NOTE: THIS REPORT IS TO PROMOTE AVIATION SAFETY AND NOT TO ESTABLISH LEGAL LIABILITY.

ACCIDENT REPORT:

Aircraft Registration: ZS-SPI

Date of Accident: 09 Nov 2012

Time of Accident: 8.59 pm

Type of Aircraft: Cessna 172R

Pilot-in-command: a 24 year old Nigerian national with a valid PPL and night rating.

Total flying: 194 hours

On type: 158 hours

Last Point of departure: Wonderboom (FAWB)

Final place of intended landing: Wonderboom (FAWB)

Accident site: On a mountain at GPS coordinates (S 24° 07 6.76 E 029° 13 7.58) at 5 940 feet AMSL.

Persons on board: 1+1

Persons killed: 1+1

Unless stated otherwise all times are local (Bravo time)

The CAA’s 30 page report contains a large amount of padding, repetition, poor English and incompetence. Here’s an example of the latter: The estimated flight time was three hours, ten minutes {(0310) (at flight level 075 feet above mean sea level) (AMSL)}. So, in the interest of clarity and readability, I have had to correct and paraphrase extensively.

Jim Davis

METEOROLOGICAL INFORMATION:

Satellite image. The satellite image indicated overcast low-level cloud in the area. And the 21:00Z SIGWX chart forecast scattered low-level cloud base of 1,000ft, poor visibility and moderate low-level turbulence in the area of the accident. Observed weather Polokwane Airport 18:00Z METAR indicated overcast low-level cloud at 2000ft, good visibility and light north easterly winds. 1900Z & 2000Z AUTO METARs indicated that the dew-point depression decreased by a degree from 18:00Z to 2°C i.e. possible indication of 500ft to 1000ft cloud base drop close to the time of the accident.

SYNOPSIS:

At 7.58 pm the pilot and a passenger departed Wonderboom on a private VFR flight to build night hours. According to ATC, takeoff and climb out from Wonderboom appeared to be normal. There was no further communication between the pilot and ATC.

The aircraft did not return to Wonderboom as planned. The flight plan was direct to Warmbaths, then direct to Nylstroom, then direct to Polokwane where he would do a touch and go, and then return to Wonderboom.

The following day the aircraft was found tohave hit a mountain 21 nautical miles south of Polokwane. The aircraft was destroyed on impact and the occupants were pronounced dead on the scene.

The navigation log recovered from the wreckage.

ADDITIONAL INFORMATION:

When the aircraft departed Wonderboom the school was hosting a year-end function. The flight school indicated that a designated flight instructor had checked the pilot’s flight planning prior to departure and found it satisfactory.

The local QNH at FAPP was 1018 hpa. However the altimeter at the accident site was set on 1013 hpa.

According to radar, the accident occurred an hour after departure at 8.59 pm. Search and Rescue was started when the pilot failed to cancel his SAR. The police and emergency medical services (EMS) were notified. The following morning at 10.15 the search mission was started by a police helicopter. However it was called off due to poor weather.

The planned route – but it was not actually flown.

At 11.25 the search recommenced and the aircraft was found on the side of a mountain.

A farm worker told the investigators he had seen a small single engine aircraft with flashing navigation lights routing in a south westerly direction. Then he heard a loud explosion.

ATC at Polokwane said the pilot phoned approximately 1.5 hours before departure enquiring if the runway lights would be on. The controller confirmed the lights are on permanently. He also advised the pilot that the weather was not good. He recommended that the pilot reconsider his flight into FAPP. The pilot phoned again just before the ATC’s shift ended at 8 pm. He asked for an update of the weather at FAPP, which was still VMC but overcast at 2000 feet with visibility of 8000 metres. The next morning when the tower reopened, they received a call from FAWB tower asking if ZS-SPI was parked there. The answer was negative.

Radar images show deviations from the intended flight plan. The pilot routed directly to Polokwane from Warmbaths, instead of going via Nylstroom. It is not known if the diversion was planned prior to departure.

The aircraft completed a left hand orbit immediately prior to the accident. It then headed directly into the mountain. Prior to impact it was descending and its groundspeed varied between 120 and 150kts.  

During on site investigation, the team could smell fuel, but it was not possible to determine the position of the fuel selector.

All the seats were still secured to their anchors inside the wreckage and both occupants seat belts snapped.

Basic errors – despite being below the transition
altitude the 1013 QNE was still set on the altimeter.

ANALYSIS:

The pilot was a commercial student at an ATO and was completing training towards his Instrument rating for his Commercial Pilot’s License. He had completed seventeen hours of dual instrument simulator training prior to the accident.

His progress reports stated that he was inconsistent. His instructor said that he was eager to complete his training and return to his home country, however he was not utilising his time to prepare sufficiently for his simulator lessons.

The flight level planned for the flight was 075. This would have given minimal terrain clearance. The minimum safe altitude for an IFR flight was 9000ft. So flight level 095 would have been required, but this would have placed the aircraft in cloud. As it was a VFR flight the pilot opted for flight-level 075.

The pilot’s navigation log and map were recovered at the accident site. The navigation log did not contain any en-route checkpoints and there were no tracks drawn on the map.

JIM’S COMMENTS:

There is so much wrong here that it is hard to know where to start. Unfortunately this accident is representative of the low standard of training at some of the flight schools that are cashing in on the foreign student market.

Let’s try to figure out what was going on.

The fact that the student was in a hurry to finish his training and return home, patently influenced his decision to fly that night.

There is always GO pressure once you have driven out to the airfield. You don’t want to waste the drive or disappoint your pax. And the same pressure is present to continue the flight into deteriorating weather conditions.

The weather would have been marginal for a day flight. To me it was little short of criminal stupidity to fly into low cloud on a completely black night. I have checked and there was no moon that night.

During the day you can make weather related decisions enroute. At night his is often not possible – you are likely to fly into cloud before you see it. Also, updated weather reports from ATC are often not available as many airfields close for the night.

A night rating earned while flying around a city simply does not prepare a pilot for flying elsewhere. While instructing at Rundu one of my pupils decided that my requirements for getting a night rating were excessive so he did his night training in Johannesburg with a ‘friend’. One evening about a week later I was called out from dinner to identify the charred bodies of himself, his wife and a friend. He had lost control of the aircraft almost immediately after takeoff on a black night.

‘ATC advised the pilot that the weather was not good’

There was no flight planning. The flight log was not used and no tracks were drawn on his 1:1,000,000 chart found in the wreckage. I have just drawn his track on a WAC chart and the mountain that he hit is clearly marked with is a spot-height of 6770’. This means he had started descending from flight level 075, without knowing, or setting the QNH, before he had his destination in sight.

It’s quite spooky to be doing his flight planning for him, with lines on paper maps, nearly ten years after he and his instructor should have done it.

The student obviously intended using his phone/ GPS instead of navigating properly. I discussed this problem with my friend Wally Waldeck who owns FTC in George. He said he had to allow pupils to take their phones on all cross-countries, day or night, in case they had to divert or do precautionary landing, or any other problem. He now plans to put their phones in a sealed envelopes before departure.

This pilot’s diversion was unplanned and he did not inform ATC. This was very foolish because SAR teams will look for you where you are supposed to be – not where you have decided to go.

If the report is correct, the pilot would not qualify for a night rating because all his 17 hours of instrument flying had been in a simulator. The Regs call for at least five hours IF in an aircraft.

I believe the pilot’s simulator time very likely gave him a false confidence that he could handle flying into cloud at night.

The instructor who is reported to have signed him out was possibly distracted by the company’s end-of-year function. I can’t believe that he personally checked on the weather and the flight planning, and then signed his approval for the flight to proceed. There is no written evidence that this actually happened.

‘criminal stupidity to fly into low cloud on a black night’

To me that the flight was also illegal because night VFR requires that the flight be flown with visual reference to identifiable objects on the surface. It was established in court, following another fatal night VFR flight, that lights on the ground do not constitute identifiable objects. At my own flying school I made a rule that there must be half a moon, or more, visible for the duration of the flight. Many other schools use the same rule. But it is not the law.

Had the pilot planned the flight properly he could have routed along the N1 highway, which would have given him a reliable navigation feature with its four well-lit toll-gates.

So near the top – but unseeable on a dark night.

I believe that the school, and the instructor, have a moral responsibility to wait for the student’s return from any cross-country – but particularly a night one. I am appalled that this apparently did not happen.

This leads us into muddy waters. Legally there is no requirement for this if a correctly licensed and rated pilot hires an aircraft. However, does the fact that the student is on a full-time, specific course mean that the school has a moral duty of care? I would say so. But, does this mean that they do not have the same responsibility for a walk-in hirer. This is one for the law courts to sort out.

The 360 on the radar track, moments before he flew into the mountain was either the start of a classic graveyard spiral, or maybe the pilot spotted lights through a gap in the cloud and was trying to orientate himself.

The report correctly notes that strobes and rotating beacons should be turned off at night or in haze as they tend to increase the chance of suffering from vertigo and disorientation.

The report says that post-mortem and blood toxicology reports were still outstanding at the time of compiling this report. I believe this to be nonsense because every single accident report I have seen says exactly the same thing. It seems likely that the accident investigators simply can’t be bothered. This is disgraceful, it means that we will never know whether alcohol or drugs were involved – in this or any other accident.

‘simulator time gave him a false confidence’

The student’s file notes that his progress was ‘inconsistent’. This is one of the known warning signs that drugs may be involved. This may seem harsh, but I have asked around the flying schools who take it upon themselves to conduct random drug tests, and it seems that on average, between 10% and 20% of students tested were indeed on marijuana. The CAA’s failure to take toxicology reporting seriously is to be deplored. If the government labs can’t handle them, then they should be contracted out to private enterprise in the same way that private AMOs are detailed to investigate possible mechanical failures.

The aircraft hit a mountain that was almost on track, 2000’ above airfield elevation, and only 21 miles from the airfield. This tells me that the pilot did not know where he was due to poor navigation and/or poor flight planning.

The school must have been aware of this hazard and seemingly failed to brief the student properly.

The report recommended that ATOs should be made to implement monitoring programmes for students doing commercial pilot training. This should prevent pilots with little experience from making poor decisions that may be influenced by circumstances such as time and financial constraints. This excellent recommendation has not been acted upon in ten years.

And while I am hammering the CAA – the 30 page report is undated and unsigned. I have no idea when it came out.

The last moments of the flight showing the 360 turn and then the attempted turn back in the dark.

TAKE HOME POINTS:

  • Never fly when you are in a hurry or under pressure.
  • You often can’t see bad weather at night so it’s critical to make weather decisions on the ground.
  • Night flying should be with a visible horizon and at least half a moon.
  • You must be able to navigate using ‘identifiable’ objects on the ground.
  • A night rating earned in city lighting is likely to kill you.
  • Flight logs and lines on maps are primary navigation tools. GPS may be used as a backup.
  • If you divert – tell someone, otherwise SAR is meaningless.
  • The bit of instrument flying that you need for a night rating does not qualify you to fly in cloud or on a black night.
  • Instructors – be very aware of your responsibilities when signing pupils out – particularly at night. I know an instructor who killed three pupils before CAA finally shut him down.
  • Instructors – be on the lookout for signs of drug or alcohol abuse in pupils.
  • Flight planning is important during the day and critical at night.
  • If strobes and beacons are distracting – switch them off.

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