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Section/division Occurrence Investigation Form Number: CA 12-12a

AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY

Reference: CA18/2/3/8817

Aircraft Registration ZS-RVB Date of Accident 5 August 2010 Time of accident 16:08:18Z

Type of Aircraft Robinson R22 Beta II Type of Operation Private

Pilot-in-command Licence Type Private - Helicopter Age 45 Licence Valid Yes

Pilot -in -command Flying Experience Total Flying Hours 516.2 Hours on Type 516.2

Last point of departure Klein Zwart Bast Farm – Northern Cape

Next point of intended landing Groot Riet Farm - Northern Cape

Location of the accident site with reference to eas ily defined geographical points (GPS readings if possible)

Open deserted landscape approximately 3.7nm North of Groot Riet Farm Northern Cape at GPS coordinates: S29˚24.572 E020˚43.265 Meteorological Information Wind: 010º/04kt. Temperature: 25ºC Cloud Base: >10000 Cloud: None

Number of people on board 1 + 1 No. of people injured 0 No. of people killed 2

Synopsis The pilot who was also the owner of the helicopter was accompanied by a passenger on a repositioning game culling flight from Klein Zwart Bast Farm to Groot Riet Farm in the Northern Cape when the helicopter failed to arrive at their destination at the expected time of arrival. The South African Police Service (SAPS) assisted by local farmers community initiated a search and rescue operation along the flight path track between Klein Zwart Bast farm and Groot Riet farm. The search and rescue operation continued throughout the night and the wreckage of the helicopter located the following morning of 6 August 2010 at approximately 0810Z. The aircraft was destroyed on impact and the both occupants were fatally injured. It was established during the on-site investigation, that the navigation light wiring and the strobe light electrical cable inside the tail boom was wrapped around the tail rotor drive shaft and stacked up against the flex plate assembly at the tail rotor gearbox end. The pilot, most likely, was concerned when he experienced some vibration and a noise when the wiring was being stacked against the flex plate at the tail rotor gearbox and decided to land as soon as possible. According to the GPS that was downloaded, the accident occurred at approximately 1608Z that was past sunset and at the time that the sun already disappeared below the horizon with the lack of visual reference. Observations during the on-site investigation showed that the helicopter was submitted to a very hard landing on the main landing skids during a vertical descent. The helicopter remained upright but was destroyed on impact with the level bush type terrain. The pilot and passenger were fatally injured on impact with the ground surface. Evidence showed that the engine was not running on impact with the terrain as indicated by the engine squirrel cage fan. Probable Cause /s

Unsuccessful autorotational landing. Contributory factor: The pilot became disorientated due to reduced visibility conditions after sunset

IARC Date Release Date

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Section/division Occurrence Investigation Form Number: CA 12-12a Telephone number: 011-545-1000 E-mail address of originator: thwalag@caa.co.za

AIRCRAFT ACCIDENT REPORT

Name of Owner/Operator : A.W.A van Wyk Manufacturer : Robinson Helicopter Company Model : R22 II Beta Nationality : South African Registration Marks : ZS-RVB Place : Approximately 3.7nm North of North Riet Farm GPS

Coordinates 29˚24.572 E020˚43.265 Date : 05 August 2010 Time : 16:08:18Z 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. Purpose of the Investigation: In terms of Regulation 12.03.1 of the Civil Aviation Regulations (1997) this report was compiled in the interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and not to establish legal liability . Disclaimer: This report is given without prejudice to the rights of the CAA, which are reserved.

1. FACTUAL INFORMATION 1.1 History of Flight 1.1.1 On 5 August 2010 at approximately 1600Z, the pilot who was also the owner of the

helicopter, was accompanied by a passenger on a repositioning game culling flight from Klein Zwart Bast Farm at GPS coordinates S29 29.249 E20 42.900 to Groot Riet Farm at GPS coordinates S29 20.512 E20 43.332 in the Northern Cape when the helicopter failed to arrive at their destination at the expected time of arrival.

1.1.2 The South African Police Service (SAPS) at Kenhardt assisted by local farmer’s

community initiated a search and rescue operation along the flight path track the helicopter was scheduled to have flown between Klein Zwart Bast farm and Groot Riet farm. The search and rescue operation continued throughout the night and the wreckage of the helicopter was located the following morning of 6 August 2010 at approximately 0810Z. The aircraft was destroyed on impact with the terrain and the both occupants fatally injured.

1.1.3 It was established during the on-site investigation, that the navigation light wiring and the strobe light electrical cable inside the tail boom was wrapped around the tail rotor drive shaft and stacked up against the flex plate assembly at the tail rotor gearbox end. It is assumed that during mid-flight, the noise and some vibration from the tail boom most probably disturbed the pilot and he decided to land immediately.

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Available evidence indicated that the engine was not running prior to impact with the terrain and also confirmed by the squirrel cage fan that was stationary on impact.

1.1.4 According to the GPS that was downloaded, the accident occurred at approximately

1608Z on 6 August 2010 that was past sunset and at the time that the sun already disappeared below the horizon with the lack of visual reference. Observations during the on-site investigation showed that the helicopter was submitted to a very hard landing on the main landing skids during a vertical descent. The helicopter remained upright but was destroyed on impact with the level bush type terrain. The pilot and passenger were fatally injured on impact with the ground surface. The collective stick was found in the fully up position that suggest that he attempted to cushion the landing just prior to the impact.

1.1.5 The location of the accident site was in an open deserted landscape at GPS

coordinates S29 24.572 E20 43.265.

Figure 1 shows track flown from Klein Zwart Bast to Groot Riet farm.

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Figure 2, GPS downloaded track flown up to the point of impact.

1.2 Injuries to Persons

Injuries Pilot Crew Pass. Other Fatal 1 - 1 - Serious - - - - Minor - - - - None - - - -

1.3 Damage to Aircraft 1.3.1 The aircraft was destroyed during a vertical descent and hard landing with the terrain.

View from right side

View from left side

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Figure 3, shows the wr eckage on impact during a vertical descent. 1.4 Other Damage 1.4.1 None. 1.5 Personnel Information 1.5.1 Pilot-in-command:

Nationality South African Gender Male Age 45

Licence Number 0272329020 Licence Type Private-Helicopter

Licence valid Yes Type Endorsed Yes Ratings Flight Test – Single Engine Piston Medical Expiry Date 30 June 2011 Restrictions Corrective Lenses Previous Accidents None

1.5.2 Flying Experience:

Total Hours 516.2 Total Past 90 Days 193.1 Total on Type Past 90 Days 193.1 Total on Type 516.2

1.5.3 A “red flag” was inserted by the SACAA in the pilot file against his name regarding unauthorised owner/pilot flights transgression. The reason for the red flag was to prevent the PPL being issued if the unauthorised owner/pilot flights were not resolved. However, the red flag was removed by the SACAA Flight Operations Department and the PPL issued without any proof that the mishap had being completely resolved.

1.5.4 During the eight months from November 2009 until August 2010, the pilot recorded 113 flights and logged an amount of 423.0 hours which were predominantly for game or livestock cull operations . The pilot was not in possession of a game or livestock culling rating according to his license and did not receive specialised game or livestock culling training.

1.5.5 The pilot revalidation check or initial license skills test was due within 12 months

from the date of initial issue. He was still within the initial issue period, thus not yet required to do a skills test.

1.5.6 Other Personnel : The passenger that was carried on board the helicopter was a 20 year old male who was specifically to assist the pilot in the event of ‘Game or livestock culling

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operations”. He however did not receive any game or livestock culling training. 1.5.7 Pilot’s History Information

The history of the pilot’s training is included in this report as: Annexure “A”.

1.6 Aircraft Information

1.6.1 Airframe: Type Robinson R22 Beta Serial Number 4363 Manufacturer Robinson Helicopter Company Date of Manufacture 2008 Total Airframe Hours (At time of Accident) 647.2 Last MPI (Date & Hours) 29 July 2010 605.9 Hours since Last MPI 41.3 C of A (Issue Date) (Expiry Date) 11 March 2009 10 March 2011 C of R (Issue Date) (Present owner) 13 February 2009 Operating Categories Standard – Part 91

1.6.2 Engine: Type Lycoming O-360-J2A Serial Number L-41207-36 E Hours since New 647.2 Hours since Overhaul TBO not yet reached.

1.6.3 Main and Tail Rotor Blades:

Main Rotor Blades: Part No A016-4 Serial No 7241 Serial No 7272

Tail Rotor Blades: Part No A029-2 Serial No 2740 Serial No 2741

Total Time: 647.2

1.6.4 The pilot was also the owner of the helicopter. The helicopter was imported as a

new product from United States of America (USA) to Republic of South Africa (RSA). The helicopter was registered on the Civil Aircraft Register and issued with a Standard Certificate of Airworthiness (CoA). The helicopter was approved to be operated in the general aviation (GA) sector which is in accordance with CAR Part 91.

1.6.5 All the aircraft documentation (e.g. certificate of registration, certificate of airworthiness, and certificate of release to service etc.) was valid and complied with

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the applicable regulation.

1.6.6 Scheduled Maintenance: The helicopter was recovered to an aircraft maintenance organisation (AMO) for scheduled maintenance, which was a mandatory periodic inspection (MPI) on 23 July 2010. After the MPI was completed, the pilot flew the helicopter on an acceptance flight where after the AMO certified the helicopter airworthy and the helicopter issued with a certificate of release to service (CRS) on 29 July 2010.

1.6.7 Unscheduled Maintenance: The pilot was supposed to take the helicopter to the AMO on 5 August 2010 after 25 flying hours for an oil change at 637.6 hours. The entry in the flight folio shows that the owner/pilo t was aware of the scheduled oil change requirement but there was no evidence that h e had complied with the oil change requirement.

1.6.8 The aircraft maintenance documentation was reviewed during the investigation: (i) Work Pack: All the manufacturers’ maintenance requirements were complied

with during the last MPI. The maintenance records work pack were found to be in compliance with applicable general maintenance rules and regulations.

(ii) Logbooks: The maintenance that was carried out on the helicopter were appropriately recorded, on completion of the maintenance being performed. The logbooks were certified accordingly by the person responsible for the maintenance carried out. The logbooks were found to be in compliance with applicable regulations except the oil change as referred in paragraph 1.6.7.

(iii) Flight Folio: The helicopter flight folio was opened on 17 February 2010. The

defects entered in the flight folio were rectified and certified by the AMO. There was only one entry, which was the 25 hour oil change that was not rectified or certified.

1.6.9 Fuel Status: The helicopter was refuelled with aviation gasoline (Avgas) from a fuel

drum that was transported by a light delivery vehicle which was driven to and from different locations where the helicopter operated from. According to the driver of the light delivery vehicle, the main fuel tank (19.8 US gallons/75 litres) and the auxiliary fuel tank (10.9 US gallons/41 litres) were refuelled to full capacity. The helicopter was refuelled at approximately 15:30Z to 16:00Z on the day where after the helicopter flew on a flight until approximately 16:58Z. The pilot flew the helicopter later again on the fateful flight. It was determined that the helicopter had a sufficient quantity of fuel for the planned flight. The remaining fuel on board the helicopter after the accident happened is unknown due to the destruction of the helicopter.

1.6.10 Mass and Balance: According to the pilot operating handbook (POH), the maximum gross weight of the helicopter was 1370lbs (622 kg). The minimum gross mass was 920lbs (417 kg). The maximum mass per seat including baggage was 240lbs (109 kg).

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(i) The helicopter was weighed on 17 June

2008 and its empty mass was determined to be 873.25lbs (396kg).

(ii) According to the Pathological Report, the pilot mass was 95.1 kg and passenger 67.3 kg. The total mass for the occupants was 162.4 kg.

(iii) The weight of the baggage carried on board the helicopter was estimated to be approximately 3 to 5 kg’s.

(iv) Based on the above information the conclusion was that the helicopter mass were within the specified limits at the time of the accident.

1.6.11Technical Defects: A chip detector warning light came on during one of the previous game or livestock culling operations. The pilot immediately executed a precautionary landing at the time on a farm in the area. The incident of the precautionary landing was not reported to the relevant authorities as required by regulations. The pilot only reported the chip detector warning defect to the AM O at the time. (i) The AMO facility is based at Kimberley Aerodrome (FAKM) and the

helicopter operated in Kenhardt area in the Northern Cape. Due to the distance between the two places, it was not possible for the AMO to assist the owner/pilot immediately in order to rectify the chip detector defect. The pilot /owner then removed the chip detector after he was advised by the AMO to check the chip detector plug and to re-install it when found to be free of any metal particles and in a serviceable condition.

(ii) There was no documented record of the chip detector warning defect, the chip detector plug removal and installation in the flight folio. There was also no evidence of an entry made or report by the pilot of the chip detector defect re-occurring during the flight. Note: Robinson Helicopter Pilot Operating Handbook, Section 3, the Emergency Procedures states “tail rotor chip detector indicates metallic particles in tail rotor gearbox. If light is accompanied by any indication of a problem such as noise, vibration, or temperature rise, land immediately on the nearest clear area where a safe normal landing can be performed and an autorotation executed if required. If there is no other indication of a problem, land as soon as practical. If no metal chips or slivers are found on detector plug, clean and reinstall (tail rotor gearbox must be refilled with new oil) ”.

(iii) It appears that the owner/pilot did not carry new tail rotor gearbox oil with

him at the time and that the tail rotor gearbox was replenished the same oil that was drained during the chip detector defect inspection.

1.6.12 Parts Failing: During the on-site investigation in order to determine the probable

cause of the accident, the following deficiencies were observed:

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(i) The chip detector plug screw to which the chip detector electrical wires are attached to was found missing. The plug was closely examined and it was determined that the screw became dislodged during the flight.

(ii) The tail navigation light and strobe light electric al wires failed . The electrical wires were found rolled up around the tail rotor drive shaft in the tail boom. Based on examination it was determined that the electrical wires failed during the flight. Below see picture showing the failure:

Figure 4: showing picture from the helicopter part s catalogue showing the routing of the electrical wiring inside the tail boom.

Figure 5: Showing electrical w ires wrapped around the tail rotor drive shaft. 1.6.13 According to available information, the left hand cabin door was removed from the

helicopter. It was determined that t he door was removed specifically for the game or livestock culling operation. The door was removed for either the passenger or animal darter to dart or shoot animals from the left seat. There was no entry made in any of the maintenance documentation regarding the removal of the door. Note: According to Robinson Pilot Operating Handbook (POH), Removal of left door should be avoided to protect the tail rotor from loose objects.

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1.7 Meteorological Information 1.7.1 The weather information below was obtained from South African Weather Services.

Wind direction 010˚ Wind speed 04 kts Visibility > 10000 km Temperature 25˚C Cloud cover None Cloud

base Nil

Dew point 04˚C 1.7.2 According to the GPS information, the helicopter departed from Klein Zwart Bast

Farm at approximately 16:00Z and the accident occurred at 16:08:19Z. At the time that the accident occurred, it was considered as night time as it was past sunset when the sun already disappeared below the horizon with the lack of visual reference. The sunset on 5 August 2010 was at 16:07:44Z .

1.7.3 The helicopter was operated under visual flight rules (VFR) during the flight and in

accordance to the applicable VFR regulation: “On a flight conducted in accordance with VFR, the pilot-in-command of an aircraft

shall not commence take-off unless current meteorological reports, or a combination of current reports and forecasts, indicate that the meteorological conditions along the route, or that part of the route to be flown under VFR, shall, at the appropriate time, be such as to render compliance with the provisions prescribed in this part possible”.

Note: Robinson Helicopter Company Safety Notice SN-18, stating that “Flying a

helicopter in obscured visibility due to fog, snow, low ceiling, or even a dark night can be fatal. Loss of the pilot’s outside visual references, even for a moment, can result in disorientation, wrong control inputs, and an uncontrolled crash. This type of situation is likely to occur when a pilot attempts to fly through a partially obscured area and realises too late that he is losing visibility”.

1.8 Aids to Navigation 1.8.1 The helicopter was equipped with the standard navigation equipment as approved by

the regulator. There was no report of a defect or malfunction experienced with the navigation equipment prior to and at time of the accident.

1.8.2 Global Positioning System (GPS) downloading: A Garmin portable GPSmap 60 CSx

receiver, Unit ID 118054748 of the helicopter was recovered from the accident site. During the testing of the GPS, it was discovered that the unit had been set up with track logging which was on the latest track logs. Using a Map Source program, it was possible to download and reproduce the track of the flight. (Refer to figure below.)

1.8.3 Track Logs: There were two track logs, No 001 and 003 (No 002 was just a brief

GPS activation).

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(i) Track Log No 001 was logged on 4 August 2010 . The total duration of the

logs was 5 hours 8 minutes with a distance of 316 km. The flight track was low level and random. There were several full stops indicated which could probably be for refuelling.

(ii) Track Log No 003 was logged on 5 August 2010 . The logging started at 05:52Z at the point where 001 ended, namely S29 20.901 E020 43.485 at a GPS altitude of approximately 830m. This flight continued at about 50m above takeoff altitude at around 85km/h with a back and forth pattern over a 15 x 15km area. A total of 4 stops are indicated, varying from 3 to 38 minutes each most probably for refueling probably.

(iii) On 5 August 2010 at approximately 11:33Z, after a 37minute full stop, the

aircraft flew in a south westerly direction for approximately 10km which was to start operating in another area, in a similar way. The airspeed, height above ground and track pattern was similar to the earlier portion of the flight, but the height above sea level of the ground seems to be 100m higher in this area. Two full stops were made, one of 13 minutes and the second 1hour 4 minutes.

Figure 6, shows the final track pl ots of the flights flown at Kenhardt on 4 and 5 Aug ust 2009.

(i) On 5 August 2010 at 16:02:25Z, the helicopter took off and headed in a

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northerly direction towards the point where it started from in the morning. By 16:06:38Z it had reached 100km/h and 1330m, which was approximately 400m above the takeoff point. The airspeed and height was maintained for another minute, after which a descent and speed reduction began. In the last 30 seconds the descent rate was about 1650feet/min. The last few track plots show a slight turn to the right in a north easterly direction, followed possibly by an abrupt left turn to the west (one track plot).

(ii) The last flight track plot was at S29 24.562 E020 43:269 at 951m, i.e. 121m

above takeoff height and occurred at 16:08:19Z. The sunset was at 16:07:44Z on 5 August 2010. The total flight duration, including full stops was approximately 10 hours 15 minutes and the track length was 574km.

Figure 7, Shows the track plot up to last logged po int. 1.8.4 Below is the flight information from GPS download of the aircraft from Klein Zwart

Bast Farm up to the accident site:

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1.8.5 The

information of terrain elevation, altitude and time in the table above was plotted on a graph to show the track of the flight flown. See below picture of graph:

Way Points

Speed between way points

Terrain Elevation

Altitude Time

Kph

kts M Ft M ft

6211 0 0 921.7 3023.95 923 3028.21 17:02:00 6216 0.1 921.8 3024.28 930 3051.18 18:02:12 6221 54 29.15 920.1 3021.98 949 3113.51 18:02:31 6226 87 46.97 915.1 3002.29 969 3179.13 18:02:42 6231 101 54.53 912.5 2992.13 985 3231.62 18:02:49 6236 106 57.23 913.2 2991.47 1005 3297.24 18:03:00 6241 115 62.09 896.3 2940.62 1005 3297.24 18:03:16 6246 122 65.86 905.2 2960.96 1019 3334.17 18:03:52 6251 107 57.77 896.7 2939.63 1039 3408.79 18:04:15 6256 102 55.07 902.0 2937.66 1060 3477.69 18:04:32 6261 90 48.90 896.8 2925.85 1083 3553.15 18:04:40 6266 89 48.05 895.8 2921.59 1104 3622.05 18:04:49 6271 96 51.83 894.6 2923.23 1119 3671.26 18:05:00 6276 99 53.45 890.5 2930.77 1144 3753.28 18:05:17 6281 80 43.19 886.3 2950.13 1164 3818.89 18:05:26 6286 75 40.49 890.2 2952.75 1189 3900.92 18:05:35 6291 68 36.71 891.8 2960.95 1210 3969.82 18:05:43 6296 63 34.01 895.0 2958.33 1235 4051.84 18:05:49 6301 55 29.69 897.3 2959.97 1256 4120.74 18:05:57 6306 53 28.61 899.2 2936.35 1282 4206.03 18:06:04 6311 53 28.61 901.2 2913.05 1305 4281.49 18:06:14 6316 58 31.31

902.8 2913.05 1328 4356.96 18:06:24

6321 69 37.27 901.7 2906.82 1308 4291.34 18:06:34 6326 94 50.75 901.3 2901.24 1290 4232.28 18:06:49 6331 96 51.83 898.0 2900.59 1271 4169.95 18:07:00 6336 94 50.75 892.2 2898.62 1246 4087.94 18:07:16 6341 88 47.51 889.5 2918.30 1225 4019.03 18:07:27 6346 97 52.37 888.1 2896.65 1202 3943.57 18:07:39 6351 102 55.07 888.4 2894.68 1181 3874.67 18:07:44 6356 97 52.37 887.2 2894.47 1148 3766.40 18:07:51 6361 80 43.19 884.3 2901.24 1140 3740.15 18:08:03 6366 63 34.01 883.7 2899.27 1131 3710.63 18:08:08 6367 60 32.39

883.5 2898.62 1121 3677.82 18:08:09

6368 58 31.31 883.3 2897.96 1092 3582.67 18:08:10 6369 56 30.23 883.1 2897.31 1051 3448.16 18:08:11 6370 55 29.69 882.9 2896.65 1034 3392.38 18:08:12 6371 50 26.99 882.6 2895.66 1012 3320.21 18:08:14 6372 45 24.29 882.4 2895.01 991 3251.31 18:08:15 6373 52 28.07 882.3 2894.68 977 3205.38 18:08:16 6374 16 6.63

882.2 2894.35 951 3120.07 18:08:17

6375 47 25.37 882.2 2894.35 884 2900.26 18:08:18 6376 0 0 882.2

2894.35 884 2900.26 18:08:19

6377 0 0 884.0 2900.26 884 2900.26

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1.8.6 The information in the graph above shows that the terrain elevation is between 951m to approximately 884m (2900ft) AMSL. At 18:06:47Z the helicopter commenced with a gradual rate of descend from an altitude of approximately 1328m (4356ft) AMSL to 1121m (3677ft) AMSL within 1 minute and 46 seconds. The helicopter rate of descent then increased rapidly at this stage from 1121m (3677ft) AMSL that is actually 3677ft minus 2900ft = 777ft AGL and impacted the terrain within approximately 8 seconds at 18:08:18Z.

1.9 Communications. 1.9.1 The helicopter was fitted with Bendix/King KY197A VHF type radio communication

equipment. There was no report of a defect or malfunction experienced with the aircraft radio communication equipment. The helicopter radio communication equipment was considered to be serviceable prior and at time of accident.

1.9.2 There were two (Rexon & Q16C) types of hand held radio′s carried on board the

helicopter. The radio′s were used to communicate with personnel that assisted the owner/pilot with ground support. The two hand held radio′s were in a serviceable condition and it was possible to determine the frequency used when broadcasting.

1.9.3 On Wednesday morning, 5 August 2010 at 09:30:00, the owner/pilot experienced a

defect of a tail rotor gearbox chip detector warning during the flight. The owner/pilot landed the helicopter and made a telephone call to the AMO to report the defect. The owner/pilot was given instructions on the phone to remove the chip detector, inspect and clean with tooth brush before re-installing it. There was no further communication between the pilot and AMO thereafter.

1.9.4 The owner of Groot Riet Farm attempted to contact the pilot and/or the passenger

telephonically when they failed to arrive on the farm destination at the expected time. There was no response from the pilot and passenger on board the helicopter. The South African Police Services at Kenhardt, assisted by the local community

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that consisted of “farm owners’ and the local farmer at Groot Riet farm, immediately initiated a search and rescue operation for the missing helicopter.

1.9.5 The SAPS and farm owners in the rural area communicated with the farmer at Groot

Riet farm during the search and rescue operation via a Marner radio controlled system where after a search and rescue operation was conducted throughout the night until the following morning when the wreckage of the helicopter and the bodies of the occupants were located on 6 August 2010 at approximately 0810Z. The accident was reported to South African Search and Rescue (SASAR) and SACAA.

1.9.6 The SAPS notified the families of the fatal helicopter accident. The wife of the

deceased pilot arrived at the accident site and requested permission to remove the pilot’s personal belongings from the wreckage. The SAPS agreed and resulted whereby important and valuable information were removed fro m the accident site without consent by the SACAA.

1.10 Aerodrome Information 1.10.1 Game culling operations were normally operated from Groot Riet Farm in the

Kenhardt area and considered as the main base. The helicopter was parked and being operated from a gravel open area on the farm at a GPS coordinates: S 29˚ 29.249 E 020˚ 42.900.

1.10.2 The accident occurred in an open deserted landscape, approximately 3.7nm South of Groot Riet Farm in the Northern Cape, outside the boundaries of an aerodrome. The wreckage was located at GPS coordinates: S29˚24.572 E020˚43.265 at an elevation of 2900ft AGL.

1.10.3 Terrain Condition: The accident occurred in an open deserted landscape with very little plant life, usually because of low rainfall. There were no obstacles in the vicinity of the accident site.

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Figure 8, shows deserted landscape where helicopter crashed 1.11 Flight Recorders 1.11.1 There was no flight data recorders (FDR’s) and/or cockpit voice recorders (CVR’s)

installed in the helicopter, neither was it required by regulations. 1.12 Wreckage and Impact Information 1.12.1 The helicopter was heading in a northerly direction from Klein Zwart Bast Farm to

Groot Riet Farm when the accident occurred, approximately 5.5 nm (10.2 km) in a north-easterly direction from Klein Zwart Bast Farm and approximately 3.7nm (6.8 km) south of Groot Riet Farm at GPS coordinates of S29˚24.572 E020˚43.265.

1.12.2 During the on-site investigation, it was established that the helicopter impacted the

deserted landscape level ground surface at a high velocity, vertical descent on the main landing skids. The evidence of this can be seen by the damage caused to the structural damage caused to the helicopter on impact and the seats of the helicopter that collapsed.

1.12.3 The GPS download information indicated that the terrain elevation is between 951m

to approximately 884m (2900ft) AMSL. At 18:06:47Z the helicopter commenced with a gradual rate of descend from an altitude of approximately 1328m (4356ft) AMSL to 1121m (3677ft) AMSL within 1 minute and 46 seconds. The helicopter rate of descent then increased rapidly at this stage from 1121m (3677ft) AMSL that is actually 3677ft minus 2900ft = 777ft AGL and impacted the terrain within approximately 8 seconds at 18:08:18Z. The high impact energy was absorbed by the landing gear skids and bottom of the fuselage. The helicopter remained upright after it impacted the terrain.

Figure 7 and 8, shows the ground impact damage sust ained. 1.12.4 Engine Damage: The engine components such as the direct - drive, squirrel - cage

fan indicated that the squirrel cage fan sustained substantial damage during the

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hard vertical impact sequence. Compression impact forces acted on the one side of the fan structure that impacted the ground.

(i) According to the Aircraft Maintenance Manual (AMM), the direct - drive,

squirrel - cage fan is mounted to the engine output shaft and supplies cooling air to the cylinders and oil cooler via a fibreglass and aluminium shroud. Ducts from the shroud supply cooling air to the alternator and main rotor gearbox. The fan drives at the same speed as the engine. Implying that the fan may pick up rotational damage during the impact and assist in determining if whether the engine was turning or not during the impact sequence. In this case, if the engine was turning, the damage caused to the squirrel cage fan was would be much more severe. The final observation was that the engine and squirrel cage fan was stationar y at the time of the impact.

Figure 8 – engine shroud Figure 9 – engine squirrel cage fan 1.12.5 Rotor and Transmission System:

(i) The evidence shows that the speed of rotation of the rotors was very low or not turning at all during the impact sequence. The main rotor assembly was still intact and the damage caused was to the rotor blades only.

(ii) The transmission system was remained intact after the accident. The condition of the vee-belt was satisfactorily. The bottom vee-belt sheave, engine output shaft and upper sheave connection did not sustain any damage.

1.12.6 Tail boom: The tail boom structure failed into three sections. The damage caused

to the tail boom structure was as a result of the hard ground impact. The tail rotor drive shaft did not sustain any damage during the impact.

1.12.7 Landing Gear Skids: The spring and yield skid type landing gear sustained a

extremely hard landing in the ground impact sequence. The struts hinged up and outward as the centre cross tube yields absorbed the impact.

1.13 Medical and Pathological Information

Shroud

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1.13.1 A Medico Legal Post Mortem examination and Toxicology test were performed on

the pilot. The results of the post mortem report concluded that the pilot and passenger cause of death were due to multiple injuries.

1.14 Fire 1.14.1 There was no evidence of a pre or post impact fire. 1.15 Survival Aspects 1.15.1 The pilot and passenger were fatally injured in the accident. The accident was

categorised as being not survivable due to the very hand landing and vertical speed during the impact sequence. The helicopter including the cockpit area was destroyed on impact with the ground. Although the occupants were properly restrained by the helicopter safety harnesses, the impact forces on the occupants were beyond human tolerance.

1.15.2 Search and Rescue Operation: The South African Police Service (SAPS) at Kenhardt assisted by the local community of farmers and the local farmer at Groot Riet Farm, initiated a search and rescue operation along the flight path track the helicopter had flown between Klein Zwart Bast farm and Groot Riet farm. The environment and size of the terrain necessitate the use of predominantly off road vehicles. A total of 10 SAPS and private off road vehicles were utilised in the SAR operation. The search and rescue operation continued throughout the night and the wreckage of the helicopter was located the following morning of 6 August 2010 at approximately 0810Z. The aircraft was destroyed on impact and the both occupants were fatally injured.

1.15.3 The Search and Rescue Operation was faced with several challengers such as co-ordination, communication and environmental. The natural light conditions with the sunset was also an impediment for the rescue team and subsequently acquire flash lights to continue with the search during the night until the wreckage was located the following morning after a search of 13 hours.

1.15.4 The South African Search and Rescue (SASAR) was not involved in the search and rescue operation; however they were notified of the missing helicopter.

1.16 Tests and Research 1.16.1 During the wreckage investigation the following were observed inside the

cockpit/cabin area of the helicopter:

Items Condition Master Battery Switch ON

Ignition (Key) Both

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Alternator Switch ON Protects the electrical system from overvoltage conditions. ALT switched on with starting engine.

Clutch Actuator Switch Engaged Mixture Disturbed on impact

Carb Heat Off When conditions conducive to carburetor ice use carburetor heat.

RT Trim Pulled Cyclic Friction Pulled

Governor Switch ON RPM 102 to 104% Landing Light Switch OFF Landing light operate only when CLUTCH switch is

in engaged position. Increase the pilots field of vision

Strobe Light Switch ON Anti-collision lights – switched on with starting engine.

Navigation Light Switch ON Night lights Panel Light Knob Bright Panel lights function only when Navigation lights

switched on. Illuminates the instrumentation. 1.16.2 The information of the systems description of the equipment in the block diagram

indicates the following:

(i) The examination of the cockpit/cabin equipment shows that the aircraft systems were set appropriately for normal flying mode.

(ii) The factor of the night lights like navigation and panel lights being switched

on indicates that the helicopter was flown in night time conditions with impaired visibility.

(iii) There was no evidence of any setting which could have negatively influenced

the performance of the helicopter. 1.16.3 Engine Investigation: The engine of the helicopter was removed and recovered for

an engine teardown investigation at an approved engine overhaul facility. The findings were as follows:

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Figure 10, shows damage caused to the engine .

(i) The engine was substantially damaged and could not be bench tested.

(ii) The engine was disassembled and all components closely examined for any defects.

(iii) Piston number one (1) top compression ring was found broken, but it was

considered that it was not caused during the impact sequence. (iv) The engine crankshaft serial number: V537950757, part number: 13B47143

was free from any defects. All main bearings appeared to be in a good working order and properly lubricated. There were no signs of binding or seizure.

Figure 11, magneto′s were tested and found to be Figure 12, spark plugs appeared normal and no

signs in a serviceable condition. of damage or excessive wear found. .

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Figure 13, shows impacted damage to carburettor. Figure 14, shows engine oil screen filter. The filter was found to be clean of contamination.

Figure 15, shows the four cylinders. The cylinders showed signs of proper combustion and carbon deposits found to be normal on this type of engine. 1.16.4 According to the engine teardown examination that was carried out, no mechanical

defects were found that could have contributed to the cause of the accident.

1.16.5 Transmitter System: According to Robinson R22, Pilot’s Operating Handbook (POH), Manual Part no: RTR 061 dated 16 March 1979.

(i) Drive System: A vee-belt sheave is bolted directly to the engine output

shaft. Vee-belt transmits power to the upper sheave which has an overrunning clutch contained in its hub. The inner shaft of the clutch transmits power forward to the main rotor and aft to the tail rotor.

(ii) After the engine is started, it is coupled to the rotor drive system through

vee-belts which are tensioned by raising the upper drive sheave. An electric actuator, located between the drive sheaves, raises the upper

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sheave when the pilot engages the clutch switch. The actuator senses compressive load (belt tension) and switch off when the vee-belts are properly tensioned. A caution light illuminates whenever the actuator is operating, either engaging, disengaging or re-tensioning the belts. The light stays on until the belts are properly tensioned or completely disengaged. A point of caution is made stating: “Never to takeoff while clutch caution light is on”.

1.16.6 There was no evidence found of failure to the upper and lower vee-belt sheaves,

vee-belts, fly wheel and engine output shaft which may have affected the operation of the engine during the flight. The damage caused to the upper vee-belt sheave by the fly wheel shows that it appears that the engine was not rotating at the time of the impact.

Figure 16, shows lower and upper vee-belt sheaves. 1.16.7 Clutch Actuator: The clutch actuator was removed from the wreckage and

examined. The following information was identified during the actuator examination process. (i) Robinson R22, Pilot’s Operating Handbook (POH), Manual Part no: RTR

061 dated 16 March 1979 states: “The electronic actuator raises the upper sheave when the pilot engages the clutch switch. A caution light will illuminate whenever the actuator is still operating (engaging, disengaging and/or re-tensioning). The caution light will stay on until the vee-belts are properly tensioned or completely disengaged. The light goes out thereafter”

Lower vee-belt sheave bolted directly to engine output shaft and transmits power to upper sheave

Lower vee-belt sheave

Upper vee-belt sheave

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(ii) The electrical clutch actuator was engaged at the time of the ground impact. Implying that the vee-belts were properly tensioned. The evidence of this fact can be seen by the outward movement of the clutch actuator shaft. The conclusion is that the electrical clutch actuator operation was as required. There was no mechanical failure found caused to the clutch actuator which could have contributed in the engine malfunctioning during the flight. If tensioned properly, the engine would have produced enough power to execute an emergency landing.

FiFigure 17, shows electrical clutch actuator.

1.16.8 Lighting System: A bundle of white electrical wires were found rolled up around the

tail rotor drive shaft. The electrical wires were bundled up close to the tail rotor gearbox flex plate assembly. It appears as though the electrical wires of the tail rotor gearbox chip detector and tail navigation light were not installed properly. The following were identified: (i) The two pairs white plugs (male and female sides) of the chip detector wires

were still intact after the accident. The plugs did not show any sign of failure which was considered to be out of the ordinary.

(ii) The pair of lugs which are normally fastened to the chip detector plug screw showed no sign of failure. It appears as though the lugs became or were loose at the time when the wires rolled up around the tail rotor drive shaft.

(iii) The tail light male and female plugs became separated. The separation

between the two plug ends was not unusual. The conclusion was that the identified plug ends were not securely inserted to lock properly.

(iv) Normally the tail light and chip detector wires would be fastened to the tail

rotor gearbox with a tie rap to secure all the wires. There was no tie rap found attached to the wires at the time of the accident.

(v) A clamp inside the tail boom through which the chip detector and tail light

wires are routed, showed that the wires broke on one end once it started rolling around the tail rotor drive shaft.

(vi) The electrical wires on the side of the tail rotor gearbox was pulled into the tail boom first and started rolling around the shaft. Thereafter the same electrical wires which are routed inside the tail boom from the cockpit side failed, then pulled through and rolled up on top of the first bundle of wires.

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Figure 18, shows method of installation of chip Figure 19, shows after effect of improper installation detector and tail light wires 1.16.9 Lighting System: The black strobe light electrical loom was also found rolled

around the tail rotor shaft inside the tail boom. The following findings were identified during the examination of the anti-collision strobe light:

(i) The tail boom failed at three places during the impact. The strobe light wire

probably failed in the process of the centre piece rolling around the shaft. The strobe wire rolled two times around the tail rotor shaft which is the same for the failed centre section tail boom structure.

1.17 Organizational and Management Information 1.17.1 Aircraft Maintenance Organisation (AMO): The helicopter was maintained by a

South African approved aircraft maintenance organisation (AMO). The AMO had a valid approval certificate and authorised to carry out maintenance on the RH22 helicopter. The AMO was operating at Kimberley Airport (FAKM). The owner/pilot normally would position (fly) the helicopter from Postmansburg to Kimberley when maintenance was required.

1.17.2 Helicopter Private Pilot License (PPL) Training: The evidence shows that the pilot

received PPL training from three different aviation training organisations (ATO′s) during the period starting in April 2009 and ending in November 2009 where after he obtained his Private Pilot’s Helicopter Licence on the R22.

(i) First ATO (Durban – Virginia Airport) :–

The ATO had a valid approval certificate which was issued in terms of CAR, Part 141. The approval certificate was valid from 2 February 2009 to 13 January 2010. The ATO was approved to give PPL training.

(ii) Second ATO (Pretoria – Wonderboom Airport ):– This ATO had a valid approval certificate issued under CAR, Part 141. The approval certificate was valid from 24 March 2010 to 17 May 2011.

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The ATO was approved to carry out PPL training.

(iii) Third ATO (Bloemfontein – Tempe Airport) :– The ATO had a valid approval certificate issued under CAR, Part 141. The approval certificate was valid from 1 April 2009 to 23 February 2010. The ATO was duly approved to conduct the PPL training.

1.17.3 Helicopter Owner/Pilot: The owner/pilot was very successful farmer and previously renowned rugby player. His ambition was to also to become a pilot and purchased a Robinson R22 helicopter in April 2009 to commence with flying training.

(a) The owner/pilot was approved to operate the R22 helicopter in general

aviation sector in accordance with requirements of CAR, Part 91. The owner/pilot was not allowed to carry out commercial operations without proper authorisation and/or certification in accordance with CAR, Part 127. The owner/pilot disregarded the applicable regulations and flew the helicopter in game culling operations without the proper game culling ratings on his licence. He did not receive any training to execute this specialised operation.

(b) During the culling operation the helicopter was flown by the pilot below the

required visual flight rules (VFR) altitude and below the height of obstacles such as hills and high tension power lines in the area.

(c) The owner/pilot was in possession a species culling/hunting permit issued by

Northern Cape Department of Environment and Nature Conservation Department. The permit authorised him to carry out hunting/culling operations on privately owned land in Northern Cape Province. The permit was valid from 14 April 2010 to 31 December 2010, provided the owner/pilot complies with the permit condition. Evidence was found that the owner/pilot disregarded several of the permit conditions which rendered the permit to be invalid.

(d) The owner/pilot made entries in the flight folio showing that he carried out oil

change maintenance on the helicopter. The oil change maintenance was carried out without supervision from appropriately rated maintenance personnel. The pilot then continued flying the helicopter without transferring the maintenance information to the applicable logbooks, which was determined to be not in accordance with applicable regulations.

1.17.4 South African Police Service (SAPS) assisted with the search and rescue operation

to locate the missing helicopter. The accident site was secured and safeguarded by the SAPS who left the accident site unattended until the aviation investigation team arrived.

1.17.5 The SACAA accident investigators arrived at the accident site and noted that

several important items carried on board the helicopter was missing. The SACAA IIC requested a copy of an inventory of the items removed by the SAPS, but

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discovered that nothing was recorded. The relevant SAPS Station Commander was informed of the importance of the documentation, but to no avail. The SACAA accident investigators then recovered the documentation from the next of kin of the pilot at Postmasburg.

1.19 Useful or Effective Investigation Techniques 1.19.1 None. 2. ANALYSIS 2.1 According to available information, the Robinson R22 helicopter was on a

repositioning flight with the pilot who was also the owner of the helicopter and a passenger on board the helicopter from Klein Zwart Bast Farm en route to Groot Riet Farm in the Northern Cape where the helicopter was normally operated from.

2.2 The status of his pilot license was reviewed during the course of the aircraft accident

investigation. It was determined that the pilot had a valid Helicopter Private Pilot License (PPL) and was type rated on the helicopter type. The PPL was valid for 12 months and the pilot was authorized to perform private flights in accordance with applicable regulations.

2.3 According to the pilot licensing records, he had a valid aviation medical certificate

with no waivers. No proof could be found which suggested that the pilot had any medical condition which may have prevented him from flying the helicopter on the day. There was also no proof found of incapacitation experienced by the pilot at any time during the flight. He was fatally injured in the accident. The forensic pathology department concluded in their pathology report that the cause of his death was as a result of multiple injuries.

2.4 The pilot was accompanied by a passenger on board the helicopter. According to

available information, the duties of the passenger were to perform the same duties as that of veterinary surgeons on board game or livestock culling operations.

2.5 According to available information, the passenger did not have any medical condition whilst on board the helicopter. He was fatally injured in the helicopter accident. The cause of death was determined to be as a result of multiple injuries.

2.6 Available evidence indicated that the pilot and passenger were operating from

Groot Riet Farm in Kenhardt. They flew from the farm in the morning with the intention to return back when the accident occurred. There is no evidence of any malfunction experienced with the helicopter prior to the accident. The helicopter was in a serviceable condition; hence the decision by the pilot to fly back to Groot Riet Farm.

2.7 According to the global positioning system (GPS) fitted on the helicopter,

downloaded information shows that the helicopter first flew to one of the

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neighbouring farm to start game or livestock culling operations. The pilot occupied the front right seat and passenger the left seat.

2.8 It was concluded that the owner/pilot involved in the helicopter accident did not

complete any theoretical and/or practical training on game or livestock culling operations and no game or livestock culling rating was endorsed on his license.

2.9 The owner/pilot was issued with a species culling/hunting permit by the Northern

Cape Environment and Nature Conservation Department. The permit authorised him to shoot small animals (e.g. rooikat and jackals). The permit limitation was to conduct culling/hunting operation in Northern Cape area only. The finding was that initially the pilot was hunting on his farm only. But later he accepted contracts from other farm owners to hunt on their properties, which was not in accordance with limitations of the permit. Because the permit clearly stated that “it becomes invalid if the conditions are not complied with” .

2.10 The owner/pilot and passenger started early in the morning and performing a pre-

flight inspection on the helicopter and found the helicopter serviceable for the flight. They took off at approximately 05:52:00Z and flew the first flight up until approximately 10:50:00Z on a game or livestock culling operation. The pilot made four stops during the flight covering 15 x 15 km area. The flight was uneventful until when the owner/pilot experienced a mechanical defect of the chip detector warning light illuminating during the flight. A precautionary landing was executed on the farm where they were flying from at the time. The owner/pilot reported the chip detector defect to the AMO responsible for the maintenance. He requested their assistance in rectifying the identified chip detector defect. The AMO agreed with the owner/pilot to carry out trouble shooting and to rectify the defect.

2.11 According to the Pilot Operating Handbook (POH), the chip detector warning

indicated the possibility of metallic particles in the tail rotor gearbox. As it was decided that the owner/pilot was to rectify the defect, he removed the chip detector plug, inspected it for metallic particles and refitted it as directed by the AMO. The requirement was that the tail rotor gearbox to be refilled with new oil. The AMO Accountable Manager stated that the chip detector maintenance procedure/s was explained to the owner/pilot in a telephone conversation.

2.12 There was no evidence found to show that the owner/pilot had experience in carrying

out the expected chip detector defect maintenance before. He was most probably confirmation-bias when accepting the responsibility to do the rectification himself. The regulation does permit a pilot to carry out aircraft maintenance activities, provided that approved materials, parts and components are used. After maintenance was performed, entries in the flight folio must be accompanied by the pilot’s signature, license number and date of entry. The maintenance is permitted to be carried out on limited items on the helicopter. The evidence shows that the chip detector was not listed which implies that the owner/pilot was not authorised to carry out the chip detector maintenance defect.

2.13 According to applicable maintenance procedures, the chip detector plug requires

specific maintenance to be followed to ensure that the helicopter is airworthy. It appears as though the pilot did not have the relevant maintenance procedures at

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hand at the time as required by the relevant regulation when he carried out the chip detector maintenance. In the absence of the applicable maintenance procedures, it was determined that he most probably carried out the maintenance from memory which was based on the instructions of the AMO. This may be the reason for the failure of both chip detector and tail navigation light wires became adrift and being rolled around the tail rotor drive shaft.

2.14 The maintenance procedure of the chip detector requires that the chip detector wires

must be loosened first by unfastening a nut that keeps the wires secure to the plug. It is possible for an inexperienced person to inadvertently loosen the screw in the plug instead of the nut. The screw was probably not fastened properly and due to normal vibration at the tail rotor drive, it became dislodged. As evidence showed, the chip detector plug screw threads were not damaged and suggested that the screw had turned out due to it not being fastened properly. The aftermath would be chip detector wires hanging freely in the rear end of the tail boom and being pulled into the tail boom by the small tail rotor flex plate.

2.15 The navigation lights wires also were found rolled up around the tail rotor drive shaft

the same as the chip detector wires which suggested that the navigation light wires plugs were not secured properly and being pulled into the tail boom by the small tail rotor drive shaft flex plate.

2.16 The helicopter was on the ground for approximately 37 minutes during the

rectification of the chip detector defect. After completion of the chip detector defect by the pilot, the helicopter was flown again on another game/livestock culling operation. The IAS of 85 km/h at 164ft above ground level (AGL) and track pattern was similar to the one flown earlier. The track pattern was back and forth over approximately 10 km area this time. The helicopter executed several turns whilst following animals below. The flights were only interrupted once for 13 minutes when fuel was being uplifted into the helicopter and the flights resumed until approximately 14:56:00 the same way as before. The helicopter landed and was on the ground for 1 hour 4 minutes at Klein Zwart Bast Farm.

2.17 After the last stop on the ground, the helicopter was flown again on a repositioning

flight back to Groot Riet Farm. The helicopter took off at approximately 16:02:25Z and climbed out in northerly direction at a height of 1330m AMSL at an airspeed of 100 km/h. The identified height and speed was maintained for another minute and descended gradually. The rate of descend was determined to be approximately 1650 feet/min. At a height of 1121m 3677ft AMSL (777ft AGL), the helicopter descended rapidly in a vertical attitude and impacted the terrain heavily. The helicopter was destroyed during the impact sequence. The GPS downloading showed that the flight time for the day was approximately 10 hours 15 minutes at an area of approximately 235 km.

2.18 The wreckage was then recovered and examined to determine if there was any

mechanical or system failure which may have contributed to the cause of the accident. During the tail boom examination it was observed that the chip detector and tail navigation light electrical wires had rolled up around the tail rotor drive shaft. The pilot most probably heard the noise and also experienced a vibration caused by the bundle of loose electrical wires around the tail rotor drive shaft and elected to execute an emergency landing as soon as possible. The helicopter

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descended vertically, and was destroyed by the hard landing that followed. 2.19 The engine was recovered to an approved engine overhaul facility to determine

whether the engine had failed during the flight. Due to the extent of damage sustained during the ground impact sequence, it was not possible to carry out an engine bench test. The engine was then subjected to a tear down inspection. The engine teardown inspection showed no mechanical failure and it was concluded that the engine operated normally and did not contributed to the cause of the accident. Damage caused to the upper vee-belt sheave at the fly whe el indicated that the engine most probably was not rotating at t he time of the impact”. The electrical clutch actuator was found to be engaged at the time of the ground impact that concluded that the vee-belts of the engine were properly tensioned with mechanical failure evident during the flight.

2.20 During the time of the vertically descent, after sun-set, the natural light conditions

were classified as night time. The pilot did not have a night rating endorsed on his license and was thus not authorised to conduct any night flights.

2.21 The natural light and VFR flying conditions after sun-set could have exposed them

to significant danger. It is for this reason that the manufacturer warning that flying in obscured visibility due to fog; snow, low ceiling, or even a dark night can be dangerous. The terrain condition also played a role. The terrain contained very little vegetation. It had very low shrubs and grass among the rocky desert like landscape. The soil was very loose and had the potential to cause a “brown out” condition during the time when the helicopter was approaching the ground. The three factors, natural light, VFR flying and brown out together most probably contributed in the pilot losing outside visual reference which resulted in him becoming disorientated, applying incorrect engine and/or flight control inputs followed by an uncontrolled hard landing.

3. CONCLUSION 3.1 Findings 3.1.1 The pilot was in possession of a valid private pilot license (PPL) with the Robinson

R22 type rating endorsed on his license.. The PPL was issued to him after he attended PPL training at three different aviation training organisations (ATO′s).

3.1.2 The pilot who was also the owner of the aircraft was reprimanded during the PPL

training for flying unauthorised flights and wilfully contravention and violated the regulations laid down.

3.1.3 The ATO responsible for the PPL training reported the matter of the wilful violation of

unauthorised flight to the SACAA. The result was that the Student Pilot License (SPL) was flagged by SACAA Flight Operations and Licensing Department to prevent issuance of PPL until contravention being resolved.

3.1.4 The flag was later removed from the SPL by SACAA Flight Operations Department,

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giving instruction to Licensing Department to process and approved the PPL application. The evidence found shows that no intervention was taken by either of the two departments to address the contravention with the owner/pilot.

3.1.5 The pilot was authorised to operate the helicopter privately in accordance with

applicable regulations of CAR, Part 91. Evidence however showed that the helicopter was operated commercially during game and livestock culling operations.

3.1.6 The pilot did not have a game or livestock culling rating on the license. He did not

receive the necessary training to empower him with the skill and/or competency to conduct game or livestock culling operations.

3.1.7 The Northern Cape Environment and Nature Conservation Department approved the

owner/pilot to hunt small species of animals in Northern Cape area only. There was evidence found that the owner/pilot contravened the restrictions and limitations of the identified approval.

3.1.8 The owner/pilot did not have an AOC which authorises him to conduct game or

livestock culling operations. He contravened the applicable regulations. 3.1.9 After the pilot accompanied by a passenger on a repositioning flight from Klein

Zwart Baas Farm en route to Groot Riet Farm failed to arrive at the intended destination at the estimated time of arrival, a search and rescue operation was initiated.

3.1.10 The SAPS assisted by the local community of farmers conducted a search and

rescue operation to search for the missing helicopter. The search and rescue operation continued throughout the night and the wreckage and occupants located the following morning of 6 August 2010 at an open deserted landscape at GPS co-ordinates: S29 24.562 E020 43:269, 3.7 nm (6.8 km) south of Groot Riet Farm. The helicopter was destroyed on impact and the occupants fatally injured.

3.1.11 The wreckage was recovered from the accident site for further examination. During

the tail boom examination it was observed that the chip detector and tail navigation light electrical wires rolled up around the tail rotor drive shaft.

3.1.12 The engine was recovered to an engine overhaul facility for further examination.

The engine components such as the direct-drive, squirrel-cage fan, were examined. It was established that the engine and squirrel-cage fan was stationary at the time of the impact. The fly wheel examination indicated that the damage caused to the upper vee-belt sheave by the fly wheel showed that the engine was not rotating at the time of the impact.

3.1.13 It was determined that the owner/pilot flew the helicopter 5 hours and 8 minutes the

day prior to the accident and 5 hours and 7 minutes on the day of the accident which gives a total of 10 hours 15 min. It is possible that the pilot became mentally fatigued with a loss of situational awareness.

3.1.14 The last flight back to Groot Riet Farm was flown after sunset when the natural light

conditions were night time with obscured visibility with a lack of visual reference.

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The pilot most probably became disorientated and applied the incorrect technique to descent and land when he was distracted by the noise of the wiring wrapped around the tail drive shaft and stacked against the flex plate at the tail rotor gearbox.

3.1.15 It was established during the on-site investigation that the helicopter was submitted

to a very hard landing on the main landing skids during a vertically descent, causing injuries to the occupants beyond human tolerances.

3.2 Probable Cause/s 3.2.1 Unsuccessful landing. 3.2.2 Pilot became disorientated due to loss of visual reference after sunset. 4. SAFETY RECOMMENDATIONS 4.1 It is recommended that the Director of Civil Aviation (DCA) should consult with

Department of Environment and Nature Conservation should receive written confirmation from the SACAA, that authorises the aircraft to fly in that area to establish cooperation pertaining to authority, approvals, permits in terms of game or livestock culling/hunting operations using aircraft.

4.2 It is recommended that the Director for Civil Aviation (DCA) should amend the Civil

Aviation Regulations (CAR’s) making special operations like game or livestock culling/hunting exclusively a commercial operation within South Africa.

4.3 It is recommended that the Director for Civil Aviation (DCA) should amend manual

of procedures (MoP) of all affected departments within the SACAA which uses the flag process to include a formal flag process/procedures to do away with inconsistencies pertaining to the particular process being followed.

5. APPENDICES 5.1 Annexure “A”. Compiled by: ....................................................... Date: ………………….……….. For: Director of Civil Aviation Investigator-in-charge: ……………………………… Date: …………………………..

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Co-Investigator: …………..………………………… Date: ……………….…………

Attachment: Annexure “A” History of Pilot PPL Training :

Anomalies noted during the course of the helicopter accident investigation, revealed that the pilot did not comply with applicable PPL training regulation . The information pertaining to the training suggested that the pilot was responsible for committing certain contraventions during the PPL training. The nature of the contraventions was identified as being serious. This resulted in the decision to review the PPL training process. During the review process the following issues were highlighted in the review:

(i) The anomaly of unauthorised flying during the PPL training. The pilot was not

in possession of an authorisation to act as pilot in command (PIC) and did not have the permission “authorisation thereto for the flight” from the responsible training instructor. The pilot (student at the time ) actions were found to be not in accordance with applicable training procedures and regulation. The pilot actions were a sign of poor airmanship .

(ii) At the time that the anomalies became known to the training instructor, he immediately reported it to the ATO Management. The ATO Management decided to reprimand the pilot with the intention to ensure that the pilot understood the transgression with another opportunity for improvement that still existed. The aim was to also discourage any further unsafe behaviour by the pilot in future during his PPL training with the responsibility that rested with the pilot to continue with the PPL training.

(iii) The pilot however continued to commit the same anomaly of flying unauthorised flights again. The pilot actions were considered to be unlawful and a definite threat to aviation safety. His actions were construed as being an act of wilful violation , especially now that it happened for the second time. The ATO Management was not happy with the actions of the pilot. It is the opinion

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of the investigator, based on the sequence of events, that the pilot committed these acts of wilful violation deliberately. It is for this reason that the ATO Management decided the corrective action plan to be: “The pilot has to rewrite air law, flying of additional 10 hours, complete the outstanding solo navigation flights and repeat the PPL test”. But the pilot did not agree with the corrective action plan conditions. The pilot was unwilling to comply.

(iv) When the ATO Management realised that the pilot was not willing to comply

with the corrective action plan, they took a decision to discontinue the PPL training indefinitely. The decision was taken mindful of the fact that the pilot could take legal action against them; however, they were confident and stand firm by it. The SACAA was also notified of the anomalies. The pilot eventually left the ATO and moved over to another ATO, where he completed the PPL flight test.

(v) There was a requirement for student training information to be shared between ATO’s. It normally took place when there was a suspicion about a student. The ATO Management/s responsible for providing training to the pilot affirmed that they exchanged the PPL training file information. The idea behind it is to then take swift action to address the anomalies. It is the opinion of the investigator that if action was taken the some of the contributing factors could have been prevented.

(vi) There were other anomalies identified with regard to the flight hours recorded in the pilot flying logbook, flight folio and aircraft logbooks. According to comments made by the SACAA Licensing Department, stating that they rely on all the ATO’s Managements and/or Instructors responsible for PPL training to ensure that the flight times are recorded correctly. With this in mind, they accept that the necessary checks and balances being taken care of by them prior to submitting the application forms.

(vii) However, according to the applicable regulations, the SACAA is ultimately responsible to approve the PPL application. This implies that the final responsibility was with the SACAA to satisfy them that the licensing requirements were appropriately complied with. Implying that they should have affirmed that the training hours flown calculations was done correctly. This way they could have easily determined that the pilot recorded his hours incorrectly.

(viii) The time when the SACAA Licensing Department received the notification of

the anomalies, they acted by putting a “red flag” against his name. The aim of the red flag was to prevent the issuance of the PPL until confirmation that the unauthorised flights anomalies were resolved. The evidence shows that the Licensing Department did not have ISO procedure for the “red flag”. This resulted in a situation whereby the owner/pilot could by-pass the red flag restriction successfully. The intended use of the red flag procedure was seen to be defeating its purpose.

(ix) It is the opinion of the investigator that the SACAA Flight Operations and

Licensing Departments should have conducted further investigation into the

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issues of unauthorised flying anomalies. Because it is the SACAA’s responsibility to act when reports are made that regulation were not complied with by anyone. However, they did “nothing” and wasted an ideal opportunity due to their indecisiveness to act.

(iix) Helicopter Private Pilot License: According to the pilot flying logbook, the training time that was flown during the PPL was as follows:

The approved aviation training organisation (ATO) submitted a statement of an event that occurred during the PPL flying hours and reported to the SACAA a situation of misconduct of “ unauthorised owner/pilot flying” during the PPL training. The pilot subsequently flew a total of 25 hours unauthorised training flights. He was reprimanded by the ATO and informed that the unauthorised flight time will not be considered toward the PPL. In the event of the amount of unauthorised pilot flight time being subtracted from the 77.9 hours total flight time, the pilot legally flew a total of 77.9 hours – 25 hours = 52.9 flying hours .

On completion of the PPL, the pilot submitted a PPL application to the SACAA with the summary of his flying experience as follows:

Private Pilot (Helicopter) Hours Total Flight Time 93.5 Dual Training Time 78.0 Solo Fight Time 15.5 Instrument Dual Instruction Time 5.0 Solo Cross Country Time 6.4

A discrepancy was noted between the total flight time logged in the flight folio, pilot Flying logbook and PPL application. The PPL application total flight time (93.5 hours) and was 15.6 hours more than the 77.9 hours logged on the flight folio. When 25.0 and 15.6 hours are subtracted from 93.5 hours; an amount 52.9 hours remains which is the same as the time logged in the pilot flying logbook.

According to the PPL requirements “Cross country flights” must be flown during training schedules. The pilot flying logbook does not show that the cross country flights were conducted as required. It implies that CAR, Part 61.04.1 (2)(b) stating: “At least 15 hours are accumulated in solo flight, of which five hours are cross-country flight time” had not been complied with.

Month Flights Dual (Hours) Pilot in Command (Hours)

Total Flight Time (Hours)

April 2009 8 8.8 None 8.8 May 2009 24 16.7 None 16.7 Aug 2009 1 3.7 None 3.7 Sept2009 14 19.3 3.0 22.3 Oct 2009 5 5.9 12.5 18.4 Nov2009 2 3.0 None 3.0 Flight Simulator Training FSTD

1 N/A N/A 5.0 (Instrument Flying Training)

Total 55 57.4 15.5 77.9

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According to the aircraft flight folio, the following flights were flown by the pilot from 26 November 2009 to 5 August 2010:

Month Flights Total Flight Time (Hours)

November 2009 5 8.4 December 2009 13 24.4 January 2010 15 32.9 February 2010 13 23.9 March 2010 9 32.4 April 2010 14 85.4 May 2010 13 68.2 June 2010 6 11.5 July 2010 20 113.4 August 2010 3 22.2

(iv) First ATO (Durban – Virginia Airport) :–

(a) The ATO had a valid approval certificate which was issued in terms of CAR, Part 141. The approval certificate was valid from 2 February 2009 to 13 January 2010. The ATO was approved to give PPL training.

(b) The pilot commenced with PPL training at this ATO on 27 April 2009.

The pilot flying logbook shows that exercises 4 to 11 were carried out at the ATO. The pilot logged 35 hours training flight time on the R22 aircraft by 28 May 2009. The pilot requested if he could complete the remainder of flight training at Postmansburg. The ATO was not able to satisfy the request of the pilot, hence his decision to discontinue the PPL training. The pilot left Durban and went back to Postmansburg.

(c) The pilot file was forwarded to the second ATO where he was going to

complete the PPL.

(v) Second ATO (Pretoria – Wonderboom Airport):–

(a) This ATO had a valid approval certificate issued under CAR, Part 141. The approval certificate was valid from 24 March 2010 to 17 May 2011. The ATO was approved to carry out PPL training.

(b) This ATO agreed with the pilot to continue where he left off. They

continued with the PPL training at Postmansburg and at Kimberley. The ATO assigned an Instructor which was charged with the responsibility to complete the PPL training. According to a statement “ The Instructor first impression of the pilot was th at he was behind on flying skills compared to hours logged in the flyin g logbook”. Exercises 8 to 29 were completed from 31 August 2009 to 11 October 2009. The Instructor observation was that the skills of the pilot had improved so much to a point where only his solo preparation and initial solo flight was outstanding.

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(c) During the training, the Instructor was away on business at

Johannesburg and when he returned, evidence showed that the pilot flew unauthorised and unsupervised flights whereby 25 hours unsupervised flight time was logged in the flying logbook. The pilot was immediately reprimanded and informed that the 25 hours will not account for the PPL. On completion of the training syllabus, the pilot was finally ready for his PPL test flight.

(d) On Sunday, 11 October 2009, the student pilot did his solo navigation

flight at Kimberley. He landed having 1.8 hours sho rt of the full 15 hours required for PPL. Due to the weather, the solo hours could not be completed on the day. The instructor advised the pilot that he will be travelling back to Johannesburg and that he should not fly unauthorised or unsupervised flights in his absence.

(e) The pilot was not satisfied of not completing or being signed out by the Instructor due to the 1.8 hours and made offers to the Instructor suggesting inappropriate means to obtain the remain ing 1.8 hours. The Instructor refused and advised the pilot the 1.8 hours will be flown within the next three days. The pilot once again disregarded the instructions and flew the aircraft on another unaut horised and unsupervised flight from Kimberley to Postmansburg. The ATO immediately reprimanded him again and withdrawn the ir PPL test completely with the following options:

(vi) The pilot was to comply with the following instructions:

(a) He was to rewrite air law, specifically focusing on regulations of Student Pilot License and Private Pilot License.

(b) To fly additional 10 hours, until he shows proficiency and that he can operate the aircraft safely in respect of visual flight rules (VFR) operations from Wonderboom Airport.

(c) To complete the outstanding solo navigation flights from Wonderboom.

(d) Lastly, the PPL test must be repeated.

(vii) The pilot refused to comply with the instructions and the ATO management decided to report the matter of the unauthorised/unsupervised flight to the SACAA on 16 October 2009. The ATO then refused training the pilot further towards his PPL. The ATO management was very concerned that the pilot showed total disregard for authority and regulations. The pilot finally contacted another ATO to complete his PPL.

(viii) Third ATO (Bloemfontein – Tempe Airport) – The ATO had a valid approval

certificate issued under CAR, Part 141. The approval certificate was valid from 1 April 2009 to 23 February 2010. The ATO was duly approved to conduct the PPL training.

(a) The ATO did not investigate the training history of the pilot before

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accepting him for his PPL training. There was also no request made for a copy of his training file from the last (second) ATO. The ATO management was willing to complete the PPL training, being satisfied with the pilot’s flying logbook information. They were not aware of the conflict caused by the pilot during his training at the previous ATO.

(b) The pilot completed his PPL at the ATO. The ATO tested him on 3

November 2009. His experience logbook shows that the PPL test was a three (3) hour dual flight. After the flight, the instructor certified the logbook indicating that the PPL test was successfully completed.

END