air serv international – beechcraft 1900c-1 (zs-old)

AIR SERV INTERNATIONAL –
BEECHCRAFT 1900C-1 (ZS-OLD)
Background Information
Page 1
Background Facts and Potential Cause Analysis
Aubin N.Mabanza
Avocat a la Cour
KLAM & Partners
4955 Avenue de la Gombe
Kinshasa - Gombe
Democratic Republic of Congo
On the 1st of September 2008, a Beechcraft 1900C-1, registration ZS-OLD operated by Air Serv
International, departed Kinshasa Airport on a humanitarian flight to Goma (GOM). En route
stops were made in Mbandaka (MDK) and Kisangani (FKI). The last stop before Goma would
be Bukavu (BKY), a one hour flight from Kisangani. En route to Bukavu, the aircraft flew into
a steep ridge, some 15 km northwest of Bukavu. The crash site is at about 9000 ft - 10000
ft above sea level and is a steep slope of mount Kahuzi. The area is thick jungle. The 2 crew
and 15 passengers were killed.
Bernard Solitude
Avocat a la Cour
Cabinet d’avocats Bernard Solitude
7 rue de la Bourse
Paris
France
Noel Enzouni
Avocat a la Cour
Cabinet NOEL ENZOUNI & Associates
Immeuble Basile Local
11 avenue du Commerce
Kinshasa - Gombe
Democratic Republic of Congo
Calehr & Associates
2700 Post Oak Boulevard,
Suite 1220
Houston
Texas 77056
Stewarts Law LLP
5 New Street Square
London
EC4A 3BF
Tel: +44 (0)20 7822 8000
Fax: +44 (0)20 7822 8080
Website: www.stewartslaw.com
Email: [email protected]
There is very little information on what caused the crash other than the location and the
fact that contact was lost. Reports indicate that the weather conditions were poor at the
time meaning that if the aircraft entered cloud it would have to ensure that it stayed above
its safety altitude in the mountainous terrain and fly a published instrument approach into
Bukavu.
The location of the crash is approximately on the track it would have been flying from
Kinsangani Airport. In this location the Minimum Safe Altitude (MSA) is 12400 ft because
of the line of mountains west northwest of Bukavu. The height the Beechcraft crashed was
AIR SERV INTERNATIONAL –
BEECHCRAFT 1900C-1 (ZS-OLD)
Background Information
Page 2
over 2000 ft below the MSA. The MSA is shown on the Global Navigation Satellite System (GNSS) approach chart.
The GNSS approach for Bukavu (Runway 35) shows that at the starting points for the approach (OLSON and DOPEM),
which are south/ southwest of the airfield, an aircraft should be at or above 11000 ft. For some reason the Air
Serv Beechcraft descended early ( while over mountains) northwest of the airfield, below its safety altitude of
12400 ft and below the 11000ft starting altitude for the published approach. As a result of this descent the aircraft
crashed near the top of the mountain ridge. There are no reports/ record of any emergency transmissions from
the aircraft.
MSA
Crash site - on
mountains approx
15 KM northwest of
Bukavu at 9000 –
10000 ft
BUKAVU
AIRPORT
GNSS start
point
GNSS start point
GNSS Approach Chart - Bukavu
AIR SERV INTERNATIONAL –
BEECHCRAFT 1900C-1 (ZS-OLD)
Background Information
Page 3
Beechcraft 1900C-1 Registration ZS-OLD
The accident aircraft, a Hawker Beechcraft 1900 C-1, is a 19-passenger, pressurized twin-engine turboprop airplane
manufactured by the Beech Aircraft Corporation, previously the Beechcraft Division of Raytheon and now a unit
of Hawker Beechcraft. It was designed as and is primarily used as a regional airliner. It is powered by two PT6A
turbine engines, which are manufactured by Pratt & Whitney Canada, a Canadian aircraft engine manufacturer.
Beechcraft 1900C-1
The Air Sev Beechcraft was built in 1990 and owned by CemAir, based in South Africa. It was being leased to Air
Serv International which is a not for profit aviation organization based in America.
Potential Causes of the accident
This crash is one of 5 Beechcraft 1900 crashes in 2008. In total there have been 27 catastrophic Beechcraft 1900
crashes since 1987.
The Democratic Republic of Congo is conducting an accident investigation into the Bukavu crash but the report will
take some time. Fortunately the Accident Data Recorder (ADR) has been recovered which will hopefully enable the
investigators to determine the cause(s) of the accident. Until the final report is made available there are limited
facts, which mean any accident analysis at this stage cannot determine the exact cause of the crash. As there
are many potential factors that could have contributed to the crash, this analysis will only on focus on 4 potential
causes at this stage, namely, controlled flight into terrain, faulty flight instruments, weather and engine failure.
1.
Controlled Flight into Terrain (CFIT).
CFIT describes an accident whereby an airworthy aircraft, under pilot control, inadvertently flies into terrain, an
obstacle, or water. The pilots are generally unaware of the danger until it is too late. The incidents often involve
AIR SERV INTERNATIONAL –
BEECHCRAFT 1900C-1 (ZS-OLD)
Background Information
Page 4
impact with significantly raised terrain such as hills or mountains, and may occur in conditions of clouds or otherwise
reduced visibility. CFIT often occurs during aircraft descent to landing, near an airport.
If the pilot is using automated systems to fly and navigate the aircraft, he must ensure that the data he inputs
into those systems is correct. If it is incorrect, the pilot may mistakenly believe that he is over low ground when
in fact he is on a collision course with high ground. An example of this situation is Air New Zealand Flight 901,
a McDonnell Douglas DC-10-30 that crashed into Mount Erebus, killing all 237 passengers and 20 crewmembers
aboard because the crew made a mistake when entering the flight coordinates into the aircraft computer.
CFIT can also occur when a pilot descends into cloud believing, through visual illusion/ mistake, that below (or
between a break in the cloud) there is good clearance from terrain and good visibility, enabling him to fly visually
below the cloud. An example of a pilot mistakenly flying a Beechcraft into terrain in similar circumstances is a
Raytheon Aircraft Ferry Flight of a Beechcraft 1900C on 9 December 2002. This case involved the pilot descending
and crashing into a mountain ridge which was below a layer of cloud.
2.
Flight Instrument Fault
CFIT may be associated with equipment malfunction. Malfunction of the flight instruments or navigation equipment
can confuse/ distract crew and cause them to fly the aircraft into the ground.
Beechcraft 1900C-1 flight instruments
Pilots rely on the flight instruments to fly the aircraft safely. The primary flight instruments display information to
the pilot so that he knows what the aircraft is doing in terms of roll, pitch, speed, height and heading.
Attitude Indicator (AI) – shows roll and pitch
Airspeed Indicator (ASI)
Horizontal Situation Indicators (HSI)
Show heading/ navigation information
Altimeter – displays
height
In good visibility, the pilot is not totally reliant on the flight instruments but can also use visual cues to fly.
AIR SERV INTERNATIONAL –
BEECHCRAFT 1900C-1 (ZS-OLD)
Background Information
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While in cloud he will be totally reliant on the instruments.
If the Air Serv Beechcraft entered cloud and there was a fault with any of the flight instruments, the aircraft could
have ended up in an unusual flight parameter which would have been difficult to recover from and or distracted
the pilots, resulting in a loss of height and possible descent below the safety altitude.
Beechcraft Autopilot/ Global Positioning System (GPS).
The pilots engage these systems to fly the aircraft automatically and to navigate in all weather conditions. If there
is a fault in these systems that is not noticed promptly, the aircraft can end up in a dangerous flying attitude and/
or stall causing it to descend. Furthermore, if there is a fault in the GPS/ navigation systems the displayed position
of the aircraft may be incorrect which could lead the crew to start a descent too early.
As with many other passenger aircraft, the Air Serv Beechcraft 1900C-1 had a Ground Proximity Warning System
(GPWS), probably manufactured in the USA by Sundstrand/ Honeywell, which uses a Radar Altimeter to assist in
calculating terrain closure rates. When this system senses the aircraft is going to collide with the ground, it gives
an audible warning and tells the pilot to “pull up”. Unfortunately, there have been previous accidents in a number
of different types of aircraft where the GPWS systems have not given the prior warning they were designed to,
resulting in the aircraft crashing into the ground. Examples of this are the Ansett New Zealand DHC-8-102 flight on
9 June 1995 and the Garuda Airbus A300 crash on 26 September 1997.
Ansett New Zealand DHC-8-102: During an instrument approach in cloud to Palmerston North Airport(PMR), New
Zealand, the aircraft descended below the glideslope and crashed. The Sundstrand GPWS audio alarm sounded
only 5 seconds before impact when it should have given a 17 second warning. 1 crew and 3 passengers were
killed.
Garuda Airbus A300 Flight 152: All 224 occupants were killed when this aircraft crashed 18 miles from its destination
airfield. There has been a successful lawsuit by the Wisner Law firm concerning the late proximity warning by the
Sundstrand GPWS system because it only gave a 5 seconds warning instead of an 18 – 23 seconds warning.
Further information on how well the flight instruments, autopilot, GPS and GPWS were performing in the Air Serv
Beechcraft is required to determine if a fault in these systems caused/ contributed to the crash.
3.
Weather
As the Air Serv Beechcraft was flying over mountainous terrain, adverse weather may have caused it to lose height.
Two factors that can cause this are thunderstorms and airframe icing.
If an aircraft enters a thunderstorm, it can experience severe updrafts and downdrafts and in addition to large
hailstones, damaging lightning, torrential rain and airframe icing, all of which are potentially hazardous to aircraft.
AIR SERV INTERNATIONAL –
BEECHCRAFT 1900C-1 (ZS-OLD)
Background Information
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Due to the dangers, pilots should avoid flying within 5 miles of a thunderstorm. They do this by analysing the weather
forecast before flight and monitoring the weather radar during flight. If the Beechcraft pilots flew close to a thunderstorm
and encountered severe turbulence, this could be the reason it ended up descending over 2000 ft below safety altitude.
Also, when flying in cloud the droplets of water in the cloud can be at a temperature lower than zero degrees
Celsius, known as “super cooled”. When these droplets come into contact with the surface of the aircraft they
freeze onto the surface. In severe icing this can adversely affect the aerodynamics of the aircraft, restrict the
movement of flying controls and cause the engines to lose power. This can lead to a descent/ departure from
controlled flight.
In-flight icing on the leading edge of a wing
Because of the dangers of icing, the Beechcraft 1900C-1 has an airframe anti-icing system manufactured by Goodrich,
USA. Analysis of the ADR should reveal whether the Air Serv Beechcraft was in icing conditions and whether the
anti-icing system was working correctly.
4.
Engine problems.
Aircraft engines can fail for a number of reasons such as mechanical failure, fuel contamination/ blockage, and fire.
Twin engine passenger aircraft are designed so that they can fly safely on one engine. Single engine (asymmetric)
flight is more difficult because there is much less thrust available and the aircraft thrust vector is out of balance,
meaning the aircraft always wants to veer (yaw) towards the side where the failed engine is – e.g. if the failed
engine is on the left wing the aircraft will want to veer left and vice versa.
Properly trained and experienced flight crew are constantly practicing this kind of emergency in flight simulators
and should have no difficulty in flying the aircraft by applying appropriate rudder (controls yaw), aileron (controls
roll) and power inputs.
If the flight crew of the Beechcraft had the appropriate experience and training, a single engine failure on its
own would not have caused the crash – there would have to be an additional failure such as problems with both
AIR SERV INTERNATIONAL –
BEECHCRAFT 1900C-1 (ZS-OLD)
Background Information
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engines, adverse weather, or fire.
Alternatively, if the crew were inexperienced and/ or not properly trained, the handling pilot may have mishandled
the aircraft by not controlling the asymmetric thrust induced yaw and or not efficiently managing the 50% reduction
in thrust, resulting in an uncontrolled descent or the aircraft stalling and dropping out of the sky. Two examples
of Beechraft 1900C engine failures are Southern Air Charter in October 2004 and Southern Sudan Air Connection in
May 2008.
Southern Air Charter Flight 204: During flight the right engine lost power and eventually the engine failed.
Unfortunately, while approaching to land , the left engine also lost power resulting in the aircraft ditching short of
the runway. Fortunately all occupants survived.
Southern Sudan Air Connection: The Beechcraft 1900C-1 departed Wau, Sudan on a flight to Juba, Sudan via Rumbek.
Near Rumbek the pilot reported engine problems then the aircraft crashed killing all 21 on board. The accident
investigation is ongoing and there is speculation that both engines failed. As for Air Serv International, this
Southern Sudan Air Connection Beechcraft was owned by CemAir. Stewarts Law is representing the families of 15
passengers.
Other factors
As has already been explained, there is not yet enough evidence to say exactly what caused the crash – other
factors such as fire, electrical problems, flying control malfunctions etc could have caused/ contributed to the
accident. The scenarios set out in paragraphs 1 – 4 above are possibilities based on the limited evidence that is
available at this time.
Liability Investigation
The families of those who were killed have the right to seek compensation for the damage they have suffered
against various potential defendants. Viable potential targets for liability include the following:
1.
2.
3.
4.
5.
6.
7.
Hawker Beechcraft – the designer and manufacturer of the Beechcraft 1900C-1, based in the USA.
Pratt & Whitney – as the manufacturer of the engines, based in the USA.
Various component/ sub-component manufacturers of flight instruments and flight critical products on the
Beechcraft 1900C-1.
Air Serv International, based in the USA – as air carrier and lessee of the aircraft, Air Serv International have
specific responsibilities for their passengers and crew.
CemAir – the owner of the aircraft, based in South Africa.
Atlantic Turbines – the company responsible for the maintenance and overhaul of aircraft engines for CemAir,
based in Canada and the USA.
Insurers and re-insurers of the potential targets, mostly based in London, UK.