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2012 C-47TP Drakensberg crash was avoidable - Inquiry

The C-47TP that crashed into the Drakensberg.The Board of Inquiry (BOI) report into the crash on 5 December 2012 of a South African Air Force (SAAF) C-47TP Dakota near Giant’s Castle in the Drakensberg finds that the accident was mainly caused by human error and was avoidable.

The report was obtained by Rapport and declassified following a Public Access to Information Act (PAIA) process, with most of the names redacted.

The aircraft, C-47TP number 6840, belonged to 35 Squadron based at Air Force Base (AFB) Ysterplaat and was on a routine flight taking protection members from AFB Waterkloof to Mthatha Airport when it crashed, killing all 11 people on board. It also apparently had three boxes of medicine destined for Mthatha, where Nelson Mandela was sick in nearby Qunu.

The cause of the accident, the BOI found, was that “The crew filed a flight plan with an incorrect flight level (FL) and routing”, causing the aircraft to be too low when it reached the Drakensberg.

Contributing causes are given as the weather and lack of situational awareness among the aircrew. The inquiry further found the lack of an aircrew pre-flight briefing was a key issue and that unnecessary time pressure and insufficient flight planning also played a part. The aircrew did not adhere to standard checks and procedures and failed to do a proper risk assessment.

In addition, the report speaks of the “organisational culture” at 35 Squadron, pointing out that unsafe practices were condoned and reinforced by commanders. In addition, the unit used operational flights to double as training flights, thus depriving many crew members of proper training.

The former Officer Commanding 35 Squadron, Lieutenant Colonel Gerrie van der Merwe, stressed that while he felt the report was fair, it omitted two key factors: namely, lack of proper air safety management, as the computer did not pick up that the flight plan submitted included a flight level that was too low for the area and also that pressure from the SAAF’s Air Force Command Post (AFCP) and the abusive nature of its commander and Senior Staff Officer (SSO) led to an atmosphere where aircrews were under pressure to perform.

The main problem identified by the investigation was the incorrect flight plan, which was filed on a civilian website, while the pilots were playing golf. This may indicate an extremely casual attitude, which was noted by the inquiry.

The online computer programme rejected the first flight plan, so another plan, from a later date, was filed. It too, was an earlier flight plan and not drawn up specifically for the day of the 5 December flight.

The pilots did not request a weather report on the day nor did they ask for one at AFB Waterkloof Movements, nor did they phone for a weather report and would have been unaware of the weather over the Drakensberg.

The report adds that if a pre-flight briefing had taken place as was standard, someone in the aircrew would likely have noticed the problem with the planned height and the dangers of flying over the Drakensberg.

Another problem was that while the aircraft was equipped with a multi-phase weather radar, no-one among the aircrew had been trained to use it. The report says it had five modes, three of which showed the ground beneath the plane, thus showing how dangerously close they were to the mountains, and also two modes showing the weather. The radar was apparently not used.

The aircraft was not equipped with a Ground Proximity Warning System, nor did the type have data or cockpit voice recorders on board.

Also, no radio calls were sent at half-hourly intervals confirming all systems normal, which should have been standard procedure, according to 35 Squadron instructions and the Transmission Order Request. In addition, the Board found a “lack of synergy” or co-operation among the aircrew.

The normal route from Waterkloof (WKA) to Mthatha was to fly towards Ladysmith (LDY), then on to Estcourt at FL 110 (11 000 ft) and then descend to FL 100 (10 000 ft) and turn towards Kokstad and Mthatha towards the DURBA reference point. The pilots apparently turned on a bearing of about 210 degrees (South-Southwest) and flew into the mountains near Giant’s Castle, which is at some 13 800 feet.

Before the C-47TP turned, the pilot requested permission from the Air Traffic Controller (ATC) to descend to FL 100 under the Semicircular Rule, but was not warned about the dangers of flying over the high ground.

The Semi-Circular Rule was devised to create “vertical separation” between aircraft in the air. So aircraft flying more-or-less West must use an even Flight Level (FL), while aircraft flying more or less East, choose an odd FL, thus avoiding mid-air collisions.

Additional causes for the crash are given as cloud and fog; weather with minimal visibility; and poor situational awareness.

The flight plan was filed to fly under Instrument Flight Rules (IFR) and the aircraft was equipped to fly in instrument weather conditions. The pilots were also instrument rated.

The Dakota was also well serviced and the accident was not caused by any component of the aircraft or onboard systems malfunctioning, according to the Board of Inquiry.

The report suggested the once the aircraft entered cloud, the aircrew went onto instruments and therefore failed to see the looming mountains.

The SAAF Board of Inquiry into the crash of C-47TP 6840 comes to the conclusion that the accident was “avoidable”.