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 TRANSCOM BUILDING NGONG ROAD P.O. Box 52592-00100 NAIROBI AIR ACCIDENT INVESTIGATION DEPARTMENT FINAL INCIDENT REPORT 5Y-LEO 31.12.2012
CIVIL AIRCRAFT INCIDENT REPORT CAV/INC/LEO/12 OPERATOR : SAFARILINK AVIATION LTD OWNER : SAFARILINK AVIATION LTD AIRCRAFT : CESSNA 208B REGISTRATION : 5Y-LEO PLACE : WILSON AIRPORT (HKNW) Co-ordinates 01 19 18 S 36 48 54 E DATE : 03 JANUARY 2012 TIME : 0915 HOURS All times given in this report are Coordinated Universal Time (UTC) East African Local Time is UTC plus 3 hours. 2
OBJECTIVE This report contains factual information which has been determined up to the time of publication. The information in this report is published to inform the aviation industry and the public of the general circumstances of accidents, serious incidents and incidents. This investigation has been carried out in accordance with The Kenya Civil Aviation (Aircraft Accident and Incident Investigation) Regulations, 2013 and Annex 13 to the ICAO Convention on International Civil Aviation. The objective of the investigation of an accident or incident under these Regulations shall be the prevention of accidents and incidents. It shall not be the purpose of such an investigation to apportion blame or liability. 3
TABLE OF CONTENTS OBJECTIVE... 3 ABBREVIATIONS... 7 SYNOPSIS... 8 1. FACTUAL INFORMATION... 9 1.1. History of Flight... 9 1.2. Injuries to persons... 10 1.3. Damage to Aircraft... 10 1.4. Other damage... 10 1.5. Personnel Information... 11 1.5.1. The Captain... 11 1.5.2. The Aircraft Marshaler... 12 1.6. Aircraft Information... 12 General... 12 1.7. Meteorological Information... 13 1.8. Aerodrome Information... 14 1.9. Flight Recorders... 15 1.10. Wreckage and Impact Information... 15 1.11. Medical and Pathological Information... 15 1.12. Fire... 15 1.13. Survival Aspects... 16 1.14. Tests and Research... 16 1.15. Organizational and Management Information... 16 Kenya Airports Authority (KAA)... 16 5
1.16. Additional Information... 16 1.17. Useful and Effective Investigative Techniques... 16 2. ANALYSIS... 17 3. CONCLUSIONS... 18 Significant Findings... 18 Probable Cause... 18 4. SAFETY RECOMMENDATIONS... 19 APPENDICES... 20 Appendix I Aerodrome Ground Movement Chart... 20 Appendix II Wilson Airport Chart... 21 Appendix III - Photographs... 22 6
ABBREVIATIONS AAID : Air Accident Investigation department ATC : Air Traffic Control C of A : Certificate of Airworthiness C of R : Certificate of Registration CPL : Commercial Pilot License CVR : Cockpit Voice Recorder FDR : Flight Data Recorder HKNW : ICAO designation for Wilson Airport ICAO : International Civil Aviation Authority ILS : Instrument landing System KAA : Kenya Airports Authority KCAA : Kenya Civil Aviation Authority METARS : Meteorology Aerodrome Routine Weather Reports 7
SYNOPSIS The Air Accident Investigation Department (AAID) was notified of a ground incident by Wilson Airport Air Traffic Control (ATC) on 03 January 2012 and a response team was dispatched immediately for on-site investigation. At 0915 hours on 03 January 2012, a Cessna 208B of registration 5Y-LEO collided with a DHC8-402 of registration 5Y-VVZ as it was taxiing towards the Customs Parking area of Wilson Airport for passengers to disembark. The aircraft 5Y-VVZ had been parked near the Customs Area. 5Y-LEO was on a regular passenger flight from Masai Mara to Wilson Airport with 13 persons on board 12 passengers and 1 crew member. There were no injuries reported as a result of the incident. 5Y-LEO sustained skin damage on its tail fin and the left wing leading edge deicer boots for 5Y- VVZ were also damaged. The report concludes that the probable cause of the incident was the failure of the pilot of the taxiing aircraft to maintain adequate clearance and visual outlook during taxi at a congested area of the airport. The key contributory factors were absence of a marshaler to facilitate safe aircraft taxi and temporary parking of aircraft in close proximity to the Terminal. 8
1. FACTUAL INFORMATION 1.1. History of Flight The aircraft 5Y-LEO operated by Safarilink Aviation Limited departed Nairobi, Wilson Airport, on 3 January 2012 at 0658 hours on a regular commercial passenger flight to Masai Mara. It landed at Ciana Airfield at 0740 hours before departing for Musiara at 0742 hours. The aircraft landed at Musiara Airstrip at 0755 hours and departed for Kichwa Tembo at 0805 hours. Kichwa Tembo was the last stop over at the Masai Mara before a return flight to Wilson Airport. The aircraft landed at 0811 hours at Kichwa Tembo Airstrip. According to the crew, all these flight sectors were uneventful. The aircraft took off from Kichwa Tembo Airstrip at 0820 hours for the return flight to Wilson Airport. According to the pilot, the return flight was uneventful and they landed at Wilson Airport runway 07 at 0908 hours. The aircraft exited the runway via taxiway C and taxied towards Apron 1 at the Customs Area for passengers to disembark. At 0915 hours, the aircraft turned right and exited taxiway C as it headed towards the Apron 1 parking area. According to the pilot, there was no marshaler on sight as he was maneuvering the aircraft towards the parking area. The DHC8-402 aircraft of registration 5Y-VVZ and operated by Bluebird Aviation Limited was parked to the left of the direction of taxi of 5Y-LEO. The left wing of 5Y-LEO went under the left wing of 5Y-VVZ as the aircraft taxied towards the parking area. As the pilot attempted to turn right for the final parking position, the tail fin of 5Y-LEO hit the left wing leading edge of 5Y-VVZ close to the wing tip. Meanwhile, the only marshaller on duty was marshalling another aircraft 5Y-BNE which was ahead of 5Y-LEO. The tail fin of 5Y-LEO was dented and the left wing leading edge deicer boots of 5Y-VVZ were damaged as a result of the ground collision. 9
The aircraft came to a stop facing a heading of 25 NE at latitude 36 48 53 E and longitude 1 19 7 S. The pilot reported the incident and safely evacuated the passengers from the aircraft. 1.2. Injuries to persons Injuries Crew Passengers Others Fatal - - - Serious - - - None 1 12 1.3. Damage to Aircraft The tail fin of 5Y-LEO was dented and the left wing leading edge deicer boots of 5Y-VVZ were damaged as a result of the ground collision. 1.4. Other damage None 10
1.5. Personnel Information 1.5.1. The Captain The captain was a Kenyan male aged 32 at the time of incident. He held a valid Commercial Pilot s License (CPL) No. YK-4103-CL issued on 12 April 2001 by Kenya Civil Aviation Authority (KCAA). The CPL had coverage for single engine aeroplanes of less than 5700kg maximum total weight and was valid till 13 March 2012. The pilot also held an instrument rating which was valid until 6 April 2012. Records indicated that the date of the last instrument flying test was on 6 April 2011. The Captain held a valid Flight Radio Telephony Operator License YK-4103-RL which was valid until 13 March 2012. The pilot was medically examined on 16 February 2011 and issued with a Class One medical certificate. The Captain had a Cessna 208 aircraft type rating endorsed on his CPL on 16 March 2007 under Group I. The pilot undertook a route check on 8 August 2011 and was due for a base check on 14 January 2012. A summary of the pilot information is as shown in the table below: Date of Birth/Age 5 March 1979 Sex Male Nationality Kenyan License No. YK-4103-CL Type of License CPL (Aeroplanes) Validity of license Valid till 13 March 2012 Ratings Cessna 208 Profiency check Instrument rating Renewal Flight Test on 6 April 2011. Route Check conducted on 8 August 2011. 11
Base check was due on 14 January 2012. Total hours 3619 Total hours on type 2500 Hours in the last 7 days 26.5 Hours in the last 28 days 73.8 Hours in the last 90 days 258.5 1.5.2. The Aircraft Marshaler The Aircraft Marshaler on duty at the time of incident was a Kenya Airports Authority (KAA) employee. There was only one marshaler available to handle both arriving and departing traffic at the Wilson Airport Terminal Area on this particular occasion. At the time of incident, the Marshaler was engaged in marshalling another aircraft when 5Y-LEO was taxiing towards Apron 1. The Marshaler had been trained on Aircraft Marshalling at the KAA Training School and the East African School of Aviation. According to KAA Wilson Airport Operations Office, there were normally at least two or three marshalers working at the Terminal at any particular time. However, on this occasion, other marshalers who were supposed to be on duty were reportedly attending to personal matters. Majority of the employees at the KAA Wilson Airport Operations Office were out on holiday at the time of incident. 1.6. Aircraft Information General Manufacturer Type Year of Manufacture Cessna Aircraft Company Cessna 208B 2008 12
Aircraft Serial Number 2063 Number and type of engines Certificate of Registration (C of R) 1 Pratt & Whitney PT6A-114A C of R 2177-A was issued on 9 June 2011. C of R initial issue was on 19 January 2009. Certificate of Airworthiness (C of A) C of A 2309 was initially issued on 23 January 2009. The last renewal was done on 27 January 2011. The C of A was valid for one year until 26 January 2012. Category Commercial Air Transport (Passenger) The aircraft was equipped with one Pratt and Whitney PT6A-114A turbo-propeller engine and an aluminum-bladed, constant-speed, full-feathering, reversible, and hydraulically-actuated McCauley propeller. The aircraft was being maintained at Phoenix Aviation Limited, a KCAA Approved Maintenance Organization. The aircraft had single-disc, hydraulically-actuated brake system on each main landing gear wheel. Brakes are operated by applying pressure on the rudder pedals. The brakes were functionally tested and found to be operating satisfactorily. The aircraft was generally in a satisfactory condition and none of its systems was considered as a factor in this investigation. 1.7. Meteorological Information Weather information was available to the crew from ATC. Official Meteorology Aerodrome Routine Weather Reports (METARs) for HKNW were issued hourly and sometimes as conditions may warrant, such as during wind shift, change in visibility or cloud cover. 13
At the time of incident, visual meteorological conditions prevailed at Wilson Airport. Weather was dry and KAVOC. Weather was not considered a factor in this investigation. 1.8. Aerodrome Information Wilson Airport (ICAO designation HKNW) is located five kilometers south of Nairobi and serves both domestic and international traffic. It is located at latitude 01 19' 18.19" S and longitude 036 48' 53.40" E at an elevation of 5546 feet AMSL. The aerodrome operating hours are from 0330 to 1730. The airport has four asphalt runways 07/25 (4800 79 ft), 14/32 (5118 75 ft). The airport is not equipped with ILS equipment. The airport has five taxiways A, B, C, E, and H. Aircraft landing on runway 07 will normally exit through taxiway C. There are four aprons at the airport with Apron 1, which is near the terminal, being utilized for passengers to board and disembark from the aircraft. The airport is also equipped with a control tower normally manned by four air traffic controllers per shift. Approach control is achieved through monitoring of radar display monitors at the Visual Control Room. Aircraft Ground Control was being achieved through visual monitoring and radio communication between the Ground Controller and the aircraft on ground. Wilson Airport is regarded one of the busiest airports in Kenya. Majority of the aircraft operating at Wilson Airport are of the General Aviation category. For customs purposes and to facilitate passenger movement, all aircraft arriving or departing from Wilson Airport usually pass through the Terminal Area. The Terminal Area is therefore very busy and highly congested. The issue of congestion at the airport is not something new and has been a subject of discourse in various safety forums. However, at the time of incident no long term solution had been achieved. 14
1.9. Flight Recorders The aircraft was not equipped with either a Flight Data Recorder (FDR) or a Cockpit Voice Recorder (CVR) and neither was required. 1.10. Wreckage and Impact Information The aircraft structure remained generally intact after the incident except for the contact damage with 5Y-VVZ on the tail fin. The tail fin contacted the left wing of 5Y-VVZ at approximately one third of its length from the tip. The skin of the tail fin was dented with some loss of paintwork. The left wing leading edge deicer boots for 5Y-VVZ were damaged at approximately one metre from the wing tip. The nose wheel appeared slightly steered to the right. 1.11. Medical and Pathological Information No medical examination of the crew was conducted. 1.12. Fire There was no evidence of fire resulting from the incident 15
1.13. Survival Aspects Not applicable 1.14. Tests and Research None was conducted 1.15. Organizational and Management Information Kenya Airports Authority (KAA) At the time of incident, Wilson Airport was being operated by KAA. The Aerodrome had not been fully certificated by KCAA but the process of certification was ongoing. KAA was responsible for marshaling operations at Wilson Airport. All marshalers were employees of KAA and the operators had little control and role during marshaling. KAA was also responsible for allocation of both shortterm and long-term parking at the airport. The aircraft 5Y-VVZ had been parked close to the taxi area for arriving and departing traffic. 1.16. Additional Information None 1.17. Useful and Effective Investigative Techniques None 16
2. ANALYSIS The pilot continued taxiing the aircraft towards the parking area at Customs despite having no marshaler on sight for proper and safe guidance in a congested area of the airport. The pilot reported that the left wing of his aircraft went under the left wing of the parked 5Y-VVZ as he taxied. In both cases the pilot decided to proceed with taxi in spite of the risk of collision with the parked aircraft. It was considered that the pilot failed to maintain adequate clearance with the parked aircraft and in the absence of adequate visual outlook and absence of marshaler, the pilot failed to seek external assistance. The only available marshaler at the time of incident was engaged in marshaling another aircraft 5Y-BNE. The pilot reported sighting the marshaler who was busy with another aircraft. The pilot, however, did not stop the aircraft to wait for the marshaler to finish with 5Y-BNE. At the time of incident, there was only one marshaler at Terminal Area responsible for both departing and arriving traffic. This was against the usual number of two to three marshalers. The incident occurred during a holiday season, just after the New Year celebrations. It was probable that majority of the marshalers were on holiday during this occasion. One marshaler for a busy Terminal Area at Wilson was considered inadequate for safe handling of taxiing aircraft. The Terminal Area of Wilson Airport was a highly busy area requiring constant monitoring and direction of both arriving and departing aircraft. Aircraft were being temporarily parked within the vicinity of the parking area for boarding and disembarking passengers. This increased congestion in an area of busy traffic and also increased the risk of ground collisions. 17
3. CONCLUSIONS Significant Findings 1. The pilot continued taxiing the aircraft in the absence of adequate visual outlook 2. The pilot failed to maintain adequate clearance with the parked aircraft during taxi. 3. There was no marshaler available to assist the aircraft during taxi and parking 4. The pilot held appropriate qualifications and experience for the flight 5. Wilson Airport had not been fully certificated by KCAA at the time of incident. 6. The one marshaler on duty at the time of incident was not adequate for maintenance of safe ground operations at the terminal area. 7. KAA held full responsibility for marshaling operations at the airport. The operators did not have any responsibility for marshaling. 8. Some aircraft were being temporarily parked near the Terminal Area further exacerbating the congestion at the Terminal. Probable Cause The probable cause of the incident was the failure of the pilot of the taxiing aircraft to maintain adequate clearance and visual outlook during taxi at a congested area of the airport. The key contributory factors were absence of a marshaler to facilitate safe aircraft taxi and temporary parking of aircraft in close proximity to the Terminal Area. 18
4. SAFETY RECOMMENDATIONS 1. KAA should allow operators to utilize own marshalers as a back-up to those it provides. Such marshalers should, however, be approved by KAA upon meeting adequate training requirements. 2. The parking near the Terminal Area should only be utilized by aircraft parking for purposes of passenger boarding and disembarking. Temporary parking should be disallowed by KAA. 3. KAA in conjunction with key stakeholders at Wilson Airport should evaluate all possibilities for a long-term solution to the aircraft congestion problem at the airport. 19
APPENDICES Appendix I Aerodrome Ground Movement Chart 20
Appendix II Wilson Airport Chart 21
Appendix III - Photographs 22
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