Quarterly Report, January - March 2013

The Accident and Incident Investigation Division (AIID) is a division within the

South African Civil Aviation Authority. The mandate of the division is to

investigate aircraft accidents and serious incidents in line with the Civil

Aviation Regulations Part 12, and according to the International Civil

Aviation Organisation (ICAO) document Annex 13, and supporting

documents.

The aim of an investigation is to establish the probable cause of an accident

/ serious incident, and to issue safety recommendation(s) to prevent the

recurrence of such an accident / serious incident.

The aim of this quarterly newsletter is to inform the public regarding

investigations that were reported for the first quarter of 2013 (January –

March 2013). This report therefore contains aircraft accident and serious

incident statistics in which the public might be interested.

We will furthermore report on any other interesting activities that took place

in the division.

It is hoped that the reader will get a general overview of the aircraft

accidents and serious incidents that have taken place and the reported

causes of such occurrences. It must be noted that most of these

investigations are still ongoing. Once concluded, the final reports will be

published on the CAA website as a public document. It should be noted

that not all reported occurrences result in long reports. Some are being

captured for statistical reasons, as there are no safety benefits in conducting

a comprehensive investigation and writing a long report on some accidents.

General Overview

Accidents Quarterly Statistics

JANUARY – MARCH 2013

Compiled by Ms Bongi Mtlokwa

Senior Researcher

Accident and Incident

Investigation Division

T: 011 545 1238

E-mail: [email protected]

mailto:[email protected]

ACCIDENTS QUARTERLY STATISTICS

A total of 37 accidents were reported during the period 1 January to 31

March 2013. Thirty-four of these accidents occurred in South Africa, while

three involved South African-registered aircraft that occurred outside the

borders of South Africa (two in Mozambique and one in Namibia). For the

same period in 2012, 27 accidents were reported. This means that we have

recorded 10 more accidents in 2013, in comparison to the same period last

year. A total of 15 accidents were reported in January, 12 in February and

10 in March 2013.

Aircraft Accidents

A total of five fatal accidents were reported for the first three months of 2013

with eight fatalities. Three fatal accidents with five fatalities occurred in

January. The first fatal accident of the year occurred near Phalaborwa

airport, where it was reported that the engine had failed after take-off. The

aircraft crashed and was consumed by post-impact fire, and we lost two

occupants. The second accident involved a micro-light aircraft. An engine

sputter, followed by a loud bang was reported. The aircraft was also

consumed by post-impact fire. A paraglider crashed due to reported strong

cross-winds and vortex, resulting in a subsequent loss of control and the

paraglider crashed in a residential area. A second paraglider accident was

reported in February. It occurred in Burgersdorp in the Eastern Cape. This

accident was also due to strong winds, which resulted in loss of control and

the subsequent crash. Another fatal accident involving an aircraft

registered in South Africa occurred in Namibia. The aircraft was reported

missing and was found several days later. The two occupants on board were

fatally injured. Namibia as the State of Occurrence will be investigating the

accident with assistance from the AIID.

Fatal Accidents

Wreckage of ZU-EFH –

Fatal Accident

A total of 37 Accidents

were reported between

January – March 2013.

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2011 2 4 4 5 6 10 11 12 12 12 14 16

2012 1 3 5 9 12 13 15 17 18 18 19 19

2013 3 4 5

0

2

4

6

8

10

12

14

16

18

20

Tota

ls

Fatal Accidents Accumulative

Graph indicating accumulative fatal

accidents for the past three years. The

number of fatal accidents is exactly the

same in 2013 as it was in 2012 for the

same period.


Aircraft Accidents

The monthly reported accumulative graph indicates the total reported

accidents from 1 January to 31 March 2013. In comparison, there were 37

reported accidents for 2013 against the 27 reported accidents for 2012.

We thought it would be useful to include an extract from the ICAO Annex

13 document. This is a definition of an accident. We have observed some

confusion with regard to the exact definition of an accident.

Accident: An occurrence associated with the operation of an aircraft

which, in the case of a manned aircraft, takes place between the time

any person boards the aircraft with the intention of flight until such time as

all such persons have disembarked, or in the case of an unmanned

aircraft, takes place between the time the aircraft is ready to move with

the purpose of flight until such time as it comes to rest at the end of the

flight and the primary propulsion system is shut down, in which:

a) a person is fatally or seriously injured as a result of:

— being in the aircraft, or

— direct contact with any part of the aircraft, including parts which have

become detached from the aircraft, or

— direct exposure to jet blast,

except when the injuries are from natural causes, self-inflicted or inflicted

by other persons, or when the injuries are to stowaways hiding outside the

areas normally available to the passengers and crew; or

b) the aircraft sustains damage or structural failure which:

— adversely affects the structural strength, or performance or flight

characteristics of the aircraft, and

— would normally require major repair or replacement of the affected

component, except for engine failure or damage, when the damage is

limited to a single engine, (including its cowlings or accessories), to

propellers, wing tips, antennas, probes, vanes, tires, brakes, wheels, fairings,

panels, landing gear doors, windscreens, the aircraft skin (such as small

dents or puncture holes), or for minor damages to main rotor blades, tail

rotor blades, landing gear, and those resulting from hail or bird strikes

(including holes in the radome); or

c) the aircraft is missing or is completely inaccessible.

The graph indicates monthly

reported accidents. January

recorded the highest accidents

so far.


Total 2011 5 19 31 43 49 57 67 77 87 93 103 111

Total 2012 9 20 27 41 52 57 68 81 89 105 115 123

Total 2013 15 27 37

-10

10

30

50

70

90

110

130

150

To

tals

Accidents

2013 has the highest reported

accidents so far.


It must further be noted that all accidents/incidents/serious incidents must be reported to the accident investigation

division. However, not all reported accidents/incidents/serious incidents warrant full investigation. All received occurrences

are reviewed and categorised according to the severity of the occurrence. Occurrences are classified into 6 categories.

These categories are indicated below:

CATEGORY CIRCUMSTANCES

1 Accidents and incidents are those where the facts indicate a significant threat to the safety of the

general/travelling public or where they are the subject of widespread public interest. The

investigation will be conducted by a team involving specialist groups, and will include the collection

and analysis of all relevant facts, the issuing of safety recommendations and the production of an

ICAO-style report, normally within about 12 months from the date of occurrence.

2 Accidents and incidents are those where the facts indicate a concern for the safety of the

general/travelling public. Category 2 investigation requirements and reports are similar to those for

Category 1 investigations. The investigation will be conducted by a team involving specialist groups,

and will include the collection and analysis of all relevant facts, the issuing of safety

recommendations, and the production of an ICAO-style report, normally within about 12 months

from the date of occurrence.

3

Accidents and incidents are those where the facts indicate actual or potential serious safety

deficiencies. The category is used when there is some concern for public safety and a need for an

in-depth investigation to determine the facts. The investigation may be conducted by a team

involving specialist groups, and will include the collection and analysis of all relevant facts, the

issuing of safety recommendations, and the production of an ICAO-style report, normally within

about 6 - 12 months from the date of occurrence.

4 Accidents and incidents are those where the facts do not indicate a serious safety deficiency. The

category is used for accidents and incidents where the circumstances were sufficiently complex to

require detailed information from the pilot, operator and/or other involved parties. The accident

and incident reports may include Safety Recommendations where appropriate. The investigation

may be conducted by one or two investigators, and will include the collection and analysis of all

relevant facts, the issuing of safety recommendations if applicable, and the production of an ICAO-

style report, normally within about 6 months from the date of occurrence.

5 Accidents and incidents are incidents where some investigation actions are needed to expand on

and/or substantiate the initially reported facts. Investigations associated with this category

specifically aim to identify whether safety enhancement action is appropriate for accidents and

incidents. Category 5 reports may contain Safety Recommendations where appropriate. The report

will be available on request. The investigation may be a desk-top investigation conducted by an

investigator, and will include the collection and analysis of all relevant facts, and may include safety

recommendations and the production of an ECCAIRS-style report, normally within about 2 months

from the date of occurrence.

6 Accidents and incidents are occurrences which are primarily of statistical interest and are not

investigated. The initially reported information is recorded on the database ECCAIRS. Further

information may be available on request.

Decision to Investigate


We wish to reiterate that all occurrences must be reported to AIID as per

the Civil Aviation regulations. AIID does not investigate to apportion blame

or liability, but to improve aviation safety. It is therefore important that

occurrences are reported so that data can be collected and safety

deficiencies can be identified and addressed accordingly, in partnership

with the regulator and the industry.

The 37 received occurrences were categorized as follows:

All accidents must be reported

as per Civil Aviation

Regulations.

All reported accidents receive

attention.

Approved and released Accident Reports

The Advisory Safety Panel had three meetings between January and

March 2013. The panel consists of experts from the industry and their

mandate is to assist the AIID and the Director of Civil Aviation in producing

good quality reports; allocate the probable causes of accidents and

enhance safety recommendations to improve safety. We had a good start

and a total of 16 reports were reviewed and approved. These reports were

subsequently released by the Director and they are available on the CAA

website for the public. These finalised reports will further be used for safety

research and data analysis. Safety research and data analysis reports will

be released during the course of the year. A total of five significant

recommendations were produced from the reviewed accidents and were

forwarded to the regulator for action and implementation.


Some Reported Accidents

The aircraft was reported to

have entered into a spin and

subsequently crashed near

Panorama Airfield.

This is the wreckage of a

Bantam B22J. The accident

occurred in Mpumalanga. The

aircraft flew into a valley, was

unable to clear obstacles and

collided with trees.


Other Statistics

Accident Risk Exposure


2011 3 9 2 3 6 5 5 7 3 4 8 9

2012 5 11 7 7 15 4 4 4 7 2 8 1

2013 0 6 6

0

2

4

6

8

10

12

14

16

Serious Incidents 2013


Fatal Accidents 3 1 1

Fatalities 5 1 2

Serious Injuries 6 1 12

Persons on board 22 16 24

22 16

24

6

1

12 5

1

2 3

1

1

0

5

10

15

20

25

30

35

40

45

2013 Pax, Injuries, Fatalities & Fatal Accidents

A total of 12 serious incidents

were reported between 1

January and 31 March 2013.

These will also be investigated

and reports will be published in

accordance with internal

processes.

This graph indicates the number

of people exposed to

accidents in the past three

months. A total of 62 people

were exposed in the 37

accidents. Five of these

accidents were fatal, in which

eight people perished. It further

indicates a total of 19 serious

injuries as a result of being

involved in an aircraft

accident.


NTCA and TCA Accidents

Civil Aviation Register January to March 2013

2011 2012 2013

TOTL NTCA 15 17 17

TOTL TCA 27 10 20

0

5

10

15

20

25

30

TCA and NTCA Reported 3-Year Comparison

9

1

3

1

3

5

3

1

8

3

0

1

2

3

4

5

6

7

8

9

10

GP NW LIMP FS EC WC MP NC KZN O/B

Provincial January to March 2013


Air Traffic Movements

Civil Aviation Register

Jan Feb Mar

Arrivals 23322 23183 25206

Departures 22977 23084 25068

21500

22000

22500

23000

23500

24000

24500

25000

25500

Air Traffic Movements January - March 2013

Aeroplanes Helicopters NTCA

2013 4729 1086 5 874

0

1000

2000

3000

4000

5000

6000

7000

Civil Aviation Register January to March 2013


Personnel Licences

Central Reporting System The Central Reporting System is a tool used by the industry to report incidents. The system was established

to support Safety Management System activities. The system has two components; the voluntary

component and the confidential component (Confidential Aviation Hazard Reporting System). Every

member of the industry and the public is welcome to use the system. Occurrences reported through the

system are categorised according to the risk matrix and the classification table above. Some

occurrences are elevated to accidents or serious incidents and receive a full investigation. The rest of

the reports are for statistical purposes, safety research and data analysis. AIID is currently looking into

airspace infringements. A full-scale research is under way and findings and recommendations will be

released in due course.

0 1000 2000 3000 4000 5000

Hot Air Balloon Pilot

Flight Engineers

SPLIC

Airline Transport - Helicopter

Validations

Commercial Pilot - Helicopter

Private Pilot - Helicopter

Maintainance Engineers

Student pilot

Airline Transport - Aeroplane

Commercial Pilot - Aeroplane

Cabin Crew

Personnel Licences Jan - Mar 13


Central Reporting System Statistics

0

50

100

150

200

250

300

350

400

JAN FEB MAR

TOTAL RECEIVED INCIDENTS January - March 2013

0

50

100

150

200

250

300

350

Total Incidents received per Aerodrome

Jan - Mar 13

Comprehensive statistics will be

released in due course.

Quarterly Report, January - March 2013

Documents

Transcript of Quarterly Report, January - March 2013