MINISTRY OF TRANSPORT AND INFRASTRUCTURE

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AIR ACCIDENT INVESTIGATION

FINAL ACCIDENT REPORT

5Y-HVT

21st March, 2014

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

Table of content

1 Title ........................................................................................................................................... 1-7

2 Synopsis ................................................................................................................................... 11

3 Factual Information ......................................................................................................... 13

3.1 History of flight .......................................................................................................... 13

3.2 Injuries to persons .................................................................................................... 14

3.3 Damage to Aircraft: .................................................................................................. 15

3.4 Other Damage .............................................................................................................. 17

3.5 Personnel Information ............................................................................................ 18

3.5.1 Duty times before the accident: .............................................................. 18

3.6 Aircraft Information ................................................................................................ 19

3.7 Meteorological information ................................................................................. 19

3.8 Aids To Navigation .................................................................................................... 20

3.9 Communication .......................................................................................................... 20

3.10 Aerodrome Information ...................................................................................... 20

3.11 Flight Recorders ...................................................................................................... 22

3.12 Wreckage and Impact Information .............................................................. 22

3.13 Medical and Pathological Information ....................................................... 23

3.14 Fire ................................................................................................................................... 23

3.15 Survival Aspects ...................................................................................................... 23

3.16 Tests and Research ................................................................................................ 23

3.17 Organisation and Management Information .......................................... 23

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3.18 Additional Information ........................................................................................ 24

3.19 Useful or Effective investigation Techniques ....................................... 24

4 Analysis .................................................................................................................................... 25

4.1 Fuel System .................................................................................................................. 25

5 Conclusions ........................................................................................................................... 27

6 Probable course ................................................................................................................... 27

7 Safety Recommendations ............................................................................................. 29

8 Appendix .................................................................................................................................. 31

List of Figures and Tables Figures Figure 1: Aircraft at the site of accident ............................................................................................... 15

Figure 2: Damaged Propellars and collapsed nose gear ................................................................ 16

Figure 3: collapse and damage nose gear/deflated starboard tyre .......................................... 16

Figure 4: damaged nose undercarriage with deflated nose wheel ............................................ 17

Figure 5: Damaged taxi lights ................................................................................................................... 17

Figure 6: Malindi Airport layout ............................................................................................................. 21

Figure 7: Initial impact point and wreckage distribution ............................................................. 22

Tables Table 2 : Injuries to Persons ..................................................................................................................... 14

1 Title

OPERATOR: Aeronav Limited

AIRCRAFT TYPE/ MANUFACTURER: Cessna 206/Cessna Aircraft

Company YEAR OF MANUFACTURE: 1964

AIRCRAFT REGISTRATION: 5Y-HVT

AIRCRAFT SERIAL NUMBER: 206 0213

DATE OF REGISTRATION: 03th May 2001 TYPE OF ENGINE: Continental IO-520

DATE OF OCCURRENCE: 28th Sep 2012

TIME OF OCCURRENCE: 0830

LOCATION OF OCCURRENCE: Malindi Airport (HKML) TYPE OF FLIGHT: Charter

NUMBER OF PERSONS ON BOARD: 6

INJURIES: None

NATURE OF DAMAGE: Substantial

CATEGORY OF OCCURRENCE: Accident NAME OF PIC: Harro Trempenau

PIC’S FLYING EXPERIENCE: CPL 4663 hrs

Times given in this report are Coordinated Universal Time (UTC) East African Local Time is UTC plus 3 hours.

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2 Synopsis

The Chief Inspector of Air Accidents, Air Accident Investigation Department under the Ministry of Transport was notified of an accident at Malindi Airport (HKML) on 28th September 2012, which had occurred at 0830. It was reported that a light aircraft, a Cessna 206 had had an engine failure after take off on runway 17, and executed a forced landing in the same airport. Two Air Accident investigators were dispatched to the site of the accident on the same day to begin preliminary investigations into the probable cause of the accident. Investigations were started four hours after the accident.

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3 Factual Information

3.1 History of flight Investigations revealed that the aircraft, a Cessna 206, registration 5Y-HVT was on the second charter flight of the day after successfully completing another charter flight in the same airport for skydivers para-drop an hour earlier. There were 6 souls on board, a crew of one and five passengers. The chartered flight was to climb to flight level 105 for the para-drop, then return to the same airport. The pilot reported to have started his day well, and arrived at the airport at 0605. He went straight to the aircraft and performed a preflight check. He reported to have physically checked the fuel tanks with a dipstick, where he found he had 55 litres of fuel in each tank. He also reports to have confirmed this by his electronic fuel gauge in the cockpit instrument panel, (JPI FS 450), which also indicated similar readings as the dipstick measurements. All was well with the first flight, and the pilot took-off runway 17 at 0650 for FL 105 with a normal descent and landing after the drop. The landing was at 0622 with fuel usage of about 30 liters for the 32 minutes of flight. No top-up of fuel was done after the flight. At 0825, the next group of five skydivers boarded the aircraft. The weight and balance check done showed the parameters were within the aircraft mass and balance limits. Before being cleared by the Malindi Tower to backtrack runway 17, all the engine run-up checks were carried out at the holding point by the pilot. He reported all parameters were within normal. He specifically stated in his report he carried out magneto drop check and the required power checks at the holding point runway 35. He also states that he did not put on the electronic fuel pump as it was ‘not one of the before take-off checks’. After clearance was obtained to backtrack runway 17 and upon lining up, he reported to have completed the take-off checks,

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including a take-off flap setting of 20 degres. Take off clearance was obtained at 0830 with a normal take off roll and rotation. No abnormalities were noted, with normal manifold pressure and an engine RPM of 2850. At about 200 feet agl, the pilot reported to have cleaned up and trimmed the aircraft for best climb rate at the speed of 85 knots at an engine RPM of 2700. He reported have lost all power shortly afterwards, while still above the airport, and opted to land on the adjacent runway 26. He declared emergency to the Malindi Tower and proceeded to execute a forced landing on runway 26. However, after touching down on the threshold of runway 26, the aircraft veered off to the left and excursed the runway. The hard-landing lead to the collapse of the nose gear under-carriage and resultant propeller ground strike. The aircraft also span around after the nose gear collapse leading to the damage sustained in the main undercarriage. The crew and the passengers did not sustain any injuries. Location The Flight was being executed at Malindi International Airport, Kenya, HKML. The accident occurred at 0830, during the day.

3.2 Injuries to persons Table 1 : Injuries to Persons

Injuries Crew Passengers Others

Fatal 0 0 0

Serious 0 0 0

Minor/none 1 5

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No injuries were sustained by any of the person onboard or outside the aircraft.

3.3 Damage to Aircraft: The aircraft sustained substantial damage. Due to the resultant hard landing, there was mild warping of the tail section fuselage of the aircraft. The nose undercarriage also collapsed, and sustained substantial damage. This lead to the resultant propeller ground strike, leading to substantial damage to all the propellers. The starboard gear strut and assembly also sustained substantial damage, with tyre damage leading to deflation.

Figure 1: Aircraft at the site of accident

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Figure 2: Damaged Propellars and collapsed nose gear

Figure 3: collapse and damage nose gear/deflated starboard tyre

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Figure 4: damaged nose undercarriage with deflated nose wheel

3.4 Other Damage Minor damage was sustained by taxiway lights, at the threshold of runway 26. No other objects sustained any damage

Figure 5: Damaged taxi lights

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3.5 Personnel Information The pilot in command was Mr. Harro Volker Trempenau, a German citizen by birth. He is a holder of a validly issue Kenyan Commercial Pilot license YK-2049-CL, with an expiry date of 19th December 2012. He also has a valid first class medical certificate issued on 13th June 2012. Having been born on 16th September 1946, he was 66 years and 12 days old at the time of the accident. He has a total of 4663 hours as of the date of accident with over 4000hrs on type. He is rated to fly landplanes, and holder of Cessna 206, Cessna 150, and Cessna 182 ratings. Most of his flying hours are on Cessna 206. The last flight check he had was for his Commercial Pilot License in 1999. There is nothing on his personal file at the KCAA indicating any other checks after the achievement of his Commercial Pilot License. He does not have an Instrument Rating and neither does he have any training on instrument flying. This was a single crew operation.

3.5.1 Duty times before the accident:

Last 24 hrs: 0.5 hours

Last 7 days: 1.5 hours

Last 30 days: 18.75 hours

An air traffic controller manned the tower at the time of the accident. The ATC reported having received a distress call from 5Y-HVT shortly after take-off. Emergence response was initiated immediately, but no fire or injuries were reported after the forced landing.

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3.6 Aircraft Information The aircraft, 5Y-HVT, a Cessna 206 is owned by Argonaut Limited and was registered in 2001. It had been leased to Aeronav Limited as the Operator. It had a valid certificate of airworthiness upto 24th may 2013, and categorized as Commercial Air Transport (Passengers). A certificate of release to service (CRS) serial no. 0201 had been issued for check 1 maintenance carried out at Wilson airport by AMREF Flying Doctors, a KCAA approved Maintenance Organization. It was signed out by engineer D. Mutava, license no YK-C24 on 29th August 2012. The aircraft had a valid Aircraft Station License expiring on 30th June 2013. There were no known deficiencies prior to the incidence. The aircraft had completed a 30 minutes para-drop flight an hour earlier with no problems reported. Mass and center of gravity were within the prescribed limits as per attached load sheet. The Aircraft had been fueled with AVGAG, 110 liters prior to the initial flight and was not refueled for the second flight of the day.

3.7 Meteorological information Prevailing meteorological conditions at the time of accident were CAVOK, with very light southerly winds. The flight was during the day, so there was sufficient lighting.

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10:00 AM

29.0 °C 30.7 °C 20.0 °C 58% 1017 hPa 10.0 km South 9.3 km/h / 2.6 m/s - N/A Partly Cloudy

11:00 AM

30.0 °C 31.2 °C 19.0 °C 51% 1016 hPa 10.0 km South 18.5 km/h / 5.1 m/s - N/A Partly Cloudy

12:00 PM

31.0 °C 33.0 °C 20.0 °C 52% 1015 hPa 10.0 km South 18.5 km/h / 5.1 m/s - N/A Partly Cloudy

3.8 Aids to Navigation There is a DVOR/DME with SIDS and STAR.

3.9 Communication The pilot was in two way communication with the Malindi Tower through out, and no communication failure was reported.

3.10 Aerodrome Information The airport is a medium-sized airport that serves the town of Malindi. Situated at 76 feet (23 m) above sea level, the airport has two bitumen runways:

the first one, 17/35 measures 4,600 feet (1,400 m) long and is 98 feet (30 m) wide,

the second runway, 08/26 measures 3,549 feet (1,082 m) and is 76 feet (23 m) wide.[5]

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Figure 6: Malindi Airport layout The aerodrome has ATC, with Malindi Tower providing control services relevant information.

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3.11 Flight Recorders The Aircraft was not fitted with any flight recorders.

3.12 Wreckage and Impact Information The aircraft came to rest about 20 meters from the initial point of impact. The under belly cargo pod had disintegrated and was resting 10 meters from the aircraft. There was no evidence of pre-impact break-up of the aircraft.

Figure 7: Initial impact point and wreckage distribution

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3.13 Medical and Pathological Information No injuries were sustained in the crash. No pathological tests were deemed necessary after the accident.

3.14 Fire There was no post crash fire at the site of accident. No evidence of engine fire was found at the site of accident.

3.15 Survival Aspects The aircraft is used to drop skydivers from height and so, the doors and seats had been removed as per specifications of the functions of the aircraft. Evacuation after the aircraft came to a stop was immediate with no hindrances whatsoever. No search and rescue was needed. No evidence of failures of any structures such as seat belts attachments was found.

3.16 Tests and Research No tests and research was carried out on any components.

3.17 Organization and Management Information

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The aircraft was a lease from Argonaut Limited to Aeronav Limited and was operating under the Aeronav Aircraft Operators Certificate (AOC). It was mostly carrying out commercial passanger operations, the bulk of which was para-drops to skidivers.

3.18 Additional Information

N/A

3.19 Useful or Effective investigation Techniques

N/A.

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4 Analysis

4.1 Fuel System Fuel is supplied to the engine from two tanks, one on each wing. Usable fuel in each tank, for all flight conditions, is 31.5 gallons for standard tanks. Note Unusable fuel is at a minimum due to the design of the fuel system. However, with ¼ tanks or less, prolonged uncoordinated flight such as slips or skids can uncover the fuel tank outlets, causing fuel starvation and engine stoppage. Therefore, with low fuel reserves, do not allow the aircraft to remain in uncoordinated flight for periods in excess of one minute. (Section II owners manual 2-1) Fuel from each tank flows through a fuel reservoir tank to the fuel selector valve. Depending upon the setting of the selector valve, fuel from the left or the right tank flows through a by-pass in the electric auxillary fuel pump (when it is not operating) and fuel strainer to the engine-driven fuel pump. From here, fuel is distributed to the engine cylinders via a fuel control unit and manifold. Note: Fuel cannot be used from bot tanks simultaneously. Vapor and excess fuel from the engine-driven fuel pump and fuel control unit are returned by way of the selector valve to the reservoir tank of the wing tank system being used. Note iii

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If the engine-driven pump is functioning and the auxillary fuel pump switch is placed in the ON position, a fuel/air ration considerably richer than the best power is produced unless the mixture is leaned. Therefore, the switch should be turned off during take-off. Note IV If the auxiliary fuel pump switch is accidentally placed in the ON position with the master switch on and the engine stopped, the intake manifolds will be flooded. The auxiliary fuel pump switch is located on the left side of the instrument panel and is a yellow and red split-rocker type switch. The yellow right half of the switch is labeled START, and its ON position is used for normal starting, minor vapour purging and continued engine operation in the event of the engine-driven fuel pump failure. The red half of the switch is labeled EMERG, and its upper HI position is used in the event of an engine-driven fuel pump failure during take-off of high power operation. The HI position may also be used for extreme vapor purging.

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5 Conclusions

1. The Pilot was over age to be holding a commercial pilot license as per CAP 394.

2. The aircraft was properly certificated and licensed for the

operation it was carrying out.

3. The Pilot mismanaged his take off by not:-

Switching to the fuller tank for take-off

Switching on the electrical fuel pump for take-off

This lead to fuel starvation of the engine during a critical period which resulted in the engine shut down and loss of power.

6 Probable course

With the evidence deduced during the investigation, the probable course of the accident was loss of power due to fuel starvation leading to a forced landing.

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7 Safety Recommendations

1. The KCAA oversight role must be enhanced to ensure the

personnel license regulations are adhered to.

2. Regular Emergency drills should be carried out to ensure readiness and optimal preparedness resulting in minimal casualties in times of actual emergencies.

3. During renewal of license, an examiner should certify that

the Pilot is competent in handling emergencies in the relevant aircrafts.

………………………………………………….........

Chief Investigator of Accident Air Accident Investigation Department

……………….………………………………….

Cabinet Secretary Ministry Transport and Infrastructure

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8 Appendix

Appendix 1: PL License ............................................................................................................................... 35

Appendix 2: RL License .............................................................................................................................. 36

Appendix 3: CPL License ............................................................................................................................ 37

Appendix 4: CPL/PL License .................................................................................................................... 38

Appendix 5: CPL License ............................................................................................................................ 39

Appendix 6: Radio Operator License ..................................................................................................... 40

Appendix 7: License Ratings ..................................................................................................................... 41

Appendix 8: English Proficiency ............................................................................................................. 42

Appendix 9: Log book Copy ...................................................................................................................... 43

Appendix 10: Logbook copy ..................................................................................................................... 44

Appendix 11: Logbook copy ..................................................................................................................... 45

Appendix 12: Pilots Statement ................................................................................................................ 46

Appendix 13: Pilots statement ................................................................................................................. 47

Appendix 14: Logbook Copy ..................................................................................................................... 48

Appendix 15: Certificate of insurance................................................................................................... 49

Appendix 16: Pilots First Class Medical Certificate ......................................................................... 50

Appendix 17: Weight and Balance ......................................................................................................... 51

Appendix 18: Certificate of Registration.............................................................................................. 52

Appendix 19: Certificate of Airworthiness ......................................................................................... 53

Appendix 20: Certificate of release to service ................................................................................... 54

Appendix 21: Aircraft station license .................................................................................................... 56

Appendix 22: Tower flight strip .............................................................................................................. 56

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35

Appendix 1: PL License

36

Appendix 2: RL License

37

Appendix 3: CPL License

38

Appendix 4: CPL/PL License

39

Appendix 5: CPL License

40

Appendix 6: Radio Operator License

41

Appendix 7: License Ratings

42

Appendix 8: English Proficiency

43

Appendix 9: Log book Copy

44

Appendix 10: Logbook copy

45

Appendix 11: Logbook copy

46

Appendix 12: Pilots Statement

47

Appendix 13: Pilots statement

48

Appendix 14: Logbook Copy

49

Appendix 15: Certificate of insurance

50

Appendix 16: Pilots First Class Medical Certificate

51

Appendix 17: Weight and Balance

52

Appendix 18: Certificate of Registration

53

Appendix 19: Certificate of Airworthiness

54

Appendix 20: Certificate of release to service

55

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Appendix 21: Aircraft station license

Appendix 22: Tower flight strip