MEDIA STATEMENT 2 OCTOBER 2009
STATUS REPORT: INVESTIGATION INTO THE CAUSE OF AN ACCIDENT INVOLVING
A JETSTREAM 41 AIRCRAFT SHORTLY AFTER TAKE OFF FROM DURBAN
INTERNATIONAL AIRPORT ON 24 SEPTEMBER 2009
The objective of an accident investigation is to establish the cause (s) of the accident and
to take steps to prevent a further occurrence. As such the objective is not to apportion
blame or liability.
The purpose of this investigation is therefore to ensure that the investigation is conducted
in the most effective and comprehensive way to establish the cause(s). The investigation
team is committed to adhering to the International Provisions defined in Annex 13 to the
Convention on International Civil Aviation, of which South Africa is a signatory.
To date no evidence has been identified that requires the Commissioner for Civil Aviation
(CCA) to implement any action, such as the prohibition of further flight by Jetstream
aircraft, nor to suspend any approvals granted to the operator.
Passengers can continue to make use of South African operators with confidence in that
their safety is being overseen to the best of its ability by the South African Civil Aviation
Authority (SACAA).
The process followed to date and in future is in compliance with internationally accepted
practices. On arrival at the accident scene, the team of accident investigators, commenced
with the onsite investigation which included the photographing and video-taping of the
accident site and wreckage. It should be noted that the first priority following an accident is
to render assistance to injured parties. The investigators will await completion of this
process prior to taking control of the accident site, so as not to interfere with any rescue
operation.
Following completion of the initial assessment and documenting of the accident site, a
decision was made to remove the wreckage to a hangar at Johannesburg, where a more
detailed investigation and strip down of selected components could be made. This had
been done with the support and cooperation of the operator.
SA Civil Aviation Authority
Private Bag X73
Halfway House
1685
Tel: (011) 545 1000
Fax: (011) 545 1201
Website:
CAA Website
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The South African investigation team has since been joined by an Accredited
Representative (AR) from the Air Accident Investigation Branch (AAIB) of the United
Kingdom, who is being assisted by Advisors from the AIIB and the aircraft manufacturer.
The National Transportation Board (NTSB) of the United States of America (USA) has
nominated a non-travelling AR, but with an Advisor from the engine manufacturer on site.
Actions taken to date include:
· The aircraft wreckage is being examined in detail for defects and to exclude factors
that are not relevant to the cause of the accident;
· The Cockpit Voice Recorder (CVR) and Digital Flight Data Recorder (DFDR) have
been hand carried to the AAIB facilities in the UK and data has been successfully
downloaded. Both recorders were fully functional and data retrieved is of good
quality;
· The Air Traffic Control recordings have been obtained and are being transcribed
and analyzed;
· The engines have been removed from the airframe and will be shipped to the
manufacturer in the USA where they will be stripped down in the presence and
under supervision of the Investigators, accredited representatives, advisors and
observers from the operator;
· Compilation and review of relevant records in respect of the aircraft maintenance,
operational and crew records is ongoing.
Factual information obtained to date can be summarised as follows:
· Aircraft design and certification requirements for a multiple-engine aircraft are that it
should be able to continue take-off once passing the decision speed, climb, fly en
route and continue to a landing, should one engine become inoperative. This is
demonstrated during the aircraft certification process at maximum take-off mass.
· The Jetstream 41 aircraft requires an operating crew of two pilots and meets all of
the required certification criteria for a twin-engined turboprop aircraft, even at its
maximum certificated mass.
· It is a requirement that pilots be trained and competent to take-off, fly, and land such
aircraft with one engine inoperative. Pilots are required to maintain competency and
are assessed a minimum of every six months to ensure that such competency is
maintained.
· Operators define standard operating procedures (SOPs) which pilots are to follow
during the various emergencies that may occur. Such competency is again verified
during an actual flight test or in a simulator.
· Smoke was observed to originate from the no. 2 or right-hand engine during the
take-off roll and ATC advised the crew accordingly. This was only transmitted to the
pilot during take-off rotation, thus excluding the possibility of rejecting the take-off.
Duration of the take-off roll was about 18 seconds.
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· The no.2 or right-hand engine failed on rotation and a power reduction occurred on
the no. 1 engine as the aircraft climbed to about 450 ft. above sea level.
· The aircraft was seen to climb and thereafter descend and impact terrain. (Total
time from start of the take-off roll until impact was about 50 seconds);
· Rescue and fire-fighting services responded appropriately;
· The three crew members on board received injuries to various degrees of severity
and a member of the public was also injured at the accident site;
· Investigators have as yet to interview the crew members and the bystander, due to
their medical conditions.
With reference to the above factual information, the aircraft’s mass was such that it should
have been able to have continued to climb and return to land on one engine. It is therefore
necessary to address the following factors that may shed further light as to the cause of the
accident:
· The reason for the power reduction experienced on the no.1 engine, which will
include continued analysis of the DFDR and CVR information;
· Analysis of any human factor aspects, such as whether the power reduction on
engine No. 1 resulted from an incorrect identification of the failed engine, or a
decision to land the aircraft as soon as possible, or other factors unknown at this
time, that necessitated a deviation from standard operating procedures to continue
the flight on one engine;
· Verification that the no.1 engine had in fact been serviceable throughout the flight by
means of a strip-down examination;
· Strip-down of the no 2. engine to establish the cause of this engine’s failure.
The investigation will be ongoing with participation by the accredited parties.
The Aircraft Accident and Incident Investigation Division (AIID) of the South African Civil
Aviation Authority (SACAA) wishes to acknowledge and thank the above participants and
the operator for their assistance and services rendered to date.
It is trusted that the investigation will lead to the introduction of corrective actions, should
any deficiencies be identified, to ensure the continued safety of passengers transported in
South African airspace and on South African aircraft.
-ENDSAbout
the SACAA:
The South African Civil Aviation Authority (SACAA) was established on 1 October 1998 following
the enactment of the South African Civil Aviation Authority Act, No.40, in September of the same
year. The SACAA promotes and maintains a safe, secure and sustainable civil aviation
environment, by regulating and overseeing the functioning and development of the industry in an
efficient, cost-effective, and customer-friendly manner according to international standards.