued to all involved parties months ago. Is she lying or does our favourite CEO not think it pertinent for the GM of the Air Charter company to know why one of their air craft crashed, killing 9 people (including their former GM)
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From the Nagami Times last week:
A very important flight safety aspect is to publish and circulate accident reports so that lessons can be learnt and necessary changes made. We all know that this accident report was leaked ages ago. It lists the CEO on the very small distribution list. Perhaps it got lost in the Botswana post to her 
It makes interesting reading. As you say GRM we must not lose sight of the fact that it was an engine failure nothing more nothing less. The trees were not a factor. The trees were a performance issue but Martin would almost certainly have cleared them if the engine had not blown up. End of story - well not really, but you know what I mean.
The Sunday Standard is not correct considerable improvements have been made. The reporter failed to note:
This doesn't mean that we should be complacent however.
Botswana in aviation safety shake up
A shake up of Botswana's aviation – both the national carrier and other aircraft registered in the country - is on the go following the International Civil Aviation Organisation (ICAO) validation of the country for effective implementation of ICAO's standards and recommended practices.
This follows a validation mission conducted in Botswana in April.
The purpose was to check on the progress made by Botswana following a safety audit carried out in May 2006 which showed, then, that Botswana was only at 27.8% of effective implementation of standards and recommended practices.
The new mission was a full-scale one covering all the eight audit areas of legislation, organisation, personnel licensing, flight operations (OPS), airworthiness, accident and incident investigation, air navigation services and aerodromes and ground aids.
Botswana was this time rated at 59.6% of effective implementation as compared to 27.8% in 2006, says the Civil Aviation Authority Botswana (CAAB).
The positive rating is better than the average for Africa which is 41% and is almost equal to the global average of 60%.
The mission team acknowledged “the commendable progress made by Botswana since the 2006 audit, noting that significant improvements have been made in almost all the safety-related areas.” There were however two potential significant safety concerns, one relating to the certification process for the issuance of air operator certificates and the other relating to the approval of aircraft modifications and repairs.
ICAO wrote to the CAAB and requested Botswana, through the CAAB, to submit a correction action plan detailing how the safety concerns would be resolved. It is anticipated that this wilkl have been completed by October.
The CAAB has since submitted a detailed corrective action plan with an estimated completion date of October 2013.
This entails the re-certifying all air operators in accordance with the Civil Aviation (Air Operator Certification and Administration) Regulations, 2013 which were published on March 8.
In addition, the CAAB will conduct a comprehensive structured review of all major modifications and major repairs embodied on Botswana registered aircraft to ensure compliance with associated civil aviation regulations of Botswana and ICAO provisions.
In both recertification and review and approval of modifications and repairs, the CAAB is in close consultations with and provides guidance to all affected air operators and is pleased with their
Co-operation. These consultations and co-operation are critical.
“In its correspondence with Botswana, ICAO acknowledged Botswana's commitment
in helping ICAO achieve its safety objectives and called on the CAAB to continue giving
progress updates on the corrective actions for ICAO's continued monitoring of the
status,” the CAAB said.
“The CAAB, as an aviation regulator in Botswana, is currently working around the clock to
correct the two significant safety concerns on Botswana. It is worth noting that
Botswana's rating at 59.6% of Effective Implementation in 2013 as compared to 27.8% in 2006 represents a significant improvement. “ In terms of the process agreed between Botswana and ICAO, the draft report will be ready within 90 days from April 9 after which Botswana will have 45 days to respond or comment.
A shake up of Botswana's aviation – both the national carrier and other aircraft registered in the country - is on the go following the International Civil Aviation Organisation (ICAO) validation of the country for effective implementation of ICAO's standards and recommended practices.
This follows a validation mission conducted in Botswana in April.
The purpose was to check on the progress made by Botswana following a safety audit carried out in May 2006 which showed, then, that Botswana was only at 27.8% of effective implementation of standards and recommended practices.
The new mission was a full-scale one covering all the eight audit areas of legislation, organisation, personnel licensing, flight operations (OPS), airworthiness, accident and incident investigation, air navigation services and aerodromes and ground aids.
Botswana was this time rated at 59.6% of effective implementation as compared to 27.8% in 2006, says the Civil Aviation Authority Botswana (CAAB).
The positive rating is better than the average for Africa which is 41% and is almost equal to the global average of 60%.
The mission team acknowledged “the commendable progress made by Botswana since the 2006 audit, noting that significant improvements have been made in almost all the safety-related areas.” There were however two potential significant safety concerns, one relating to the certification process for the issuance of air operator certificates and the other relating to the approval of aircraft modifications and repairs.
ICAO wrote to the CAAB and requested Botswana, through the CAAB, to submit a correction action plan detailing how the safety concerns would be resolved. It is anticipated that this wilkl have been completed by October.
The CAAB has since submitted a detailed corrective action plan with an estimated completion date of October 2013.
This entails the re-certifying all air operators in accordance with the Civil Aviation (Air Operator Certification and Administration) Regulations, 2013 which were published on March 8.
In addition, the CAAB will conduct a comprehensive structured review of all major modifications and major repairs embodied on Botswana registered aircraft to ensure compliance with associated civil aviation regulations of Botswana and ICAO provisions.
In both recertification and review and approval of modifications and repairs, the CAAB is in close consultations with and provides guidance to all affected air operators and is pleased with their
Co-operation. These consultations and co-operation are critical.
“In its correspondence with Botswana, ICAO acknowledged Botswana's commitment
in helping ICAO achieve its safety objectives and called on the CAAB to continue giving
progress updates on the corrective actions for ICAO's continued monitoring of the
status,” the CAAB said.
“The CAAB, as an aviation regulator in Botswana, is currently working around the clock to
correct the two significant safety concerns on Botswana. It is worth noting that
Botswana's rating at 59.6% of Effective Implementation in 2013 as compared to 27.8% in 2006 represents a significant improvement. “ In terms of the process agreed between Botswana and ICAO, the draft report will be ready within 90 days from April 9 after which Botswana will have 45 days to respond or comment.
It makes interesting reading. As you say GRM we must not lose sight of the fact that it was an engine failure nothing more nothing less. The trees were not a factor. The trees were a performance issue but Martin would almost certainly have cleared them if the engine had not blown up. End of story - well not really, but you know what I mean.The Sunday Standard is not correct considerable improvements have been made. The reporter failed to note:
The positive rating is better than the average for Africa which is 41% and is almost equal to the global average of 60%.
Last edited by Exascot; 14th Jun 2013 at 08:18.
Está servira para distraerle.
That's a relatively meaningless piece of self congratulation on the part of the CAAB.
Effective implementation by Region currently stands as follows:
Africa 41%, Asia 68%, Europe 72%, Latin America & the Caribbean 64%, North America 93%, Oceania 47%
Worldwide Average 60%
Source: ICAO
http://www.caab.co.bw/caab-news-deta...=517&type=news
Oceania and Africa pull the world standard down from the 74% success rate achieved by excluding them to the lamentable 60% including them. A mark of 60% wouldn't even achieve a pass in either a South African or British ATPL examination.
What's truly astonishing is the gap between the 92% achieved by the US and the comparatively pitiful 72% European success rate. If you were to take the US out of the equation, the overall average decreases to 58.4%. The US rate of achievement is thus perhaps reflective of the capable, accountable and efficient authority to be found in the FAA.
Effective implementation by Region currently stands as follows:
Africa 41%, Asia 68%, Europe 72%, Latin America & the Caribbean 64%, North America 93%, Oceania 47%
Worldwide Average 60%
Source: ICAO
http://www.caab.co.bw/caab-news-deta...=517&type=news
Oceania and Africa pull the world standard down from the 74% success rate achieved by excluding them to the lamentable 60% including them. A mark of 60% wouldn't even achieve a pass in either a South African or British ATPL examination.
What's truly astonishing is the gap between the 92% achieved by the US and the comparatively pitiful 72% European success rate. If you were to take the US out of the equation, the overall average decreases to 58.4%. The US rate of achievement is thus perhaps reflective of the capable, accountable and efficient authority to be found in the FAA.
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What's truly astonishing is the gap between the 92% achieved by the US and the comparatively pitiful 72% European success rate. If you were to take the US out of the equation, the overall average decreases to 58.4%. The US rate of achievement is thus perhaps reflective of the capable, accountable and efficient authority to be found in the FAA.
The 41% for Africa are still scary, though....
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CEO of Moremi Air
Sorry guys, you know that I only stick my head over the parapet on this particular issue as I am in a very sensitive position down here.
Golf Romeo Mike and Exascot. I am sure that you know that SS saw the main report as soon as it was published.
The report slates SS and her non-existent managerial skills. It doesn't mention her zero previous knowledge of aviation before her amazing promotion into this post (still a mystery). It also criticizes the CAAB. This is why it has been suppressed.
Also it is all very well giving the whole country a ICAO rating but regarding the air charter companies the tour operators should be informed about individual safety records. We all know who are the best and the one that is the worst. No names mentioed
Golf Romeo Mike and Exascot. I am sure that you know that SS saw the main report as soon as it was published.
The report slates SS and her non-existent managerial skills. It doesn't mention her zero previous knowledge of aviation before her amazing promotion into this post (still a mystery). It also criticizes the CAAB. This is why it has been suppressed.
Also it is all very well giving the whole country a ICAO rating but regarding the air charter companies the tour operators should be informed about individual safety records. We all know who are the best and the one that is the worst. No names mentioed
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The only way forward is for the CEO to resign.
MOREMI AIR PARTLY BLAMED FOR CRASH
The report of the aircraft accident investigation of the Cessna 208B Grand Caravan plane that crashed shortly after take-off from Xakanaxa airstrip in the Okavango Delta on October 14, 2011 - killing 8 of its 11 passengers, including the pilot - has almost if not entirely put the blame for the accident at the door of the operator, Moremi Air Services.
The report, by the Directorate of Accident Investigation in the Ministry of Transport and Communications, concluded that the crash was caused by engine failure resulting from failure of the engine's compressor turbine blades.
It had harsh words to say about Moremi Air's training culture as well as how its pilots had resigned owing to authoritarian management.
Those who died in the accident were the British-born pilot Martin Gresswell, 51, and seven of his passengers from Switzerland (3), France (3) and Britain.
The survivors were two French and two Botswana government officials. One of the French survivors died in the Milpark Hospital, in Johannesburg, while a Botswna government official died of natural causes late last year..
Gresswell's mother, Barbara Hoad, of Hull, England, told the BBC that as the investigation found the engine failed due to corrosion on the compressor blades, it cleared her son of any responsibility close to the first anniversary of his death. She was quoted by Hull media some months after the crash as saying: “It was 100 per cent engine failure and definitely not Martin's fault. In our hearts, we knew it wasn't pilot's error because we had flown with him and he was a good pilot.”
The accident report found that contributing factors to the accident were “an inadequate safety culture and lack of an established safety management system within Moremi Air Services, subjugating and authoritarian management control at the carrier, a poor training programme at Moremi Air Services and carrying more passengers than authorised out of Xakanaxa airfield.”
The report also blames the Civil Aviation Authority of Botswana (CAAB) for poor supervision and oversight to the operator, aircraft maintenance organisation and airfield certification. The engine manufacturer was also at fault for lack of dissemination of critical maintenance information to the operators and aircraft maintenance organisations.
Tall trees that have been bedevilling Xakanaxa airstrip also contributed to the accident. According to the report, the Cessna, registration A2 AKD, departed Maun on the morning of October 14, 2011, for a series of flight sectors in the Okavango Delta that took the aircraft to Kasane. The aircraft was refuelled there and at 11.50am “11 passengers boarded the aircraft which was going to Pom Pom but the pilot changed the schedule and the aircraft diverted to Xakanaxa to drop two passengers.
“There was no flight plan filed for Xakanaxa sector, nor was the company base informed of the
diversion before the aircraft's departure from Kasane airport,” says the report.
It goes on to say at Xakanaxa the pilot was informed that he was required to pick up another two passengers who were going to Maun. After some hesitation, the pilot agreed to take the passengers, departing from Xakanaxa with 11 passengers although the aircraft was restricted to carry 10 passengers out of that airfield.
The Pratt and Whitney aircraft engine lost power during the climb out at Xakanaxa and the aircraft collided with a tree. It crashed nose first approximately 600 metres from the airfield.
According to the report, Xakanaxa airfield is owned by the Department of Wildlife and National Parks and has tall trees at either end of the runway. It also says that the owners were not willing to remove the trees even after being advised by the Civil Aviation Authority.
“There had been an effort to relocate the airfield as a lasting solution but the project was abandoned mid-way reportedly due to financial constraints faced by the Department,” the report added.
Investigations to the accident revealed that the compressor turbine of the engine had failed, leading to engine failure.
“ Sulphidation corrosion was found on the inter-platform area of the compressor turbine although this could not be positively established as the root cause of the turbine failure,” the report found.
It goes on to say the possibility of material failure and inappropriate operation of the engine could not entirely be ruled out as the possible cause of the compressor turbine failure.
“It was also established that Moremi Air Services' top management style, safety culture and pilot training structure had eroded to the extent that safety was being compromised.
“At the time of the accident the pilot had tendered his resignation as had many pilots before him after experiencing antagonism with the top management at the company.”
It further reveals that although the CEO position did not feature in the Operations Manual, “witness reports within the organisation stated that all the major decisions pertaining to the running of the company were only carried out upon approval by the CEO.”
According to witness reports, the management style at Moremi Air Services is described as being single-handedly run by the CEO who ensured a full grip on operational control. “Her leadership style was described by many as aggressive and assertive, which effectively demoralised many of the staff,” the report added.
It further states “that others described her leadership style as draconian while others referred to her as a micro-manager.”
Moremi Air Services pilots had been discussing management issues in their own forum but there were no positive changes.
“Moremi Air Services had experienced four accidents within two years prior to the
employment of the occurrence pilot and the management stated that they had employed
the occurrence pilot to assist in resolving safety related issues,” the report said.
Findings and recommendations
Probable Cause of the Accident
3.2.1 Engine failure resulting from the failure of the Compressor Turbine Blades.
Other Contributing Factors
3.3.1 Sulphidation corrosion on the inter-platform area of turbine blades.
3.3.2 Tall trees at the end of Xaxanaka airfield.
3.3.3 Inadequate safety culture and lack of an established Safety Management System within Moremi Air Services.
3.3.4 Subjugating and authoritarian management control at Moremi Air Services.
3.3.5 Poor training programme at Moremi Air Services
3.3.6 Issuance of Dispensation to Xaxanaka airfield.
3.3.7 Carrying more passengers than authorised out of Xaxanaka airfield.
3.3.8 Lack of dissemination of critical maintenance information to the operators and AMOs by the engine manufacturer.
3.3.9 Poor supervision and oversight by CAAB to the aircraft operator, aircraft maintenance organisation and airfield certification.
RECOMMENDATIONS
4.1 Pratt and Whitney Canada and Cessna to continue supporting the effort of SERT team to identify the major causes of engine shut down on single-engine aircraft.
4.2 That the aircraft manufacturer and the relevant certification authorities should ensure that the ADAS system is protected against fire damage.
4.3 That the CAAB reinforces its work-force at Maun airport to ensure that the oversight responsibility for aircraft operators and maintenance organisations is carried out diligently.
4.4 The CAAB should ensure that the Management system at Moremi Air Services is overhauled so that there is a clearly defined line of command and that the work environment is conducive for safe operation of aircraft.
4.5 The CAAB should establish a system that will ensure that commercial operators prepare load sheets for every flight sector and a provision for amending them in case of changes in the flight schedules that will affect the loading and destination of the aircraft.
4.6 The CAAB should ensure that aircraft operations at Xaxanaka airfield and other Category C airfields is limited to aircraft of the authorised performance group and it should consider to stop issuing dispensations.
4.7 The CAAB should direct the Wildlife and National Parks management to ensure that the trees at Xaxanaka airfield do not pose danger to aircraft or passengers.
4.8 The CAAB should ensure that the safety culture at MAS is improved through building up of a solid Safety Management System.4. The CAAB should put a requirement for operators to install ELTs that will activate when subjected to longitudinal as well as lateral forces.
4.10 The CAAB should ensure that MAS has a well-established training schedule for their pilots and the records are prepared and kept up to date.
4.11 The CAAB should initiate a research on the presence of sodium compounds on calcrete used on airfield surfaces and its effect on turbine engines.
4.12 The DWNP should look into the possibility of completing the relocation of Xaxanaka airfield if they are not in a position to cut the tall trees surrounding the existing airfield.
The report of the aircraft accident investigation of the Cessna 208B Grand Caravan plane that crashed shortly after take-off from Xakanaxa airstrip in the Okavango Delta on October 14, 2011 - killing 8 of its 11 passengers, including the pilot - has almost if not entirely put the blame for the accident at the door of the operator, Moremi Air Services.
The report, by the Directorate of Accident Investigation in the Ministry of Transport and Communications, concluded that the crash was caused by engine failure resulting from failure of the engine's compressor turbine blades.
It had harsh words to say about Moremi Air's training culture as well as how its pilots had resigned owing to authoritarian management.
Those who died in the accident were the British-born pilot Martin Gresswell, 51, and seven of his passengers from Switzerland (3), France (3) and Britain.
The survivors were two French and two Botswana government officials. One of the French survivors died in the Milpark Hospital, in Johannesburg, while a Botswna government official died of natural causes late last year..
Gresswell's mother, Barbara Hoad, of Hull, England, told the BBC that as the investigation found the engine failed due to corrosion on the compressor blades, it cleared her son of any responsibility close to the first anniversary of his death. She was quoted by Hull media some months after the crash as saying: “It was 100 per cent engine failure and definitely not Martin's fault. In our hearts, we knew it wasn't pilot's error because we had flown with him and he was a good pilot.”
The accident report found that contributing factors to the accident were “an inadequate safety culture and lack of an established safety management system within Moremi Air Services, subjugating and authoritarian management control at the carrier, a poor training programme at Moremi Air Services and carrying more passengers than authorised out of Xakanaxa airfield.”
The report also blames the Civil Aviation Authority of Botswana (CAAB) for poor supervision and oversight to the operator, aircraft maintenance organisation and airfield certification. The engine manufacturer was also at fault for lack of dissemination of critical maintenance information to the operators and aircraft maintenance organisations.
Tall trees that have been bedevilling Xakanaxa airstrip also contributed to the accident. According to the report, the Cessna, registration A2 AKD, departed Maun on the morning of October 14, 2011, for a series of flight sectors in the Okavango Delta that took the aircraft to Kasane. The aircraft was refuelled there and at 11.50am “11 passengers boarded the aircraft which was going to Pom Pom but the pilot changed the schedule and the aircraft diverted to Xakanaxa to drop two passengers.
“There was no flight plan filed for Xakanaxa sector, nor was the company base informed of the
diversion before the aircraft's departure from Kasane airport,” says the report.
It goes on to say at Xakanaxa the pilot was informed that he was required to pick up another two passengers who were going to Maun. After some hesitation, the pilot agreed to take the passengers, departing from Xakanaxa with 11 passengers although the aircraft was restricted to carry 10 passengers out of that airfield.
The Pratt and Whitney aircraft engine lost power during the climb out at Xakanaxa and the aircraft collided with a tree. It crashed nose first approximately 600 metres from the airfield.
According to the report, Xakanaxa airfield is owned by the Department of Wildlife and National Parks and has tall trees at either end of the runway. It also says that the owners were not willing to remove the trees even after being advised by the Civil Aviation Authority.
“There had been an effort to relocate the airfield as a lasting solution but the project was abandoned mid-way reportedly due to financial constraints faced by the Department,” the report added.
Investigations to the accident revealed that the compressor turbine of the engine had failed, leading to engine failure.
“ Sulphidation corrosion was found on the inter-platform area of the compressor turbine although this could not be positively established as the root cause of the turbine failure,” the report found.
It goes on to say the possibility of material failure and inappropriate operation of the engine could not entirely be ruled out as the possible cause of the compressor turbine failure.
“It was also established that Moremi Air Services' top management style, safety culture and pilot training structure had eroded to the extent that safety was being compromised.
“At the time of the accident the pilot had tendered his resignation as had many pilots before him after experiencing antagonism with the top management at the company.”
It further reveals that although the CEO position did not feature in the Operations Manual, “witness reports within the organisation stated that all the major decisions pertaining to the running of the company were only carried out upon approval by the CEO.”
According to witness reports, the management style at Moremi Air Services is described as being single-handedly run by the CEO who ensured a full grip on operational control. “Her leadership style was described by many as aggressive and assertive, which effectively demoralised many of the staff,” the report added.
It further states “that others described her leadership style as draconian while others referred to her as a micro-manager.”
Moremi Air Services pilots had been discussing management issues in their own forum but there were no positive changes.
“Moremi Air Services had experienced four accidents within two years prior to the
employment of the occurrence pilot and the management stated that they had employed
the occurrence pilot to assist in resolving safety related issues,” the report said.
Findings and recommendations
Probable Cause of the Accident
3.2.1 Engine failure resulting from the failure of the Compressor Turbine Blades.
Other Contributing Factors
3.3.1 Sulphidation corrosion on the inter-platform area of turbine blades.
3.3.2 Tall trees at the end of Xaxanaka airfield.
3.3.3 Inadequate safety culture and lack of an established Safety Management System within Moremi Air Services.
3.3.4 Subjugating and authoritarian management control at Moremi Air Services.
3.3.5 Poor training programme at Moremi Air Services
3.3.6 Issuance of Dispensation to Xaxanaka airfield.
3.3.7 Carrying more passengers than authorised out of Xaxanaka airfield.
3.3.8 Lack of dissemination of critical maintenance information to the operators and AMOs by the engine manufacturer.
3.3.9 Poor supervision and oversight by CAAB to the aircraft operator, aircraft maintenance organisation and airfield certification.
RECOMMENDATIONS
4.1 Pratt and Whitney Canada and Cessna to continue supporting the effort of SERT team to identify the major causes of engine shut down on single-engine aircraft.
4.2 That the aircraft manufacturer and the relevant certification authorities should ensure that the ADAS system is protected against fire damage.
4.3 That the CAAB reinforces its work-force at Maun airport to ensure that the oversight responsibility for aircraft operators and maintenance organisations is carried out diligently.
4.4 The CAAB should ensure that the Management system at Moremi Air Services is overhauled so that there is a clearly defined line of command and that the work environment is conducive for safe operation of aircraft.
4.5 The CAAB should establish a system that will ensure that commercial operators prepare load sheets for every flight sector and a provision for amending them in case of changes in the flight schedules that will affect the loading and destination of the aircraft.
4.6 The CAAB should ensure that aircraft operations at Xaxanaka airfield and other Category C airfields is limited to aircraft of the authorised performance group and it should consider to stop issuing dispensations.
4.7 The CAAB should direct the Wildlife and National Parks management to ensure that the trees at Xaxanaka airfield do not pose danger to aircraft or passengers.
4.8 The CAAB should ensure that the safety culture at MAS is improved through building up of a solid Safety Management System.4. The CAAB should put a requirement for operators to install ELTs that will activate when subjected to longitudinal as well as lateral forces.
4.10 The CAAB should ensure that MAS has a well-established training schedule for their pilots and the records are prepared and kept up to date.
4.11 The CAAB should initiate a research on the presence of sodium compounds on calcrete used on airfield surfaces and its effect on turbine engines.
4.12 The DWNP should look into the possibility of completing the relocation of Xaxanaka airfield if they are not in a position to cut the tall trees surrounding the existing airfield.
How can an air charter company operate when the CEO overrules her operations director and chief pilot on matters of aviation when she is completely ignorant of these matters. She doesn't know the difference between MTOW and MZFW, IAS and CAS, or even an aileron and a flap.
No one in their right mind would fly with this company if they knew the facts. The only business they get is by their sister company Kwando Safaris insisting that their clients fly with them. And, we all know who the CEO of this company is, yes, the very same SS.
Now the facts are out the only way forward for Moremi Air is for their CEO to resign. Otherwise they go down the tubes.
Let us not forget their record:
Moremi Air Accidents
1. A2-DOG Nov 2008 write off
2. A2-AFE 15 Aug 2010 write off
3. A2-PPL Nov 2010 write off
4. A2-KWA 27 Jan 2011 write off
5. A2-AEI Sep 2011 forced landing on road
6. A2-AKD Oct 2011 write off. 9 fatalities
I do not blame the middle management or their pilots there are some really good guys there but it need professional supervision.
Unfortunately Martin (RIP) didn't get out soon enough.
Sue Smart - Do flight safety in Botswana a favour and resign.
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Open Memo to CEO Moremi Air
Dear Madam,
I am pleased to hear that I have your undivided attention through this forum. Letters from your lawyers to the administrators of PPRuNe threatening legal action for defamation due to my posts will not stop me pursuing action against air charter companies who fall short of acceptable flight safety and operational standards.
I am qualified in law and there is no case for defamation where the facts are true. When I have a little more time I will pick out more points from the AKD accident report which criticises your company safety standards, operational procedures and leadership.
For the record, although you know me, I am not a competitor. I am just concerned with flight safety and the future of the tourism industry in Southern Africa.
I am pleased to hear that I have your undivided attention through this forum. Letters from your lawyers to the administrators of PPRuNe threatening legal action for defamation due to my posts will not stop me pursuing action against air charter companies who fall short of acceptable flight safety and operational standards.
I am qualified in law and there is no case for defamation where the facts are true. When I have a little more time I will pick out more points from the AKD accident report which criticises your company safety standards, operational procedures and leadership.
For the record, although you know me, I am not a competitor. I am just concerned with flight safety and the future of the tourism industry in Southern Africa.
Last edited by Capt Livingstone; 9th Aug 2013 at 09:27.
