DEPARTMENT OF AIR ACCIDENT INVESTIGATION

Transcription

1 REPUBLIC OF KENYA MINISTRY OF TRANSPORT DEPARTMENT OF AIR ACCIDENT INVESTIGATION P.O. Box Nairobi Telephone: Fax:

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3 CIVIL AIRCRAFT INCIDENT REPORT CAV/INC/AUC/06 OPERATOR: BLUE NILE AVIATION (E.A.) LIMITED AIRCRAFT: CESSNA 206 REGISTRATION: PLACE: 5Y - AUC MANDERA AIRFIELD DATE: 9 TH NOVEMBER 2006 TIME: 1540 HOURS All times given in this report are Coordinated Universal Time (UTC). East African Local Time is UTC plus 3 hours.

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5 AIRCRAFT TYPE: MANUFACTURER: Cessna P206E Cessna Aircraft Company YEAR OF MANUFACTURE: 1970 AIRCRAFT REGISTRATION: 5Y - AUC AIRCRAFT SERIAL NUMBER: P DATE OF REGISTRATION: 10 th February 1986 TYPE OF ENGINE: Continental IO-520-A DATE OF ACCIDENT: 9 th November 2006 TIME OF ACCIDENT: LOCATION OF ACCIDENT: TYPE OF FLIGHT: 1540 hours Mandera Airstrip Public Transport (Passenger) NUMBER OF PERSONS ON BOARD: Crew 1 Passengers 2 INJURIES: Crew Minor Passengers None NATURE OF DAMAGE: Nose landing gear, propeller and cargo bay damaged

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7 TABLE OF CONTENTS SYNOPSIS HISTORY OF THE FLIGHT PERSONNEL INFORMATION AIRCRAFT INFORMATION AERODROME INFORMATION FLIGHT PLANNING... Error! Bookmark not defined. 1.5 LANDING DISTANCE ORGANIZATIONAL AND MANAGEMENT INFORMATION ANALYSIS CONCLUSION SAFETY RECOMMENDATIONS APPENDIX...12

8 SYNOPSIS The Air Accident Investigation Department was informed of the incident at Mandera on 9 th November 2006 by the pilot. We arrived at the site on 11 th November 2006 and commenced investigations. The aircraft, a Cessna 206 registration 5Y-AUC, departed the runway as it landed at Mandera Airstrip at night and ended up in the ditch about 150 meters from the end of the runway. The pilot had minor injuries while the other two occupants were not injured. The aircraft suffered minor damage. Figure 1 5Y-AUC at accident site. Note the ditch before the aircraft came to rest

9 1 History of the flight The aircraft, a Cessna 206 registration 5Y-AUC, departed Wilson Airport at 1159 hours. The aircraft was taking two mechanics to Mandera to recover another aircraft. The planned landing time was estimated to be 1544 hours. The aircraft had a fuel endurance of 5 hours. Wajir Airfield, which the pilot estimated was about 1.3 hours from Mandera, was the alternate. When the aircraft arrived at Mandera, at about 1535 hours, it was already dark. The pilot circled the Airfield twice before he landed. Meanwhile, the Army Unit on the ground positioned two vehicles to assist with the runway lighting. One lorry was placed at the threshold of runway 05 and the other near the end of the runway. The pilot landed on runway 05. As the aircraft rolled down the runway, the pilot states that he tried to avoid hitting the lorry near the end of the runway by swerving to the right and back to the center line. He, however, lost directional control due to the bushes at the end of the runway and the aircraft went into a ditch, coming to a stop approximately 150 meters from the end of the runway. The pilot smashed his face on the instrument panel and had a small cut on the nose. He was stitched at the local hospital and discharged. The two mechanics were not injured. They all exited the aircraft safely. There was no fire. The aircraft nose wheel disengaged from the oleo strut and the fiber glass cargo bay was damaged. Two blades of the three blade propeller were slightly bent.

10 1.1 Personnel information The pilot held a valid commercial pilot licence (CPL) number YK CL with a Cessna 206 rating. He also has an instructor rating on the Cessna 150. His medical certificate was valid up to March He had accumulated 2000 hours, of which 1320 were on rotary wing and 680 were on fixed wing. He had 150 hours on the Cessna 206. The pilot was on hire to Blue Nile (EA) Limited. The pilot had operated at Mandera while he was a helicopter pilot in the Army. As a civilian pilot, he had landed at Mandera only once before, about 3 months ago, in a Cessna 172. This was his second landing at the Airstrip. The day before the accident, the pilot had a check out flight on the Piper PA 28 for about 1 hour. He was due to have a simulator class in Nairobi on 10 th November 2006 at 0930 hours. 1.2 Aircraft information The aircraft was a Cessna P206E, serial number P , registration number 5Y - AUC. It was issued with a certificate of registration number D on 10 th February 1986 and had a current certificate of airworthiness number The certificate of airworthiness was issued in the public transport category. The aircraft was manufactured in Since new the aircraft had 2

11 accumulated hours including hours since the last check III inspection. The aircraft was equipped with a Teledyne Continental Motors model IO 520A 14B engine, which had accumulated hours since new. Fitted to the engine was a McCauley variable pitch 3- blade propeller which had accumulated hours since last overhaul. 1.3 Aerodrome information The aircraft ran off the runway at Mandera Airstrip. Mandera Airstrip is unmanned and has only one runway, 05/23. It is about 1100 meters long and 23 meters wide. Runway 05 has a negative slope of 0.7. There are power lines as you approach to land on runway 23. The Republic of Kenya Aeronautical Information Publication (AIP) gives the airport s coordinates as N E. The airport elevation is 805 feet. The AIP lists the hours of operation at Mandera as sunrise to sunset. The AIP sunrise/sunset tables give sunset at Garissa (coordinates S E) on the 9 th November 2006 as 1509 hours. The website gives sunset for Mandera (coordinates N E) on the 9 th November 2006 as 1454 hours. According to the Civil Aviation Act (CAP 394), night means the time between fifteen minutes after sunset and fifteen minutes before sunrise. Therefore, by 1509 hours it was night in 3

12 Mandera. According to CAP 394 of the Laws of Kenya, Air Navigation Regulation 65(2), An aircraft shall not take off or land by night at any place in Kenya unless adequate lighting is in operation at the aerodrome. There are tall bushes around the runway which should be cleared as soon as possible. The AIP gives the runway surface as bitumen. However, the runway surface is, in fact, gravel. The windsock was noticed to be in tatters and needs to be replaced. The non-availability of a windsock is covered by AIP supplement AD S41/05 dated 13 th September 2005 which advises pilots to exercise caution. There is serious encroachment on the airstrip. Houses have been built very close to the runway. The accident aircraft could have smashed into the houses had it not been stopped by a ditch. The United States Federal Aviation Authority in its Accident Prevention Program publication FAA-P AFS-810 (1995) advises as follows: Never attempt a landing at an unlighted airport, no matter how well you think you know it. If in doubt about lighting at your destination, don't be embarrassed. Call Flight Service. 4

13 Figure Landing Distance The pilot states that he landed about 300 meters from Runway 05 threshold at his normal landing speed of 80 knots. So he had about 800 meters in which to stop the aircraft. According to the Owners Manual, he needed about 735 feet (225 meters ) to stop the aircraft. We tested the aircraft brakes during the investigation and they were in good working order. The lorry that he was trying to avoid was almost at the end of the runway. The pilot stated that he did not brake immediately on landing for fear of colliding with the lorry. This increased his landing run to beyond the end of the runway. 1.5 Organizational and management information Blue Nile (East Africa) Limited holds a current Air Operators Certificate (AOC) number 183, valid up to April 2007, for public transport. Blue Nile (EA) Limited operates two Cessna 206 and 208, and one Beech craft B100 aircraft. 5

14 The Blue Nile General Operations Manual, Chapter 8, paragraph states that: No pilot shall use and no operator or owner shall authorize the use of an aerodrome as a destination or alternate destination aerodrome unless such aerodrome is adequate for the type of aircraft and the operation concerned. Paragraph states that: Except in an emergency no take off or landing will be permitted at night at any aerodrome that is not equipped with night flying facilities. Paragraph further states that: All these operations must be strictly carried out under Visual Flight Rules as there are no landing aids in some of the areas. Therefore night landings and take off are prohibited in such areas. 6

15 2 Analysis The pilot took off from Wilson Airport at 1159 hrs. The estimated flight time was 3.75 hrs. The alternate was Wajir, which is 1.3 hrs before and enroute Mandera. The AIP gives the hours of operation at Mandera as sunrise to sunset. The calculation of sunset time plus 15 minutes give night at Mandera on the 9 th November 2006 as 1509 hours. The pilot arrived at Mandera at about 1535 hours when it was already dark. In order to make a daylight landing at Mandera and still have 1.3 hours of daylight to fly to Wajir in case of a diversion, the pilot needed at least 5.05 Hrs. To arrive at Wajir before sunset (1504 hours), he had to be in Mandera by latest 1344 hours. Considering that it would take him approximately 3.75 hours from Wilson Airport to Mandera, he would have had to leave Wilson approximately 5.05 hours before sunset in Wajir, at 0959 hours. He instead left at 1159 hours. Therefore, he took off from Wilson Airport with a shortfall in daylight hours of approximately 2 hours. Given the best circumstances in the flight, the aircraft could not have landed safely at the alternate during the published daylight. In the event the aircraft actually made a landing at the planned destination at night. He had no other option but to try and land because his alternate (Wajir) also had no lighting. It is against civil aviation regulations (CAP 394) to land by night at any place in Kenya unless adequate lighting is in operation at the aerodrome.

16 It is also against Blue Nile (K) Limited operating procedures to take off or land at night at any aerodrome that is not equipped with night flying facilities. The pilot landed at Mandera at night. Therefore, this flight was performed in contravention of Blue Nile (K) Limited operating procedures. The pilot had enough landing length to stop the aircraft before the end of the runway. He, however, did not apply the brakes in good time leading to the departure from the runway. 8

17 3 Conclusion This incident was caused by the pilot s poor flight planning and his decision to land by night on an aerodrome that did not have lighting.

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19 4 Safety recommendations 4.1 KCAA should ensure that certificated operators including Blue Nile (K) Limited follow the approved operational standards as spelt out in their approved operations manuals. 4.2 KCAA should consider further training and/or examination in aircraft performance and flight planning for the pilot. 4.3 The overrun area of Mandera airstrip, runway 05 should be cleared of all bushes. 4.4 The current encroachment on Mandera airfield should be stopped. CIA

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21 5 Appendix Accident photographs Figure 3 Figure 4

22 Figure 5 Figure 6 5Y - AUC after being moved to the parking area 14