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The SA Civil Aviation Authority has released a report that strongly suggests that the pilot was at fault in the events leading to the fatal crash, but some experts are convinced that the ageing aircraft may have malfunctioned
Officials at the SA Civil Aviation Authority (Sacaa) identified the continued use of a small passenger plane as posing an increased safety risk two days before the Cessna Citation crashed, killing three crew members.
But a preliminary investigation into the crash, conducted by Sacaa, suggests that the crash on January 23 was caused by human error.
In a memorandum presented at Sacaa’s audit and risk committee meeting on January 21, which City Press has seen, it was identified that the use of the 34-year-old aircraft posed “increased safety risk, brought about by the unpredictability of some of the ageing components of the aircraft”.
Further, the document identified the following as risks associated with the continued used of the aircraft:
- Parts not readily available owing to the age of the aircraft;
- Inability to continue providing current services;
- Abnormally high maintenance costs which place Sacaa under financial pressure; and
- Reputational harm to Sacaa caused by poor service delivery.
HUMAN OR TECHNICAL ERROR?
The preliminary report, released this week by the authority’s accident and incident investigation unit, reveals that the aircraft lost an attitude of 1 500 feet (457.2m) in nine seconds, before crashing three seconds later.
Aviation experts this week interpreted the Sacaa report in varying ways.
Some claimed that the report suggested that the crash was the result of human error, while others believed that it was owing to a technical fault.
One pilot, who didn’t want to be named, said: “My feeling, based on the preliminary report, is that there was loss of control from the crew. Someone screwed up. I think they went into a cloud and didn’t see the mountain. But the thing is that it would appear that there was lack of procedure as they shouldn’t have been where they were in the first place. They should have been at least another 500 feet above where they were.”
Owing to the fact that the investigation was carried out by the authority’s accident and incident investigation division (AIID), which reports directly to Sacaa chief executive officer (CEO) Poppy Khoza, the experienced pilot, who has been in aviation for 24 years, said he didn’t trust the report.
“It’s like me writing an exam and marking my own script. It’s like me investigating myself for corruption. Do you think I will find myself guilty? Not a chance!”
Aviation expert Guy Leitch said, based on the preliminary report, it was highly unlikely that the accident would have been a result of a technical error.
“The report strongly suggests that it was pilot error. The aircraft entered the cloud, and data from the flight recorder shows that the pilot knew that he was flying in a dangerous zone. He probably knew that he was flying below the minimum safe altitude,” said Leitch.
He was referring to the term used in aviation to describe the lowest altitude at which pilots can fly before it becomes dangerous, owing to terrain and obstacles such as mountains.
“The key issue is that the weather was bad and the aircraft was not supposed to enter the cloud.”
Another pilot, who also didn’t want to be named, said both human and technical errors could not be ruled out.
“It is difficult to tell, but there are too many questions. The preliminary report claims that the pilot turned right and was flying low. But these people have flown there before, several times. They knew there was a mountain there. Why would they have turned right while flying low?”
What complicates the matter, said the pilot, who runs a charter business, is the fact that the investigation was conducted by the AIID, which reports directly to Khoza.
“[Sacaa] is both the regulator and the operator here; it operated the crashed aircraft through the flight inspection unit (FIU). Khoza is also the chief executive of the FIU, which also reports to her. Since [Sacaa] is both the regulator and an operator, it is implicated here. As such, it will definitely want to cover itself. And what better way to cover up than to say it was a human error?”
The aircraft that crashed had been involved in many incidents and its airworthiness was therefore in question, the businessperson said.
City Press had also established that Sacaa’s ISO 9000 certificate was withdrawn following the crash.
A Sacca aircraft crash investigator, who spoke to City Press on condition of anonymity, said part of the challenge encountered by investigators was that there were no records.
“Part of the investigation was to review and analyse records of the aircraft’s history, including audit inspections conducted, issuance of an air worthiness certificates and maintenance. However, many of the records are missing owing to poor record-keeping. The only records available are from 2018,” he said.
He also questioned why Sacaa did not ground the aircraft owing to lack of a flight data recorder when about a year ago it had grounded Comair and FlySafair because of similar issues.
Sputla Lekalakala, the widower of Tebogo Lekalakala, one of the three officials who died in the accident, said the families had received the preliminary report and were studying it.
“We don’t want to say a lot at the moment. In due course we will announce our course of action.”
Lekalakala, who is involved in aviation himself, said the only way the crash could have been owing to human error was suicide: “My wife was okay and I knew [Captain Thabiso Collins Tolo], he didn’t have issues that would have forced him to commit suicide. That is all I can say for now.”
REPLACEMENT APPROVED IN 2016
The memorandum, which City Press has seen, shows that the transport department approved the procurement of an aircraft to replace the Cessna Citation in August 2016.
Sacaa first advertised a tender in July 2018.
That December, its bid evaluation committee recommended that the tender be cancelled and re-advertised as none of the three bidders who had submitted bids met specifications.
The specifications were amended and the tender was re-advertised in April last year.
In July, Sacaa cancelled the tender for the second time, claiming that bidders again didn’t comply with specifications.
After the collapse of that tender, National Treasury allowed Sacaa to deviate and buy the aircraft directly from suppliers.
A source who spoke to City Press on condition of anonymity said that Sacaa found four aircrafts, in the US and Canada, which met the specifications, but the organisation made a last-minute decision to go out on tender for the third time.
The third tender was advertised in November last year and it expired two weeks ago.
Officials have since extended the tender’s validity for another three months.
SACAA RESPONDS
Sacaa spokesperson Kabelo Ledwaba said Khoza is the organisation’s CEO and remains responsible for all functions that fall under the authority as per the Civil Aviation Act.
“The FIU is required to have an accountable manager by law, and that accountable manager is Zakhele Nhlapo. Over and above the statutory provisions, Khoza is also assisted by executive corporate services to oversee the functioning of the FIU. The legal instruments put in place ensure that any conflict of interest is managed closely,” Ledwaba said.
There is no law prohibiting the FIU from being part of the regulator, nor is there an international standard prohibiting the FIU from being part of the regulator. In many countries, this arrangement exists, he said.
“In the South African context, there are clear regulations making provisions for the FIU to operate as an approved operator and within the prescripts of the law.”
On the AIID being housed and run by Sacaa, Ledwaba said: “A ministerial order dictates the institutional arrangement of AIID operations. The order requires that the unit report functionally to the minister, and that its reports be reviewed by an independent safety review panel comprised of industry representatives and appointed by the department of transport to quality control investigation reports and advise the minister.”
Administratively, the unit reports to Khoza, a function which is not related to investigations of aircraft accidents and incidents, he said, adding that the department provides the budget for the AIID to carry out its functions.
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