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AIR ACCIDENT INVESTIGATION
FINAL ACCIDENT REPORT
5Y-BAT
09 April 2012
Table of content
1 List of Abbreviations ...... 1-7
2 Title ...... 2-9
3 Synopsis ...... 11
4 Factual Information ...... 13
4.1 History of flight ...... 13
4.2 Injuries to persons ...... 16
4.3 Damage to Aircraft: ...... 16
4.4 Other Damage ...... 18
4.5 Personnel Information ...... 18
4.5.1 Duty times before the accident: ...... 18
4.6 Aircraft Information ...... 19
4.7 Meteorological information ...... 20
4.8 Aids To Navigation...... 20
4.9 Communication...... 20
4.10 Aerodrome Information...... 20
4.11 Flight Recorders ...... 22
4.12 Wreckage and Impact Information ...... 22
4.13 Medical and Pathological Information ...... 23
4.14 Fire ...... 23
4.15 Survival Aspects ...... 23 4.16 Tests and Research ...... 23
4.17 Organisation and Management Information ...... 24
4.18 Additional Information ...... 24
4.19 Useful or Effective investigation Techniques ...... 24
5 Analysis ...... 25
5.1 Landing System ...... 25
6 Conclusions/Findings ...... 27
7 Probable course ...... 27
8 Safety Recommendations ...... 29
9 Appendix ...... Error! Bookmark not defined.
1-4 List of Figures and Tables
Figures
Figure 1: Nairobi Wilson Airport: HKNW ...... 14
Figure 2: Aircraft wreckage at the accident site: HKNW Runway 07 ...... 15
Figure 3: damaged aircraft at accident site ...... 16
Figure 4: Damaged Propellers and collapsed nose gear ...... 17
Figure 5: collapse and damage nose gear ...... 17
Figure 6: Wilson Airport, Nairobi: HKNW...... 21
Figure 7: Wreckage at the accident site showing ground marking ...... 22
Tables
Table 1: Injuries to Persons ...... 16
Table 2: Pilot Duty times ...... 18
1 List of Abbreviations
KCAA : Kenya Civil Aviation Authority CAVOK CMC CPL : Commercial Pilot License AMO ATC : Air Traffic Controller
AMO Aircraft Maintenance Organization PIC PPL Private Pilot License
SPL Student Pilot License
HKNW Nairobi Wilson Airport VMC
2 Title
Final Accident Report
OPERATOR: CMC Aviation Limited
AIRCRAFT TYPE Piper PA28-181
MANUFACTURER: Piper Aircraft Corporation
YEAR OF MANUFACTURE: 1976
AIRCRAFT REGISTRATION: 5Y-BAT
AIRCRAFT SERIAL NUMBER: 28-7690294
DATE OF REGISTRATION: 26th Nov 2010
TYPE OF ENGINE: One Lycoming (0-360-A4A)
DATE OF OCCURRENCE: 09th Apr 2012
TIME OF OCCURRENCE: 0855
LOCATION OF OCCURRENCE: HKNW runway 07
TYPE OF FLIGHT: Training
NUMBER OF PERSONS ON BOARD: One
INJURIES: Minor
NATURE OF DAMAGE: Substantial
CATEGORY OF OCCURRENCE: Accident
NAME OF PIC: Rebecca Njeri Waweru
PIC‟S FLYING EXPERIENCE: SPL: 35 Hours
Times given in this report are Coordinated Universal Time (UTC) East African Local Time is UTC plus 3 hours
2-10 3 Synopsis
The Chief Inspector of Air Accidents, Air Accident Investigation Department under the Ministry of Transport and Infrastructure, was notified of an accident at Wilson Airport in Nairobi on 09 April 2012, which had occurred on the same day at 0855.
An Air Accident Investigator was dispatched to the site of the accident on the same day to begin investigations into the probable cause of the accident. Investigation was started one (1) hour after the accident.
The aircraft had taken-off from HKNW (Wilson Airport, Nairobi) runway 14 for touch and go circuits on runway 07. The pilot in command (PIC) was a student pilot who had been released on a training flight after her first solo on 05th Apr 2012. She reported an uneventful takeoff on runway 14, and then repositioned for touch and go circuits on runway 07. On the following 3 circuits, she was instructed to go-around by the ATC due to traffic. She requested to do a full-stop landing on the 4th circuit, which she did. After touch down on runway 07, she reported the seat jerked backwards during the landing roll and could not reach the rudder pedals. Subsequently, she lost control of the aircraft and it veered to the left. She tried to realign on the runway but the aircraft veered sharply to the right of the centerline and left the paved runway on to the grass. The aircraft hit obstacles after the excursion causing the nose and port undercarriages to collapse, after which the aircraft came to a stop. Evacuation procedures were reportedly executed. No fire broke-out after the incident. The Pilot sustained minor injuries.
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4 Factual Information 4.1 History of flight
Investigations reveled that the aircraft, a Piper Cherokee PA-28- 182, registration 5Y-BAT and operated by CMC Aviation Ltd, was on a training flight at Wilson Airport HKNW.
The pilot reported to have started her day well, and arrived at the Wilson Airport at 0700. She went for a training briefing with her instructor, after which she went to the aircraft for a preflight check. She did 3 circuits with her instructor after which she was released for solo flying.
After being cleared by the ATC, she took off on runway 14 for circuits on runway 07. She repositioned for touch and go circuits and with the preceding four circuits, she was instructed to go around by the ATC due to scheduled traffic. She requested for a full stop landing on the 4th circuit, which was granted by ATC.
The approach and touchdown were reported as uneventful. However, during the landing roll, she reported to have lost contact with the rudder pedals, which resulted to the aircraft veering to the right and excursing the runway.
The aircraft hit obstacles after the excursion causing the nose gear and the port undercarriages to collapse. She immediately executed evacuation procedures.
13 32
Figure 1: Nairobi Wilson Airport: HKNW
14
Figure 2: Aircraft wreckage at the accident site: HKNW Runway 07
15 4.2 Injuries to persons
Table 1: Injuries to Persons
Injuries Crew Passengers Others Fatal - - - Serious - - - Minor/none 1 -
The pilot sustained minor injuries
4.3 Damage to Aircraft:
The nose and the port undercarriages collapsed, and sustained substantial damage, with the nose wheel strut breaking off. This lead to the resultant propeller strike, and substantial damage to all the propeller blades. And minor damage on the left wing tip. The nose gear strut and assembly also sustained substantial damage, with tyre damage and deflation. The bottom engine cowling also sustained substantial damage.
Figure 3: damaged aircraft at accident site
16
Figure 4: Damaged Propellers and collapsed nose gear
Figure 5: collapse and damage nose gear
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4.4 Other Damage
There was minor damage to the signage and cabling along runway 07.
4.5 Personnel Information
The pilot in command was Ms Rebecca Njeri Waweru, a student pilot with 35 hour experience. She was on a training flight to consolidate hour after her first solo flight. Her flight instructor had released her after he was satisfied in her competence.
There was no mention of prior weaknesses in maintaining runway centerline during her training in her training file.
4.5.1 Duty times before the accident:
Table 2: Pilot Duty times
Last 24 hours: 0.1 hours Last 7 days: 4.0 hours Last 30 days: 13.0 hours
The Airfield has an ATC and operates on as control zone airfield procedures, by Wilson Tower call sign.
18 4.6 Aircraft Information
The aircraft, 5Y-BAT, a Piper Cherokee, PA28-181 is owned by CMC Aviation Ltd was manufactures in 1976, and was registered in Kenya 2010. It was being operated by CMC Flight Training School. It had a valid certificate of airworthiness up to 10th November 2012, and categorized as Commercial Air Transport (Passengers).
The AMO for the aircraft is CMC Aviation located at Wilson Airport.
A check III inspection was carried out in 06 feb 2012, in accordance with maintenance schedule ref WAL/OE6/8 issue 2, with schedule 195-205 involving „check all undercarriage main and nose gear bolts, bushings and bearings for conditions”, “dismantling of nose gear steering mechanism and check for condition” and “reassembly of the undercarriage units” This was followed by a certificate of release to service.
A check I inspection was carried out on 29 Feb 2012 in accordance with approved Maintenance Schedule ref 19/PA28/87/06. The nose gear was removed with inspection of trinnion, bearings renewed, seals changed and gear reinstalled. This was done under job no. 2013/078. This was followed by a release to service certificate signed by appropriately licensed engineer
The last Check 1 inspection had been carried out on 12 Apr 2013 under job no. 2013/168 and afterwards, the aircraft was signed out with a certificate of release to service in accordance with approved maintenance schedule ref 19/PA28/87/06.
19 4.7 Meteorological information
Prevailing meteorological conditions at the time of accident were CAVOK, with calm northeasterly wind.
The flight was during the day, so there was sufficient lighting.
4.8 Aids to Navigation
There are no aids to navigation in the airstrip.
4.9 Communication
The pilot was in two-way communication with the Wilson Tower through out, and no communication failure was reported.
4.10 Aerodrome Information
The airfield has 2 paved runway2, RWY 07/25 Situated at 6520 feet above sea level, the runway length measures 3,600 feet (1,100 m) long and is 56 feet (17 m) wide,
20 32
Figure 6: Wilson Airport, Nairobi: HKNW
21 4.11 Flight Recorders
The Aircraft was not fitted with any flight recorders.
4.12 Wreckage and Impact Information
The aircraft came to rest on the grass, about 10 meters from the runway 07 edge. It was resting at a bearing of 0910 on the grass. The nose gear, port undercarriage had collapsed, with the aircraft resting on the collapsed nose gear assembly and the port wing. The right (starboard) undercarriage was intact and no visible damage had been sustained. There were impact marking trailing from the runway to the resting area of the aircraft. There were no debris at the crash site, and no dislodged parts were found along the impact path of the aircraft. No evidence of fire, fuel or oil spillage was found.
Figure 7: Wreckage at the accident site showing ground marking
22 4.13 Medical and Pathological Information
No injuries were sustained in the crash. No pathological tests were deemed necessary after the accident.
4.14 Fire
There was no post crash fire at the site of accident. No evidence of engine fire was found at the site of accident.
4.15 Survival Aspects
The aircraft is used for commercial passenger transport. At the time of the accident, there was only one crew onboard the aircraft.
Evacuation after the aircraft came to a stop was immediate with no hindrances whatsoever. No search and rescue was needed. No evidence of failures of any structures such as seat belts attachments was found.
4.16 Tests and Research
There was no evidence of mechanical breakdown of the engine, with compression checks done, and the ignition system was found to be intact. The mechanical fuel pump and the electrical fuel pumps were serviceable during after the accident.
23 4.17 Organization and Management Information
The aircraft was operated by CMC aviation Limited for passenger transport. The company operates a flight training school, with a syllabus approved by KCAA.
The aircraft was maintained by CMC aviation, an approved AMO by KCAA, with appropriately Licensed Engineers.
4.18 Additional Information
N/A
4.19 Useful or Effective investigation Techniques
N/A.
24 5 Analysis
5.1 Runway Excursion
During the investigations it was established that the aircraft was operating in accordance with the law.
It was established that the pilot was qualified to fly that particular category of aircraft having done her first solo flight and had undergone flying training instructions for 35 hours.
During the wreckage examination, it was established that the aircraft come to rest on the starboard main gear and the left wing. The nose and the port undercarriages had collapsed after impacting terrain.
Further examination of the left pilot seat revealed no locking mechanism failure, and both rudder pedals were not obstruction and had full motion.
With thorough scrutiny of the private pilot license training curriculum, there is not training on management on high speed taxing.
Further scrutiny of the maintenance records revealed no shortcomings in the maintenance history of the aircraft. No system or structural failures were discovered in the course of the investigation.
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6 Conclusions/Findings
The Pilot was licensed by KCAA holding a student pilot license (SPL) as per regulation 13, of the civil Aviation (Personnel Licensing) Regulation.
The aircraft was certificated and licensed for the operation it was carrying out.
The weather was VMC, and the flight was during the day.
The aircraft was within the specified mass and balance limits.
There was a Runway Excursion due to loss of directional control of the aircraft during the landing roll.
This was a training flight with the student having minimal experience in single crew operational, and holding a student pilot license, with less than 3 hours of single crew operation.
7 Probable cause
Probable cause of the accident was loss of directional control during the landing roll leading to a Runway Excursion.
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8 Safety Recommendations
KAA to cover the Drainage tunnels close to the runway to prevent worsening of any eventual excursions.
29