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.
That is from the Ngami Times last week. It is straight from the accident report. I can confirm that they are direct quotes.
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.