Air Accident Investigation
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MINISTRY OF TRANSPORT AND INFRASTRUCTURE Telegrams: “TRANSCOMS”. Nairobi TRANSCOM BUILDING Telephone: (020) 2729200 NGONG ROAD Email: [email protected] P.O. Box 52592 - 00100 Website: vvv www.transport.go.ke MMMMMMM NAIROBI 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. 11 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 17 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