Section/division Accident and Incident Investigation Division Form Number: CA 12-14 PRELIMINARY OCCURRENCE REPORT Reference number : CA18/2/3/9705 Name of Owner : Blueport Trade 121 (Pty) Ltd Name of Operator : Corporate Aviation Operation (Part 93) Manufacturer : Dassault Aviation Model : Falcon 900EX Nationality : South African Registration markings : ZS-DEX Place : Rand Aerodrome (FAGM), Gauteng Province Date : 3 May 2018 Time : 0609Z All times given in this report are Co-ordinated Universal Time (UTC) and will be denoted by (Z). South African Standard Time is UTC plus 2 hours. The information provided herein is of a preliminary nature. Readers are advised that new information may become available that may alter this preliminary report prior to the publication of the final report. Any person with information that might assist in investigating the cause of the accident are requested to present information or themselves to Accident and Incident investigation Division of SACAA. Or send an email to Aiidinbox@caa.co.za This report is issued in accordance with Civil Aviation Regulation (CAR) 2011 Part 12.05.1(2)(a) and ICAO Annex 13 Paragraph 7.1 or 7.2 whichever is applicable. 1. The South African Civil Aviation Authority (SACAA) is conducting a safety investigation into a non-scheduled domestic passenger flight involving a Falcon 900EX with registration marking ZS-DEX that occurred on Thursday 3 May 2018. 2. The investigation is being conducted in accordance with the international protocol set out by the International Civil Aviation Organization (ICAO), Annex 13. The investigation team includes three investigators from the SACAA. The BEA in France was notified of the accident and they have appointed a non-travelling Accredited Representative in accordance with ICAO Annex 13 protocol. CA 12-14 01 FEBRUARY 2017 Page 1 of 9
Figure 1: The aircraft ZS-DEX, Falcon 900EX (photograph obtained from the internet) History of flight 2.1 On Thursday morning, 3 May 2018 at 0434Z a domestic non-scheduled flight operating under the provisions of Part 93 (Corporate Aviation Operation) took-off from Cape Town International Airport (FACT) on an IFR flight plan to Rand Airport (FAGM). On board the aircraft were two (2) crew members and ten (10) passengers. The pilot-in-command (PIC) was the pilot flying (PF) this sector. 2.2 The flight to FAGM was uneventful. During the handover from Johannesburg radar as they were passing 7 600 feet above mean sea level (AMSL) the first officer was in radio communication with air traffic control (ATC) at FAGM tower. They were cleared to join at 6 500 feet on the right downwind for runway 17, for a visual approach. The QNH was 1025 millibar. There was slower traffic ahead of them, a Cessna 172, which was cleared for a touch and go landing. The crew of ZS-DEX did not have the aircraft visual during their approach but identified the aircraft on the traffic collision and avoidance system (TCAS). They were cleared to land on runway 17 number two, with the Cessna 172 number one. The ATC indicated the wind to be northerly at 10 knots; she was however corrected by the pilot flying the Cessna 172 as the wind was actually from the south. CA 12-14 01 FEBRUARY 2017 Page 2 of 9
2.3 FAGM is a licenced aerodrome (The aerodrome chart is attached as Annexure A), runway 17 is 1 197 m long and 15 m wide with an upslope of +0.71%. There was an alternate runway available which was orientated 11/29. The runway is 1 579m long and 15m wide. According to the aircraft performance software, runway 17 was long enough for a safe landing. This was the first time the crew had landed at FAGM with this aircraft, as Lanseria aerodrome (FALA) was the preferred aerodrome for landing in Gauteng. The passengers were attending a meeting in Soweto and for logistical reasons the crew were requested to land at the nearest aerodrome. 2.4 Due to the slower traffic ahead the PF opted for a wide downwind, heading 340. This placed them on path heading directly towards the Johannesburg City Centre, and subsequently the EGPWS gave them a CAUTION OBSTACLE warning. The PF then commence with the right base turn earlier than expected. FAGM ATC then asked them if they had the slower traffic ahead visual, which they still didn t have in sight. The early turn had deleted the graphical extended centreline from the FMS, but the PF opted not to have it reinserted. They were unable to visually locate the slower traffic ahead due to the right base leg turn, which had them looking into the early morning sun. Both crew members lost visual contact with the runway at approximately 1000 ft above ground level (AGL) but the PF continue with the turn to final in anticipation of re-establishing visual contact. When the PF observed the runway, he realised that the aircraft was to the right of the runway centreline and approximately one mile out. At this stage the aircraft was fully configured for landing, with the auto throttle holding the 123 knots Vref speed. The PF then opted to execute a descending left turn towards the runway and then right to establish runway heading. During the right turn they crossed over some tall trees on the Germiston Golf Course, when the right wing impacted with the trees, with no effect on the flying characteristics of the aircraft, nor did either of the crew members feel it. The PF stated that he started with the flare at 50 ft AGL, and noted the crosswind drift (from left to right). He corrected the drift with left aileron and touched down and completed the landing roll. After the aircraft was parked on the main apron, the damage to both wings became evident during the walk around. The PIC informed the South African Civil Aviation Authority (SACAA) accordingly, who was immediately dispatched to FAGM to inspect the aircraft and to interview the crew. The damage observed affected the structural strength, performance and flight characterises of the aircraft and would require a major repair or replacement of the affected components. CA 12-14 01 FEBRUARY 2017 Page 3 of 9
Findings 3. Although the investigation is on-going, the following findings have been made: 3.1 The PIC licence and aviation medical certificate were valid at the time of the accident. The PIC also held the necessary rating to operate the aircraft. He had accumulated a total of 6 362.2 flying hours at the time, of which 186.8 was on the aircraft type. 3.2 The First Officer s (FO) licence and aviation medical certificate were valid at the time of the accident. The FO also held the necessary rating to operate the aircraft. He had accumulated a total of 4 370.9 flying hours at the time, of which 161.8 was on the aircraft type. 3.3 The PIC was the pilot flying (PF). It was the first time that he had landed this aircraft at FAGM. 3.4 The ATC on duty held a valid licence and aviation medical certificate at the time of the accident. 3.5 ATC cleared the aircraft to land on runway 17, but she indicated the wind to be from the north at 10 knots. She was corrected by the pilot flying the Cessna 172, that the wind was actually from the south. 3.6 The aircraft, with serial number 65, was manufactured in the year 2000 and was in possession of a valid certificate of airworthiness. 3.7 The last maintenance inspection carried out on the aircraft prior to the accident was certified on 28 February 2018 at 9 658.7 airframe hours. Since the inspection the aircraft had flown a further 40.6 hours. 3.8 The aircraft sustained damage to both slats, ailerons and wing tips, which require replacement. The wing structure will also need to undergo a detailed structural inspection, which will include non-destructive testing on certain areas as prescribed by the manufacturer. CA 12-14 01 FEBRUARY 2017 Page 4 of 9
3.9 The aircraft was equipped with a flight data recorder (FDR) and cockpit voice recorder (CVR), these units was removed from the aircraft to be downloaded. 3.10 The BEA in France as the State of Design and Manufacturer of the aircraft was informed of the accident and they have appointed a non travelling accredited representative as per the provisions contained in ICAO Annex 13. Figure 2: The red line indicates the approach path flown for landing on runway 17 at FAGM CA 12-14 01 FEBRUARY 2017 Page 5 of 9
Figure 3: Scrape markings from the left wing at the threshold of runway 17 Figure 3: Scrap markings on the lower left wing tip surface (photograph from AIID Investigator) CA 12-14 01 FEBRUARY 2017 Page 6 of 9
Figure 4: Damage to the left wing slat, lower surface (photograph from AIID Investigator) Figure 4: Damage to the left aileron (photograph from AIID Investigator) CA 12-14 01 FEBRUARY 2017 Page 7 of 9
Figure 5: Damage to the right wing slat which was caused by vegetation (photograph from AIID Investigator) Recommendations 4. No safety recommendation has been issued. Conclusions 5. The SACAA investigation is on-going and we will be looking into other aspects of this accident, which may or may not have safety implications. Annexures 6. Annexure A (FAGM Aerodrome chart) CA 12-14 01 FEBRUARY 2017 Page 8 of 9
ANNEXURE A CA 12-14 01 FEBRUARY 2017 Page 9 of 9