Caa accident report summary: Cessna 402C
Date of accident: July 30 2001
Time of accident: 0100Z
Aircraft registration: ZS-LXY
Type Of aircraft: Cessna 402C
Pilot-in-command licence type: CPL
Pilot-in-command flying experience: Total Flying Hours: 850.7
Hours on Type: 97.2
Last point of departure: Johannesburg International Airport (FAJS)
Next point of intended landing: Harare (Zimbabwe)
Location of the accident site: FAJS
Meteorological information: Fine conditions
Number of people on board: 1
Number of people injured: 0
Number of people killed: 0
Synopsis
The pilot stated: “When I opted to retract the gear after departure I experienced airframe buffet and a gear warning light came on. I elected to return for an immediate landing. He gave me a clearance to land back on Runway 21. I then busied myself with trying to fly the airplane in that specific situation.
As I turned onto final approach I noticed the lights for the runway I was approaching were slightly dim and I asked ATC to turn the lights up. At this time I was very close to the threshold and I was concentrating on preparing the aircraft for landing. I specifically re-checked that the gear was down. I saw no improvement in the lights but they were sufficient to land. On the roll out this was the time ATC advised me that I had approached and landed on the wrong runway. From the roll-out I asked for taxi to Delta 1.”
Probable Cause
The pilot was placed under pressure when his landing gear failed to retract after rotation and landed on the closed runway (runway 21R) after being cleared by ATC to land on runway 21L. A NOTAM (A1060/2001) was issued on July 10 2001, which notified pilot’s of the closure of Runway 03L/21R for maintenance.
Jim’s Analysis
This is a classic example of what is meant by that terrible experession ‘situational awareness’. Sure, it describes what we are thinking about – but let’s find a less yuppy term that means being sharp and keeping awake.
Okay, you take off at night in a fairly sophisticated twin and something goes bang, what is the correct procedure? Where’s the checklist? There isn’t one, so what to do?
It’s very simple – Aviate, Navigate, Communicate.
• Aviate: fly the aeroplane – which he did.
• Navigate: point it away from danger – i.e. the ground – which he did, initially.
• Communicate: tell someone who cares – which he did.
The problem is that he didn’t keep navigating. Sure, he had other things on his mind and this is why he came unstuck. He allowed these other things to overtake his situational awareness. A very dangerous thing to do.
On December 29 1972 an Eastern Airlines Lockheed flew into the Everglades. killing 99 people. This happened because the entire crew had all its attention on a two buck gear warning light inside the cockpit. They nudged the stick – which disengaged the autopilot.
And no one paid any attention to where the cockpit was going. It slowly descended into the marsh while no one was minding the store.
Our guy in the Cessna understandibly got tunnell vision for a bit, and lost awareneness of which runway was which, but there should have been serious alarm bells when he asked for brighter lights and nothing happened. Also ATC should have woken up, realised the pilot was under pressure and nurse-maided him round the circuit.
And while we are looking at ATC – surely it doesn’t make sense to have the lights burning on a runway that is closed. That is just looking for trouble. Okay, they covered their arse with NOTAMS – but all the paperwork in the world would not have prevented this incidnt.
Hell, it could have been something with 200 pax on board and they could have hit a bulldozer.
I believe the Cessna pilot did a pretty good job under difficult circumstances. But it was just lucky this wasn’t a major crash with fire and widows.
What can we learn?
• When you Aviate, Navigate and Communicte, these are not one-off things – you have to keep doing them. Keep flying the aeroplane, keep navigating and keep communicating. Keep updating all three.
• When there is some sort of crap in the fan this is the very time to make sure it doesn’t distract you from the basics.
Jim Davis has 15,000 hours of immensely varied flying experience,
including 10,000 hours civil and military flying instruction. He is an
established author, his current projects being an instructors’ manual
and a collection of Air Accident analyses, called Choose Not To Crash. Visit Jim's website by clicking here.
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