AIRCRAFT ACCIDENT REPORT
On 29 Nov 2018, Cessna U206D, ZS-DIV, operating as a VFR private flight from Nelspruit to Wonderboom crashed at 1503Z. No flight plan was filed.
- This discussion is to promote safety and not to establish liability.
- The CAA’s report contains padding and repetition, so in the interest of clarity, I have paraphrased extensively.
Aircraft registration: ZS-DIV
Date and time of accident: 29 November 2018, 1503Z
Type of aircraft: Cessna U206D
Type of operation: Private (Part 91)
PIC license type: PPL Validation
License valid: Yes
PIC age: 49
PIC total hours: 175
PIC hours on type 7
Last point of departure: Nelspruit
Next point of intended landing: Wonderboom
Location of accident site: Machadodorp Sappi forestry at 4697ft AMSL
Meteorological information: 90°/4 kts. Temp: 17°C. Dew Point: 11°C. Viz: Overcast. Clouds; 1500 ft AGL
POB: 2+3
People injured: 4
People killed: 1
On-board were two pilots and three passengers. The pilot in the left seat was the pilot-in-command (PIC) and the pilot on the right was the pilot monitoring (PM).
The aircraft owner reported that the aircraft was hired by the PIC as a means of transportation for her and her siblings to scatter the ashes of a cremated family member around Hoedspruit area in Limpopo Province.
The flight to Hoedspruit was uneventful and all went according to plan. The aircraft was then flown to Nelspruit where an uneventful landing was carried out. The aircraft was then refuelled to capacity in preparation for a flight to Wonderboom. The PIC reported that upon completion of the pre-flight inspection, all boarded the aircraft. About 5 minutes later, she started the engine. She allowed the engine to run for a few minutes before taxiing to Runway 22 for departure. The aircraft took off in clear weather conditions.
Approximately 20 to 30 minutes into the flight at 7000 ft clouds developed around the aircraft. The PIC reduced height and the aircraft was unintentionally flown into a valley covered with clouds. The PIC made a 180° turn to stay clear of the clouds, but without success. As she was not instrument rated, she handed over the controls to the PM who had a current instrument rating.
As the aircraft’s height above ground was already low, it impacted the tree tops before crashing onto the ground. The aircraft was destroyed by impact forces and a fuel-fed post impact fire that erupted.
According to the PIC, it was difficult for her to get the left door open as her hands had sustained serious injuries; the PM unbuckled himself and opened the left door, allowing her to vacate, followed by all other occupants. The PM vacated the burning wreckage last and had sustained approximately 99% burn injuries. He succumbed to his injuries two days later.
‘the pilot in command made a 180° turn’
All the occupants walked to a nearby gravel road which was more than a kilometre away.
A private motor vehicle gave them a lift to Nelspruit Hospital.
The aircraft Mass and Balance was within the limits and all maintenance was up to date.
The aircraft was producing substantial power on impact. The nose was high and the flaps were retracted.
The PM was the pilot flying when the accident took place; at no stage did the PM lose control of the aircraft.
Probable cause:
CFIT – Controlled Flight Into Terrain
JIM’S COMMENTS
It seems that the basic cause of the accident was poor planning. They decided to go ahead with a VFR flight despite adverse weather and possibly IMC en-route.
The PIC only earned her PPL at the age of 46. She had a total of 175 hours, and only 7 on type. My gut feeling is that she was pushing the limits of her ability and comfort zone to be flying that sophisticated aircraft, fully loaded, into marginal weather, on a longish cross-country.
This accident releases three of my hobby horses from their stables:
- PPP – Passive People Pressures.
- Divided Responsibility
- Who Has Control?
PPP – Passive People Pressures
These are subtle, indirect forces that often drive pilots to push themselves beyond their comfort zones. In other words, the pilots would not have undertaken a particular flight – or a particular course of action – but for someone else’s expectations.
Sometimes these expectations are not subtle. Remember the new, young commercial pilot who flew an overloaded BN Islander into the Drakensburg mountains with two couples and four young children on board? He did his best to talk the bullying owner out of it but ultimately gave in to this overpowering personality and ended up killing them all.
The same sort of pressures often exist without anyone saying a word. The very fact that your passengers have got out of bed and driven to the airfield shows that they have the expectation of being flown to a family gathering, a funeral, a rugby match, or whatever.
You told them yesterday that you would take them and now they have all arrived you feel you can’t let them down, even though you are not too comfortable about the weather. And you certainly would not make the flight but for their expectations.
I have an unsubstantiated feeling that this pilot found herself in that position.
Some charter companies in the Okavango put their pilots under these pressures – usually because the passengers are too heavy, or have too much baggage. If you refuse to fly them your boss will replace you with a braver pilot before you can say ‘clear prop.’
I believe that these subtle, or overt pressures, are the reason behind the published reason for many light aircraft crashes.
With this accident, I feel she would probably not have undertaken the flight if all people pressures were removed. No passengers, no one waiting at the other end, no one with any expectations.
In addition, I suspect that having an instrument rated pilot in the right-hand seat increased the pressure to go.
‘if I had sat on my hands, it would have been nasty’
Divided Responsibility
This is my second hobby-horse – the horrendous business of divided responsibility – which is made even worse when it’s not formally discussed. With this accident there was obviously no discussion about turning it into an instrument flight. It was a panic decision that seemed to take the instrument pilot by surprise. The sensible thing would have been for the PM to have taken control and filed an IFR plan, in the air, when the dirty weather appeared ahead.
I see divided responsibility daily in flying training when pupils are shunted from one instructor to the next because that makes it easier for the school to do the scheduling and bookings.
Each instructor is unsure how well the pupil has been trained up to this point. So she doesn’t know whether she should revise engine failures after takeoff, and whether to do a couple of go-arounds to make sure the pupil will do the right thing when flying solo. If she revises these exercises unnecessarily, she is wasting the
pupil’s time and money, but she has to be happy that the pupil is competent and safe. Or should she just hope another instructor has covered them properly?
No one is really responsible – and so it was with this accident.
Who Has Control?
This is my third hobby horse and it’s similar to the above. When things go wrong who is going to make the decisions, and who is going to work the levers?
This is dangerous territory, and far too common. I see some flight schools are using newly-minted commercial pilots to go along on cross-countries with less experienced pilots to act as ‘safety pilot’. Who is responsible when there’s an accident?
I recently reported on a firey blaze when a Piper Pacer crashed on takeoff. The commercial pilot, owner, was in the left seat; and a very experienced taildragger PPL was ‘safety pilot’ in the right hand seat. It crashed because the ‘safety pilot’ left it too late to take control.
It happened to me at a private strip a bit south of Perth. My mate, Vernon, wanted me to act as ‘safety pilot’ while he practiced circuits and bumps in a Super Cub he had just converted to. (His first tailwheel.)
‘Approximately 99% burn injuries’
I agreed, on the clear understanding that if I said “I’ve got her” he was to let go of everything.
He got the first landing all crossed up – he bounced and then took half power while heading for the trees at the side. I told him I had control, and sorted it out. But if I had sat on my hands with the rather vague instruction to be a ‘safety pilot’, it would have been nasty.
That’s pretty much what happened in this accident.
Take home stuff:
- People Pressures are easy to deal with. Warn all concerned, the day before, that the flight might not go ahead because of XYZ. This gives the pax time to make contingency plans and it allows you to be comfortable about cancelling, or diverting, or telling them they have too much luggage, or whatever the problem is.
- Divided Responsibility is also easy to deal with by discussing it on the ground, before the flight.
- Who Has Control? Also easy to deal with on the ground before the flight.
- If you hear those terrible words ‘safety pilot’, then before you fly, brief on who does what, and when.
So there’s the pattern. It’s all about planning and dealing with stuff on the ground before you fly.
Pics from the CAA accident report.