CA 12-12a 11 JULY 2013 Page 1 of 28 Section/division Accident and Incident Investigations Division Form Number: CA 12-12a AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY Reference: CA18/2/3/9363 Aircraft Registration ZS-OFJ Date of Accident 25 September 2014 Time of Accident 1105Z Type of Aircraft Robinson R44 Raven II (Helicopter) Type of Operation Commercial Pilot-in-command Licence Type Commercial (Helicopter) Age 30 Licence Valid Yes Pilot-in-command Flying Experience Total Flying Hours 226.6 Hours on Type 98.7 Last point of departure Rand Airport (FAGM) - Gauteng Province Next point of intended landing Rand Airport (FAGM) - Gauteng Province Location of the accident site with reference to easily defined geographical points (GPS readings if possible) Germiston, near industrial area (Jupiter) with GPS co-ordinates reading as: S26º 14' 33", E028º 09' 04" with a field elevation of 5462 ft. Meteorological Information Wind direction: 120; Wind speed: 13 kts, Temp: 25ºC, Dew Point: 01ºC, Visibility: CAVOK Number of people on board 1+1 No. of people injured 0 No. of people killed 2 Synopsis The pilot was accompanied by a passenger (vehicle tracking personnel) on board the helicopter. They were returning from a commercial vehicle tracking flight when the accident occurred. During the approach at approximately one nautical mile heading in a southerly direction to FAGM, the ATC contacted the pilot after seeing the helicopter manoeuvring strangely. Thus, the ATC observed that the helicopter suddenly hovered and then instantly pitched its nose up before diving straight down in a nose-down attitude. The ATC then asked the pilot to confirm if that operation was normal. The pilot responded with an emergency call “MAYDAY”. Immediately after that call, the ATC saw the helicopter descending until it hit the ground. According to the eye witness, the helicopter was observed falling nose-down and it burst into flames immediately after impact. The helicopter was destroyed by fire. The main rotor assembly, tail rotor assembly and the vertical stabilizers were found within a radius of 40 meters from the main wreckage. The investigation determined that the accident was caused by the pilot suddenly stopping and attempting to make a hovering out-of-ground effect manoeuvre. This resulted with the pilot losing control and she was unable to recover from the induced abnormal forward flight hovering attitude. Probable Cause The helicopter entered into a vortex ring state from which the pilot was unable to recover. Contributory Factor/s 1. Sudden hovering out-of-ground effect at a restricted height 2. Situational unawareness 3. Loss of control IARC Date Release Date
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CA 12-12a 11 JULY 2013 Page 1 of 28
Section/division Accident and Incident Investigations Division Form Number: CA 12-12a
AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY
Reference: CA18/2/3/9363
Aircraft Registration
ZS-OFJ Date of Accident 25 September 2014 Time of Accident 1105Z
Type of Aircraft Robinson R44 Raven II (Helicopter) Type of Operation Commercial
Pilot-in-command Licence Type Commercial (Helicopter)
Age 30 Licence Valid Yes
Pilot-in-command Flying Experience
Total Flying Hours
226.6 Hours on Type 98.7
Last point of departure Rand Airport (FAGM) - Gauteng Province
Next point of intended landing Rand Airport (FAGM) - Gauteng Province
Location of the accident site with reference to easily defined geographical points (GPS readings if
possible)
Germiston, near industrial area (Jupiter) with GPS co-ordinates reading as: S26º 14' 33", E028º 09' 04" with a field elevation of 5462 ft.
Number of people on board 1+1 No. of people injured 0 No. of people killed 2
Synopsis
The pilot was accompanied by a passenger (vehicle tracking personnel) on board the helicopter. They were returning from a commercial vehicle tracking flight when the accident occurred. During the approach at approximately one nautical mile heading in a southerly direction to FAGM, the ATC contacted the pilot after seeing the helicopter manoeuvring strangely. Thus, the ATC observed that the helicopter suddenly hovered and then instantly pitched its nose up before diving straight down in a nose-down attitude. The ATC then asked the pilot to confirm if that operation was normal. The pilot responded with an emergency call “MAYDAY”. Immediately after that call, the ATC saw the helicopter descending until it hit the ground. According to the eye witness, the helicopter was observed falling nose-down and it burst into flames immediately after impact. The helicopter was destroyed by fire. The main rotor assembly, tail rotor assembly and the vertical stabilizers were found within a radius of 40 meters from the main wreckage. The investigation determined that the accident was caused by the pilot suddenly stopping and attempting to make a hovering out-of-ground effect manoeuvre. This resulted with the pilot losing control and she was unable to recover from the induced abnormal forward flight hovering attitude.
Probable Cause
The helicopter entered into a vortex ring state from which the pilot was unable to recover. Contributory Factor/s
1. Sudden hovering out-of-ground effect at a restricted height
2. Situational unawareness
3. Loss of control
IARC Date Release Date
CA 12-12a 11 JULY 2013 Page 2 of 28
Section/division Accident and Incident Investigation Division Form Number: CA 12-12a
AIRCRAFT ACCIDENT REPORT
Name of Owner : MIX TELEMATICS
Name of Operator : Henley Air
Manufacturer : Robinson Helicopter Company
Model : R44 Raven II
Nationality : South African
Registration Marks : ZS-OFJ
Place : Germiston; near the Jupiter industrial area with GPS
co-ordinates: S26º 14' 33", E028º 09' 04"and field
elevation of 5462 feet
Date : 25 September 2014
Time : 1105Z
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 produced without prejudice to the rights of the CAA, which are reserved.
1. FACTUAL INFORMATION
1.1 History of Flight
1.1.1 The pilot, accompanied by a passenger (vehicle tracking personnel), departed from
Rand Airport (FAGM) on a commercial vehicle tracking flight in the Pretoria area,
which is north of FAGM. The intention was to land back at FAGM. Approximately an
hour after departure and on the return flight to FAGM, the pilot contacted the ATC at
CA 12-12a 11 JULY 2013 Page 3 of 28
FAGM. The helicopter (MATRIX-1) was in the approach towards the FAGM
airspace and heading in a southerly direction. According to the FAGM Tower
recordings at the time, the pilot reported her position to be at approximately five
nautical miles north of FAGM. The pilot was flying over the Linksfield area and was
requesting to join the circuit and land on the heliport next to Hangar 6. The ATC
cleared MATRIX-1 inbound at about 6000 ft above mean sea level (AMSL) and
below to remain north of Runway 29; MATRIX-1 was also asked to report during the
final approach. The pilot read back these ATC’s instructions and duly confirmed
them, in accordance with the standard procedures.
1.1.2 Approximately two minutes later, while still heading in a southerly direction inbound
at 6000 ft to Runway 17, MATRIX-1 contacted the ATC and reported being ready to
cross Runway 29. The ATC denied permission because the aircraft heliport is north
of Runway 29. The runway was in use at the time because a Cessna aircraft (C150)
was doing left circuit training. MATRIX-1 was then instructed to remain north of
Runway 29 and to report when safe on the ground. At this time, the ATC located the
helicopter’s position on the northern side of the airport at approximately one nautical
mile, hovering over the factories in the industrial area. The ATC attempted to ask
the pilot whether the operation was normal as per recall of the initial instruction; at
this point the ATC observed the helicopter suddenly pitching its nose up slightly and
then pitching nose-down. On making contact, the pilot responded with an
“EMERGENCY MAYDAY” call. In the ATC recordings, a horn warning of a low main
rotor RPM could be heard sounding in the background. Refer to Appendices A for
the ATC Matrix transcript.
1.1.3 The eyewitness is an employee in one of the factories in the Jupiter industrial area.
He stated that he observed the helicopter falling in a nose-down attitude with the
engine making a high revving sound prior to impacting the ground; it burst into
flames during the impact, which was on their dumping area. That witness further
stated that after the impact he called some of his colleague and rushed to the
helicopter with chemical fire extinguishers in an attempt to extinguish the fire and
save the occupants; this attempt was unsuccessful.
1.1.4 The airport fire and rescue team was also dispatched after the ATC informed them
of the accident. They arrived at the accident site after approximately 15 minutes and
found that the helicopter was already destroyed by fire. They then extinguished the
CA 12-12a 11 JULY 2013 Page 4 of 28
fire and secured the accident side.
1.1.5 The accident occurred in daylight conditions in bushy terrain with GPS co-ordinates:
S26º 14' 33", E028º 09' 04" with a field elevation of 5462 feet.
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 helicopter was destroyed by the post-impact fuel-fed fire.
Figure 1: The wreckage of the helicopter and the accompanying debris
CA 12-12a 11 JULY 2013 Page 5 of 28
1.4 Other Damage
1.4.1 None
1.5 Personnel Information
Nationality South African Gender Female Age 30
Licence Number 0272365735 Licence Type Commercial H
Licence valid Yes Type Endorsed Yes
Ratings Single engine piston, night
Medical Expiry Date 30 May 2015
Restrictions None
Previous Accidents None
Flying Experience:
Total Hours 226.6
Total Past 90 Days 51.6
Total on Type Past 90 Days 11.5
Total on Type 98.7
1.5.1 According to information obtained from the available training records, the pilot did
most of her training towards the south of FAGM, in the Vereeniging area.
Throughout her training the pilot would always request permission to cross Runway
29 on her final approach as the heliport is situated on the northern side of that
runway. The day of the accident was the pilot’s first day on the job with her new
employer. It was also her first flight dispatching on a vehicle tracking flight mission
in the northern region, where she had rarely flown before as a sole flight operator/
commander.
1.5.2 The pilot began training on 28 August 2010 on a R22 helicopter and attained 28.9
hours prior to converting to the R44. She successfully obtained a Private Pilot’s
Licence on 30 September 2011 at 83 flying hours, of which 37.1 hours were flown
on the R22 and 45.9 hours on the R44. On 21 May 2012 the pilot successfully
attained night ratings and this was endorsed on her licence. She obtained her
CA 12-12a 11 JULY 2013 Page 6 of 28
Commercial Helicopter Licence on 28 August 2014.
1.6 Aircraft Information
Figure 2: Shows the internet picture of the accident helicopter