INTERIM REPORT IN RESPECT OF THE INVESTIGATION INTO THE CAUSE(S) OF AN ACCIDENT INVOLVING A PIPER PA-28-180 AIRCRAFT, ZS-KIN AND

A JABIRU SK AIRCRAFT, ZU-BXA AT WONDERBOOM AIRPORT ON 26 OCTOBER 2010.

The objective of an accident investigation is to establish the cause (s) of the accident and to take steps to prevent a further occurrence. As such the objective is not to apportion blame or liability. The purpose of this investigation is therefore to ensure that the investigation is conducted in the most effective and comprehensive way to establish the cause(s). The investigation team is committed to adhering to the International Provisions defined in Annex 13 to the Convention on International Civil Aviation, of which South Africa is a signatory. The process followed to date is in compliance with internationally accepted practices. On arrival at the incident scene, the team of accident investigators commenced with the on-site investigation. Following completion of the initial assessment and documenting of the accident site, a decision was made to remove the aircraft to an SACAA approved maintenance facility at Wonderboom Airport, where a more detailed investigation was carried out.

Issued by the AIID

SACAA

22 November 2010

Contents Page 1. Background 2. Actions taken to date 3. Factual information obtained to date 4. Injuries to Persons 5. Damage to Aircraft 6. Aircraft Information 7. Aerodrome Information 8. Flight Recorders 9. Survival Aspects 10. Tests and Research 11. Organizational and Management Information 12. Probable Cause(s) 13. Interim Safety Recommendations 14. Participation in the Investigation 3 4 4 5 6 6 7 7 7 7 8 8 8 9

1.

Background
On the afternoon of Tuesday 26 October 2010, a Piper PA-28-180, ZS-KIN, (a low wing type aircraft) was flown by a student pilot on his second solo flight. The student was authorized to carry out a solo circuit and landing at Wonderboom aerodrome (FAWB). At the same time, a Jabiru SK, (a high wing type aircraft), ZU-BXA, flown by an instructor and a student on a Private Pilot revalidation check flight, was inbound from Kitty Hawk aerodrome for a touch-and-go landing at FAWB. ZU-BXA was cleared by Wonderboom air traffic control (ATC) for a long final approach on Runway 29 to do a touch-and-go landing while ZS-KIN was cleared to follow ZUBXA and continue his approach as number two (2) for landing on Runway 29 at FAWB. ZU-BXA was then cleared by Wonderboom ATC for the touch-and-go on Runway 29 and a right-hand departure after the touch-and-go. ZS-KIN was then asked by Wonderboom ATC to confirm that he was still maintaining behind ZU-BXA. ZS-KIN replied by reporting that he was on final approach, Runway 29. After consultation with the instructor of the student pilot piloting ZS-KIN, who was in the control tower at that time, a decision was made to instruct him to carry out a go-around. The ATC then called the student pilot of ZS-KIN three times before he answered. The go-around instruction was given to him, which he then acknowledged. Eighteen (18) seconds after acknowledgement of the go-around instruction, the ATC called ZS-KIN again and advised him to commence the early right-hand turn when ready, as the Jabiru was going back to the circuit. At this stage there was an unclear acknowledgement from ZS-KIN and eight (8) seconds after this acknowledgement ZS-KIN and ZU-BXA collided in mid-air approximately 10 meters above Runway 29 at FAWB. Both aircraft then crashed onto the runway before both skidded off to the left of Runway 29. The occupants of both aircraft were able to evacuate their respective aircraft before the emergency services arrived on the scene. The aerodrome fire and rescue personnel were on the scene within minutes and removed the pilots away from the scene to the tri-age that was a safe distance from the accident scene. Two of the pilots were later evacuated by Netcare 911 to the Montana Private hospital and the remaining pilot was taken to the Steve Biko Academic Hospital. The accident occurred during daylight conditions at a geographical position determined to be South 253912 East 0281322 at an elevation of approximately 4125 feet above mean sea level (AMSL). Whilst air traffic control is provided at FAWB, it remains a see and be seen separation criteria in the circuit for pilots when flying under visual flight rules conditions. However, in a low wing, high wing situation, it is extremely difficult for pilots to see one another. This has resulted in many similar collisions occurring globally.

2.

Actions taken to date include: Both aircraft were examined in detail for defects and to exclude factors that are not
relevant to the cause of the incident. The air traffic control recordings have been impounded and a transcription has been finalized. Relevant records in respect of the aircrafts maintenance, operation and crew are being compiled and reviewed. Interviews have been conducted with the student pilot flying ZS-KIN, the instructor and chief flying instructor (CFI) of this student and with the air traffic controller (ATC) that was on duty at the time of the accident.

3.

Factual information obtained to date can be summarized as follows: The Piper PA-28-180, ZS-KIN was flown by a student pilot on his second solo flight;
The Jabiru, ZU-BXA was flown by an instructor (PIC) and a private pilot as the student doing his revalidation check-flight; Maintenance records revealed that both aircraft were properly maintained and were airworthy at the time of the accident; All pilots and the air traffic controller were appropriately licenced and rated; Rescue and fire-fighting services responded appropriately; Due to injuries sustained and availability, investigators have as yet to interview the pilots of ZU-BXA; Both aircrafts mass and balance were within the prescribed limits: The Aviation Training Organisation responsible for the training of the student flying ZS-KIN restricted him to flying solo only when there were a maximum of three (3) aircraft on frequency at Wonderboom tower. During the circuit with an instructor prior to the student sent for his solo circuit exercise, there were five (5) aircraft on frequency; At the time of the accident, the traffic mix in the circuit was complex due to different operations being executed within the airspace within a compressed time frame that ranged from ON AERODROME simulated engine failures, glide approaches and compass swings to OFF AERODROME NON VISIBLE traffic routings such as over flights, aircraft entering/exiting airspace boundary and survey-type flights operating in the airspace boundary; Some frequency congestion was alleviated by local pilots that were able to anticipate their next instruction and included it in their transmission;

 The air traffic controller was at a high level of alertness as a result of the traffic load and subsequent task load and therefore his speech rate was considered high and his instructions were short and concise; Following the accident the ATC had to instruct another aircraft to go-around which was carried out without any incident.

4.
4.1

Injuries to Persons:
The instructor on board ZU-BXA sustained serious injuries while the other two pilots sustained minor injuries during the accident.

5.

Damage to aircraft

5.1 Both aircraft were destroyed during the accident.

Wreckage of aircraft as on the next morning.

5.1

Other Damage:

5.1.1 Minor damage was caused to the runway surface and one runway light was damaged when the aircraft skidded off the runway. 6. 6.1 Aircraft Information Piper PA-28-180 (ZS-KIN)

6.1.1 Airframe Type: Serial Number: Manufacturer: Year of Manufacture: 6.1.2 Engine Type: Lycoming 0-360-A3A PA-28-180 28-2981 Piper Aircraft Corporation 1965

6.2

Jabiru SK (ZU-BXA)

6.2.1 Airframe Type: Serial Number: Manufacturer: Year of manufacture: 6.2.2 Engine Type:

Jabiru SK 231 Shadow Lite CC 1999

Jabiru 22A
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7.

Aerodrome Information: Aerodrome Location Aerodrome Co-ordinates Aerodrome Elevation Runway Designations Runway Dimensions Runway Used Runway Slope Runway Surface Approach Facilities Aerodrome Status 6 nm North of Pretoria South 253919 East 0281317 4095 feet 11/29 02/20 1828 x 30m 1280 x 22m 29 Down slope Asphalt NDB, Runway lights, PAPIs Licensed

8.

Flight Recorders: Neither ZS-KIN nor ZU-BXA was fitted with a Cockpit Voice Recorder (CVR) or a Flight Data Recorder (FDR) and neither was required by regulations to be fitted to these types of aircraft.

9.

Survival Aspects:

9.1 The accident was survivable as no damage was caused to the structure of the cockpit areas of both aircraft and the pilots of both aircraft were wearing their safety harnesses, which did not fail during the accident. 9. 2 This type of accident involving low wing and high wing type aircraft in a circuit is not unique and does occur globally. Refer photos below:

10. Tests and Research: 10.1 No test and research had been done at the time when this report was compiled; the investigator is still in the process of collecting information.
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11. Organisational and Management Information: 11.1 The aircraft involved in this accident were operated by different Aviation Training Organisations (ATO). Both these training organisations were in possession of a valid Air Training Organisation Certificate issued by the South African Civil Aviation Authority. 12. Probable cause(s) To establish the probable cause(s) for this mid-air collision, the following still needs to be undertaken: Whether the crew of both aircraft had followed the correct standard operating procedures; Whether the students of both aircraft were properly trained to execute the instructions given to them by the ATC; Whether both students were proficient in speaking, writing and understanding the English language; Whether both students were receiving adequate training in radio procedures; Whether the sun had an influence on the visibility at the time of the accident.

13. Interim Safety Recommendations The Director of Civil Aviation should: a. Require the Air Traffic Services Department of the SACAA to review the need for the provision of additional ATC aids such as radar and ground monitoring services on a dedicated frequency. These services could reduce the work load on the controller which will allow him/her more time for controlling aircraft in the control zone. Require the Testing and Standards Department of the SACAA to verify that correct and sufficient training is provided to all students so as to ensure they are aware that they are responsible for their own separation when flying VFR conditions in Class C controlled airspace. Require the Air Traffic Services Department of the SACAA to appoint a special investigation team to investigate all ATC related incidents at FAWB with the aim to improve the safety conditions.
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b.

c.

d.

Require the Testing and Standards Department of the SACAA to investigate the possibility of introducing a language proficiency test before the issuing of a student pilots license.

14. Participation in the Investigation Participation of the Air Safety Infrastructure Division and the Testing and Standards Department of the SACAA in the investigation are acknowledged with thanks.

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