AAID Safety Proposals

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Emil Jones
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1 AAID Safety Proposals Aug-16 Registry Narrative Safety Proposals 5Y-CCN Under the supervision of the flight instructor (FI), the student pilot (SP)took off on runway 18 and completed four successful touch-andgo landings. According to the FI, during the fifth touch and go the SP came in too high on final approach. At a speed of 60 kts, and with 700 m of the runway remaining, the SP realized he would not make a successful landing so he tried to execute a go-around, but he was unsuccessful. Immediately after touch-down the FI took control as a go-round couldn t be achieved because of the trees at the end of the runway. The aircraft rolled and veered to the right of runway 18 it hit a bumpy ground surface and came airborne before it collided with a tree trunk and the aircraft hangar at the end of the runway. The aircraft flipped over, turned opposite direction and came to rest. There were no injuries to the crew but the aircraft was substantially damage. 1. KCAA should ensure Kijipwa is licensed as per KCAA (Aerodrome) Regulations 2013 and the aerodrome meets basic safety requirements as stipulated in the ICAO Doc Part 1 section KCAA should ensure that the satellite training facility at Kijipwa are approved to meet the requirements of KCAA Legal Notice No. 77

2 5Y-BXB The airplane was on a repositioning flight from Jomo Kenyatta Airport to Wilson Airport to pick up passengers. The aircraft landed on runway 07 and backtracked to exit at taxiway C to enter onto the Apron. As the aircraft exited the taxiway, the ground controller instructed the pilot to hold short of the Apron to await a parking space. There was no ground marshaller on the Apron at the time. The aircraft was stopped briefly as the Captain consulted whether to proceed to the parking bay. A Cessna 206 and Cessna 208 were parked on the left and right side of the aircraft, respectively. The Captain was concerned about blocking the taxiway for too long. The flight crew was unable to judge the clearance between the aircraft wingtip and the Cessna 208 rudder and therefore relied on directions from an unqualified ground person to proceed with the taxi. Subsequently, the aircraft right outboard aileron tip contacted the rudder of the Cessna 208, resulting in minor damage. 1. KAA, KCAA and other key stakeholders at Wilson Airport should explore all possibilities for a sustainable solution to the aircraft congestion problem at the Airport. 2. KAA should conduct needs assessment for marshallers at Wilson Airport to ensure that an adequate number of marshallers is available at all times to facilitate safe taxi and parking operations at Apron KAA should ensure that proper planning and rostering of marshallers at Wilson Airport is performed to ensure a minimum number of marshallers is maintained at the Apron at all times. 4. KAA should ensure that Apron Controllers tasked with conducting marshalling are not given other tasks that will take them off the Apron. 5. KAA should ensure that marshallers are appropriately trained and provided with distinctive reflective jackets and marshalling kits that will make them easily noticeable by flight crew. Marshalling should also be standardized at all aerodromes. Marshalling procedures should ensure that arriving aircraft are directed right from the point of exit from the taxiway. 6. KAA should consider the possibility and viability of introduction of a new departure/arrival zone at Apron 3 or 4 as an effort to decongest Apron KAA should conduct an aircraft parking needs assessment at Wilson Airport with a view to creating more and adequate parking space for all aircraft types operating at the Airport. 8. KCAA and KAA should develop procedures for proper safety coordination, communication and handover between ATC and Apron Control. 9. KCAA should expedite the certification of Wilson Airport to ensure that it meets the minimum requirements for the safe conduct of aircraft operations. Certification should

3 ensure that KAA introduces the yellow centerline marking at the aprons to guide pilots during taxi. 10. KCAA should ensure that all ground communications between an aircraft and ATC are recorded to facilitate safety investigation when necessary. 11. Fly 540 should review its safety culture through SMS to ensure flight crew adherence to ATC instructions at all times. 12. Fly 540 should sensitize all its flight crew on the contents of the AIP relating to Wilson Airport to ensure that pilots are aware that parking at Apron 2 is available at the direction of a marshaller. 13. Fly 540 should, through its SMS program, sensitize all its new and existing flight crew on the major hazards at Wilson Airport. 14. Fly 540 should ensure that route checks for new pilots should include routes with regular repositioning flights. 15. Fly 540 should develop and implement guidance material in relation to taxi speeds for all their aircraft to avoid any variance between pilots. In addition, procedures to provide guidance to the pilot on what to do in the absence of a marshaller should be developed. 5Y-KNJ 5Y-CAR The airplane sustained a birdstrike while in range of the destination airport (HKNW). Due to the subsequent loss of oil pressure reading, the pilot made a precautionary landing in an open field. During taxi, the engine jet blast resulted in damage to two parked and unoccupied Cessna 172 airplanes. (5Y- BZS & 5Y-BYV). 1. It is recommended that KCAA conduct risk analysis of the impending bird activity at the vicinity of the Control Zone Boundary near Karai with the objective of assessing the suitability of issuing a NOTAM as appropriate. 1. Kenya Airport Authority to provide aircraft tie down knots/rings on parking bays. 2. There is need for KCAA to conduct safety risk assessment on the operation of CRJ200 and other similar jet engine propelled aircraft at Wilson airport.

4 5Y-FUN G-MKJA The aircraft was on a maintenance test flight for the renewal of a Certificate of Airworthiness. The aircraft was operating on a Special Flight Permit that had been issued by Kenya Civil Aviation Authority (KCAA). The aircraft had initially departed Wilson Airport (HKNW) at 1140 hours, but it returned 15 minutes later after the pilot was notified by Air Traffic Control (ATC) that the aircraft was not visible on radar. The transponder was inspected and tested by maintenance before the aircraft departed again and this time it was visible on radar. During climb at approximately 7500 feet, the pilot reported that the engine was running rough and he decided to return to HKNW and ATC cleared the flight accordingly via Monastery. The engine vibrations increased as the aircraft turned toward HKNW. The pilot reported swithcing the ignition switch from the magnetos from right to left position before the engine lost total power. The pilot made a forced landing on Southern Bypass road near Kibera. About 1040 hrs the aircraft was cleared by air traffic control (ATC) to taxi to the holding area of runway 06. At 1050 hrs The flight was cleared for takeoff and the flight crew initiated takeoff on runway. The aircraft accelerated to 80 kts, the crew heard a loud bang and they decided to abort the takeoff. They subsequently reported the event to ATC. Just before the airplane exitted the runway, the crew noticed that for engine no. 2, the RPM had reduced to zero and the EGT was exceeded. Thereafter the crew performed the engine failure checklist. 1. KCAA should ensure that aircraft operators and AMO s abide by the manufacturer s recommendations on longterm storage of aircraft and post-storage inspections. If no such guidelines are available, KCAA should develop relevant guidelines for operators. 2. KCAA should ensure that inspections based on calendar time for low-utilization aircraft are conducted as stipulated by the manufacturer. 3. KCAA should ensure that operators whose aircraft are on long-term storage keep records of any engine ground runs conducted on regular basis. 4. KCAA should ensure that temporary approval letters issued to AMO s prior to certification have clear specifications and limitations, where necessary. 1. UKCAA needs to consider reviewing the engine condition monitoring programs of MK Airlines to ensure that they meet the relevant requirements and can reliably determine engine deterioration.

5 5Y-BZK According to the flight Instructor (FI), the student pilot (SP) was on the first solo check-out and had been scheduled to practice take-off, landing and aircraft handling during engine failure. The SP conducted preflight checks and engine start up was initiated at approximately 0500 hours. The SP was conducting all the activities of the flight including aircraft control and communication with air traffic control. The aircraft was cleared for take-off on runway 14 at 0515 hours. After takeoff, the SP positioned the aircraft downwind 07 and performed a goaround procedure. The SP again positioned the aircraft downwind 07 and performed a touch-and-go procedure on runway 07. On downwind 07, the FI initiated an engine failure simulation exercise for the SP by positioning the throttle lever on Cut-Off position. At this point, the aircraft was at altitude of approximately 500ft above ground level. In the course of the simulation exercise, the SP inadvertently pulled the mixture lever which resulted in engine shutdown. The FI and SP unsuccessfully attempted to restart the engine but due to the low altitude that they were flying, they decided to make a forced landing at the National Park. The aircraft landed and came to rest at approximately 1670 meters from the threshold of runway 32 at a heading of 225. The FI and SP safely evacuated unassisted from the aircraft and reported the occurrence. 1. KCAA to consider reviewing the PPL training curriculum used by ATO s either the Ground Pilot Training to be mastered or completed by students before commencing practical flight training OR both flight training and ground training to be done in tandem to comprehend each other.

6 5Y-NII The aircraft struck a zebra during landing. The aircraft sustained substantial damage on the tail section. A section of the left elevator was torn off and the left horizontal stabilizer was bent at the tip as a result of the impact. The tail cone section below the leading edge of the right horizontal stabilizer was bent inwards. The tail section was not examined internally for any additional damage that might have been sustained during the occurrence. The investigation considered that the pilot s actions in an effort to detect the presence of wild animals on an open airstrip were inadequate. The pilot flew on the left downwind of runway 19. From the left seat of the cockpit and at the minimum circuit altitude, it was considered unlikely that the pilot would have had a good visual look-out of the runway. A full circuit around the Airstrip or a missed approach would have given the pilot a complete visual picture of the runway before landing. Kilaguni Airstrip was open, unmanned and in the middle of Tsavo National Park. Large wild animals including elephants, zebras and buffaloes wandered freely on the runways posing a serious safety risk to aircraft operations. Bush clearing around the runways was also considered inadequate as animals were still able to hide in some nearby shrubs. Reliance on aerial pilot surveillance for wild animals was considered inadequate to guarantee a safe landing on the Airstrip. 1. KCAA should issue an AC to aircraft operators conducting operations into open and unmanned airstrips in National Parks to utilize safety risk assessment tools such as SMS to mitigate the risk of collision with wildlife. 2. KCAA should issue a NOTAM to advise pilots to conduct a missed approach on open and unmanned Airstrips with no ground support prior to landing. 3. KCAA should ensure that operators conducting commercial flights into Airstrips with known wildlife hazards provide necessary information and procedures on how they intend to deal with the hazards. 4. KWS should ensure that all Airstrips within National Parks under their jurisdiction are fenced ff. 5. KWS should ensure that the paved runway surface on runway 01/19 is extended to cover the entire runway 6. KWS should review the maintenance cycle of airstrips under their jurisdiction from annual to a more regular basis. Maintenance should also be done on-condition. KWS should therefore, have a system of continuous monitoring and assessment of the runway throughout the year 7. KWS should ensure that bushes around the runways are cleared at regular intervals. A minimum of 50 meters clearance from the runway should be maintained at all times. 8. KWS should develop a sustainable solution to the drainage problem at the Airstri 9. KWS should relocate the road crossing runway 12/30 to avoid any conflict between cars and aircraft 10. KWS should conduct daily surveillance of the Airstrip to ensure that large animal droppings are timely removed 11. Runway 12/30 should be repaired to provide an alternative in the presence of

7 wildlife on 01/1 12. Aircraft operators should liaise with KWS to ensure that runways are prepared when they are planning their flights to airstrips in National Parks. ZS-SSY About 25 m into the takeoff roll, the pilot noticed the right wing lowered followed by a loud sound from the right main gear. The aircraft subsequently swerved side to side before the pilot rejected the takeoff. The pilot reported that immediately after he applied the brakes, the right main gear collapsed. The right propeller blades struck and produced slash marks on the ruwnay surface, resulting in the distortion of the blades. The aircraft ground looped to almost the oppoiste direction. During the accident sequence, the lower surface of the right flaps and its brackets, in addition to the lower wing surface all scrapped the runway surface. Additioinallyk, the right fuel tank was punctured. 1. The operator and SACAA should review human factor issues, errors or omissions at the overhaul facility that may have contributed to this serious incident during the next approval cycle of the facility. 2. SACAA should confirm the full implementation of AD F on F406 aircraft 3. The operator should review all its actuators overhauled at the facility to ensure that the same error was not duplicated. 4. KAA should renovate runway 08/26 of HKML to provide for alternative use in case blockage of runway 17/35. 5Y-LLG 5Y-BAT The pilot reported the aircraft accelerated slowy during the takeoff roll. As the airplane approached the end of the runway, the pilot attempted to lift off but a stall occurred and the airplane struck a pole, separating the right wing before the aircraft descended and impacted the ground. The pilot lost directional control during landing and veered off the side of the runway onto the adjacent grass area where the nose and left main gear collapsed. 1. The airstrip operator to consider relocating the water tank at the edge of runway 24 due to it s proximity to the runway threshold. 1. KAA to cover the drainage tunnels close to the runway to prevent worsening of any eventual excursions.

8 5Y-BSA 5Y-GSM During the takeoff the aircraft became airborne prematurely due to encounter with ridges on the runway. The pilot rejected the takeoff and the aircraft subsequently overran the runway onto rough terrain where the nose gear collapsed. The pilot, a student on his second solo flight, had landed safely on runway 08 in Malindi Airport. The pilot taxied to the apron near the flying school s airside office to a welcome applause by other students standing outside the office. The student pilot testified to have followed the other students instructions to continue taxiing further on and turn the aircraft even after he had made a decision to stop. There were no marshallers on site at the time of the accident. The school s marshaller was also said to have been busy, occupied with other company s assignments. The pilot proceeded to turn and the aircraft got into an open storm water drainage trench and came in contact with the wall of one of the airport s buildings. The propeller also struck the ground and the engine stopped with fuel spilling from the left wing. The pilot reported to have secured the aircraft and was pulled out of the aircraft by an eye witnesses who rushed to his rescue. The left wing tip was damaged. The pilot also testified to have frozen when he realized how close the aircraft wing was to knocking down one of his fellow student and let go all controls. It is at that moment that the aircraft got in to the trench. 1. K CAA to ensure that aircraft operators comply with the provisions of Reg. 36 and 37 of the civil aviation instrument and equipment regulations K CAA to develop a mechanism to enforce the provisions of Reg. 36 (3) and 37(5) of the civil aviation instrument and equipment regulations Kenya Civil Aviation Authority to consider making the provisions of Reg. 36 (3) and 37(5) of the civil aviation instrument and equipment regulations 2007 a C.O.A renewal requirement. 1. K AA to clearly mark the designated parking areas and extreme limits in accordance with ICAO Annex K AA to make arrangements to clear the ant hills on the left side of runway 08 and right side of runway17. These ant hills are serious hazard in case of a runway excursion.

9 5Y-BSA After taxi to the ramp from landing, the pilot attempted to park between two parked airplanes and struck one, a Cessna 208 (5Y-MLD) The impact involved the right wingtip of the Let 410 and the vertical stabilizer of the Cessna. 1. KAA to put in place measures to ensure adequate marshalling services are provided at the passenger boarding/aircraft parking area. 2. KAA to provide ample parking space and maneuvering area to accommodate the size and increasing traffic.

REPUBLIC OF KENYA MINISTRY OF TRANSPORT AND INFRASTRUCTURE STATE DEPARTMENT OF TRANSPORT AIR ACCIDENT INVESTIGATION DEPARTMENT

REPUBLIC OF KENYA MINISTRY OF TRANSPORT AND INFRASTRUCTURE STATE DEPARTMENT OF TRANSPORT Telegrams: TRANSCOMS. Nairobi Telephone: (020) 2729200 Email: info@transport.go.ke Website: www.transport.go.ke