CAA Statement - ZS -OJY
Mr. P. J. Du Plessis, the Magistrate presiding over the Judicial Inquest into the deaths caused by the fatal aircraft accident near Rand Airport on 6 December 1999, in which 10 lives were lost, released his findings and recommendations yesterday. The Judicial Inquest was conducted over sixteen days during April 2002.
The CAA welcomed and cooperated fully with the inquest proceedings and hoped that this process would assist in closing this tragic event, particularly for the families of the victims of the crash.
The crashed aircraft operated by Flightline Charters had taken off from Rand Airport on a commercial charter flight to Orangemund in Namibia, when shortly after taking off, the pilot reported an emergency to the control tower and requested clearance to return to the airport to land. The aircraft crashed about two minutes after take off and everybody on board lost their lives.
The investigation into the accident, conducted by the CAA, revealed that the probable cause of the accident was the failure of a critical exhaust pipe segment, which in turn caused the right-hand engine to lose power/fail. It is was also found that the aircraft exceeded it's designed load limit.
This overloaded condition of the aircraft was thus a highly significant contributory factor to the accident. The company’s lack of flight operations management experience, professional flight standards supervision and an operational safety management program were regarded as significant contributing factors.
The anomalies noted in regulatory oversight of the operator (airworthiness and flight operations surveillance by the former Chief Directorate:CAA in the Department of Transport and CAA are regarded as possible contributing factors.
According to the Commissioner for Civil Aviation, Mr. Trevor Abrahams "this was a landmark accident investigation for the Civil Aviation Authority as it represents a whole new approach to investigating accidents through a detailed investigation not only of the immediate circumstances and conditions surrounding the accident, but also a close look at the chain of actions and inactions by all connected parties that could be identified as possibly contributing to the tragic event.
A total of 17 safety recommendations arose out of the investigation. Fifteen of these were directed at the Civil Aviation Authority for implementation. The other two were each directed at the pilot community and at commercial charter operators.
Inquest findings highlighted the following aspects surrounding the accident.
The aircraft sustained a power loss in the right hand engine shortly after take off and that the pilot flew the aircraft in accordance with the pilot’s operating handbook.
The aircraft was certified to fly on one engine but that the overweight condition resulted in the subsequent crash.
The magistrate also found that the accident investigation conducted by the CAA was extensive and that the overweight of the aircraft was substantially under reported in the accident report and that the actual weight of the aircraft was substantially more than the certified maximum take off weight limit of the aircraft.
The magistrate also found that the operator’s practices in loading the aircraft was at variance with the approved operators manual of Flight Line Charter Services in that the baggage was not weighed nor was the required weight and balance calculated for the accident flight.
The magistrate emphasized that once the CAA approved an Operations Manual, the operators had a responsibility to ensure compliance with that approved Operations Manual.
The operator was found to have deviated significantly from the CAA approved Operators Manual in terms of the critical issue of weight and balance of their aircraft. Specifically, the accident flight was loaded to capacity and the General Manager should have ensured proper weighing of the cargo and passengers on the 6th of December 1999.
The magistrate also found that the CEO of Flightline Charter Services C.C. had erroneously amended the Pilots Operating Handbook, thereby giving the pilot an incorrect basis for calculating the maximum take off mass of the aircraft.
The magistrate’s recommendations included:
1. That the CAA consider disciplinary steps against officers who accepted the patently incorrect information submitted on the test flight report submitted to the CAA. The magistrate also ruled that the remoteness of this action ruled out any prosecution involving the CAA.
2. That the maintenance organization (AMO), PLACO’s failure to notify the CAA when the Mandatory Periodic Inspections were late or over flown, was a serious indictment of the AMO. The magistrate also found PLACO’s conduct as the seller and registration AMO as warranting severe criticism but that the remoteness to the actual accident ruled out prosecution.
3. That the manner of loading of the accident flight resulted in a clear case of negligence on the part of the operator and Mr. Declan McEneany, in his personal capacity, in respect of each passenger.
4. That Miles van der Molen, in his personal capacity and as CEO of Flightline Charter Services C.C. was negligent in relation to the death of the 9 passengers and the pilot for having erroneously altering the pilot’s Operating Handbook.
The CAA will study the findings and recommendations of this inquest and identify which steps we need to take to enhance aviation safety in South Africa.
Notwithstanding the tragic events on the 6th of December 1999, air transport remains the safest mode of travel.
The CAA has taken a number of steps in the wake of this accident, including the implementation of the accident report’s safety recommendations, to ensure continuing improvement in the level of safety in our aviation industry.
In some cases, the CAA does encounter operators who refuse to comply with the minimum safety requirements and ultimately have to take action to deprive them of their licence to operate, as was done with Flightline Charters in 2000.
The CAA will continue to work with industry to enhance our aviation safety standards but will also take decisive action to close operators who refuse to comply with aviation safety regulations.