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Report on fatal plane crash points to gross negligence...

South Africa

AIR CRASH INVESTIGATION

Report on fatal plane crash points to gross negligence by SA Civil Aviation Authority

The memorial service for three members of the SA Civil Aviation Authority flight inspection unit, Captain Thabiso Tolo, flight inspector Gugu Mnguni and first officer Tebogo Lekalakala, held at Calvary Methodist Church in Midrand on 6 February 2020. (Photo: Felix Dlangamandla)

The report on a plane crash that claimed three lives two years ago raises additional questions, and relatives of those who died in the crash are contemplating civil action against the SA Civil Aviation Authority.

The SA Civil Aviation Authority (SACAA) contravened a slew of its own aviation regulations before the crash of its Cessna calibration aircraft in January 2020, a report into the crash has found.

The final report by the Aircraft Accident Investigation Bureau (AIIB) was published on the SACAA’s website on Sunday night. Transport Minister Fikile Mbalula on Sunday met with the next-of-kin of the three crew members who died to discuss the findings of the report with them.

The captain, Thabiso Tolo, first officer Tebogo Lekalakala and flight inspector Gugu Comfort Mnguni were on board when the plane crashed into the Outeniqua Mountains near George. Lekalakala had a four-year-old daughter at the time of her death.

The most serious of the findings against the authority was that the aircraft was not maintained in accordance with the requirements of annual inspections. The certificate of airworthiness was thus rendered invalid.

SA Civil Aviation Authority crash report extract.

The aircraft experienced three incidents before the fatal accident during which an oil smell and smoke were detected in the cockpit. A faulty oil seal was diagnosed and replaced, but the oil smell and smoke were again detected in the cockpit. The crew aborted a take-off two months before the fatal crash.

One of the aircraft’s engines was replaced, a procedure that requires a full inspection by the SACAA’s flight inspection unit. However, the inspection did not take place.

The SACAA has grounded aircraft from South African Airways and other airline operators for similar contraventions.

The aircraft took off from the airport at George in inclement weather and low clouds on 23 January 2020 with Tolo, Lekalakala and Mnguni on board to perform a calibration flight.

The aircraft banked, rolled and pitched up and down before crashing into a peak of the Outeniqua mountains at high speed.

SA Civil Aviation Authority crash report extract.

In aviation terms, the aircraft had an “abnormal attitude”. However, because the flight data recorder had not been downloaded for more than a year, and there was no cockpit voice recorder, very little could be deduced about the abnormal flying attitude.

SA Civil Aviation Authority crash report extracts.

The AIIB found that Tolo was issued his annual pilot proficiency certification in 2019, but there was no record that he actually completed his flight simulation training. The simulation check would have included the topic of how to recover an aircraft with an abnormal attitude.

The SACAA failed to check whether his proficiency as pilot in command was in compliance with the SACAA’s regulations.

SA Civil Aviation Authority crash report extract.

For unknown reasons, the crew did not transmit any Mayday calls to the control tower at George airport before the crash.

SA Civil Aviation Authority crash report extract.

The AIIB found that for whatever reason, the crew drastically lost control in a very short space of time during what was an ordinary calibration flight performed above cloud cover. The loss of control caused the aircraft to lose altitude and before the crew could recover it, the aircraft flew into the mountain.

With the limited flight data that was extracted, it is unknown why two pilots could not get the aircraft under control.

SA Civil Aviation Authority crash report extract.

The Department of Transport received the report in November last year, but Mbalula’s office did not respond to inquiries on why the report was released only on Sunday, exactly two years after the crash.

His office also did not comment on allegations in the aviation industry that the department put pressure on the AIIB to omit the damning findings against the SACAA and its CEO/director of civil aviation, Poppy Khoza.

Trevor Abrahams, a predecessor of Khoza, said the report leaves the industry without a clear picture of why the crash occurred.

“There is little dispute that the aircraft entered unusual attitudes in the course of a routine calibration manoeuvre, which should not have entailed any such scenarios. The accident investigators were unable to give much insight as to why this occurred and claims of disorientation in both experienced crew in this phase of the flight are mere speculation and conjecture, while not considering other possible scenarios which could have given rise to such developments.

“Permitting the calibration aircraft to operate without all the mandatory parameters on the flight data recorder has in fact robbed the aviation industry of what happened in the moments just before the accident, and hence a more informed view of what can be done to avoid such a recurrence.”

Chris Martinus, national chairperson of the Aircraft Owners and Pilots Association of South Africa, said the report leaves more unanswered questions now than before. 

“There are many possibilities of what else could have caused the accident, [such as the aircraft malfunctioning], but none of those were considered,” said Martinus.

The provisional findings by the SACAA’s accident incident investigation unit released last year allegedly also contributed to the executive of the division, Peter Mashaba’s contract not being renewed. Mashaba made similar scathing findings about the SACAA’s operations to the ones that appeared in the AIIB’s final report.

The SACAA denied that Mashaba was fired because of the report and obtained a court order preventing Mashaba from speaking out.

Mashaba’s case before the Commission for Conciliation, Mediation and Arbitration is scheduled for arbitration on 4 February.

Mashaba said he had warned the SACAA shortly before the accident that the aircraft’s status needed to be checked before a disaster occurred — but his warning went unheeded.

Memorial service for three members of the SA Civil Aviation Authority flight inspection unit, Captain Thabiso Tolo, flight inspector Gugu Mnguni and first officer Tebogo Lekalakala held at Calvary Methodist Church in Midrand. Photo: Felix Dlangamandla

Sputla Lekalakala, the widower of the deceased first officer, and a qualified aircraft maintenance engineer and quality manager, was instrumental in the decision by the Ministry of Transport to transfer the investigation of the crash to an independent investigator rather than having the SACAA investigating itself.

“The report brings scant closure, because the words ‘contradict’ and ‘contravention’ are scattered all over the report. I told Mbalula that it amounts to gross negligence and those responsible should be held accountable.

“I will see to it that criminal charges are laid against the responsible people. I have been engaging with my legal team about a civil claim against the SACAA.”

Mbalula’s office said he will release a statement about the findings on Tuesday. DM

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All Comments 12

  • A bit of proof-reading of this article would avoid confusion between “attitude” and “altitude” – a rather important distinction in this article.

    • “Attitude” is correct. “… an unusual attitude is usually defined as a nose up pitch attitude greater than 25 degs, a nose down pitch attitude greater than 10 degs, a bank angle greater than 45 degs or flight within these parameters but with airspeeds inappropriate for the conditions.”

  • Shocking, that a government agency responsible for the oversight and safety of all South African aircraft was not able to adhere to their own rules!
    Unfortunately, this resulted in the death of three of their own staff members and their families will never have closure on what actually transpired… 😔
    We underestimate the effect that this shocking report has on the trust that we are supposed to have in these government institutions who should uphold the rules!

  • Why the surprise? This is a government agency, as are SANRAL, PRASA, SSA, need we look further? Can any of them show any sign of improvement over the last how many years.

  • This is a bit like the government’s own buildings not complying with the government’s own fire regulations as per the Parliament situation.

  • Mr Sputla Lekalakala should be applauded for his dedication to see justice done. And my deep sympathy for his loss – which must be all the more painful in these circumstances. I do hope that people get charged and convicted to save other’s lives and to show respect for theses three people.

  • Absolutely shocking and sickening. I’m very sorry for all affected by this awful loss. At the very least justice must be done and swiftly too.

  • An unbelievable mess that can directly be attributed to cadre deployment. The other issue that I have, is that the report skirts around the root cause of the accident with much sensitivity. As per Guy Leitch, the blunt assessment is that Captain Tolo was unsuitable for the job. SACAA needs to be cleaned up without delay.

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