The two highly-experienced Australian pilots of a crashed Convair CV-340 did not follow the prescribed checklist procedures when they discovered an engine had caught fire, a South African Civil Aviation Authority (SACAA) preliminary accident investigation report says.
Convair CV-340 ZS-BRV crashed shortly after takeoff from Pretoria Wonderboom Airport, South Africa on July 10 this year with 16 passengers, two pilots and a maintenance engineer on board. The South African maintenance engineer died in the accident, while the Australian pilots, one current and one recently-retired with Qantas, were seriously injured.
The preliminary report published on August 12 said the aircraft “experienced a left engine fire after rotation during takeoff”, before striking powerlines and colliding with a factory building.
On the day of the accident, the aircraft was conducting a scenic flight from Wonderboom to Pilanesberg and return. Those 19 people on board comprised three Australians as well as three Dutch nationals, 12 South Africans and one Zimbabwean, the SACAA said.
The SACAA said recovered GoPro video footage from the cockpit showed the captain was the pilot flying, while the first officer was doing the radio work.
The footage also showed the licenced aircraft maintenance engineer (LAME) operating the engine controls.
Further, “during taxi, takeoff and flight, until moments before the crash, one of the passengers was seen standing in the cockpit area behind the LAME.
“The GoPro also shows that the pilots were not sure if they had retracted the landing gears, as they can be heard asking each other whether the gears are out or not. It also shows that though the pilots and LAME were informed of the left engine fire, they were asking each other which engine was on fire,” the preliminary report reads.
The GoPro footage also showed that “at no stage did the pilots or the LAME discuss or attempt to extinguish the left engine fire, as the left engine fire extinguishing system was never activated”.
It said the emergency procedures from the inflight checklist containe
d in the aircraft flight manual (AFM) were not followed after the crew was made aware that the number 1 engine had caught fire.
“Based on the wreckage examination including the propeller and cockpit GoPro recording the above procedures were not followed by the crew when the left engine caught fire.”
The scenic flight took place shortly before the Convair, which was built in 1954, was due to be ferried to the Aviodrome museum in Lelystad in the Netherlands. It had been donated to the museum by South African travel company Rovos Rail.
The two Australian pilots, Ross Kelly and Douglas Haywood, were members of the Illawarra, NSW-based Historical Aircraft Restoration Society (HARS), and had flown HARS’s own Convair 440, which had also been acquired from Rovos Rail, from South Africa to Australia in August 2016.
However, HARS had no involvement with the accident aircraft.
The preliminary report noted the aircraft was certified for operation by two pilots and it was “not clear why the LAME was allowed to operate the engine controls during the operation of the aircraft”.
“The representatives of the current owner confirmed that in all the previous flights undertaken, the LAME was always seated with the crew and allowed to control the engine controls,” the preliminary report said.
The damage observed on the propeller at the crash site was “indicative of damage caused during rotation of the propeller that was not turning at high power”.
Further, the exhaust tubes were still secured on the centre section of the wing, while the exhaust exhibited damage by inflight fire and signs of overheating and discolouration.
The preliminary report noted Pilanesberg had been closed to fixed-wing aircraft on that day due to runway construction work. However, the crew and Wonderboom air traffic control were unaware of the notice to airmen (NOTAM) published by Pilanesberg Airport about this.
The preliminary report said documents and licences made available to the investigation team indicated only one of the pair was rated on the Convair.
“The captain had a valid Australian air transport, commercial and private licence and he was type-rated on the aircraft (Convair 340/440),” the preliminary report said.
“However the validation issued by SACAA was for private pilot license under visual flight rules (VFR) which was valid until 5th May 2021.”
“The FO had a valid Australian air transport, commercial and private pilot licence, however he was not type-rated on the aircraft (Convair 340/440).”
“The FO’s validation of his foreign licence was only limited to single-engine landing aircraft with the following aircraft types (C150, C172, C182, PA-28 A/B) this is based on his foreign licence validation application and skill test report dated 9th of May 2016 and the validation was valid until 05 May 2021.”
The preliminary report said “crew resource management in the cockpit was found lacking”.
The investigation is continuing. The investigation team includes representatives from Australia, Canada, the Netherlands and the United States.
“As the investigation is on-going we will be looking into other aspects of this accident which may or may not have safety implications,” the preliminary report said.