What happened
On the morning of 16 April 2024, a Beechcraft 1900D, registration ZS-PKB, was operating a commercial Part 135 charter flight from O.R. Tambo International Airport to Venetia Mine Airfield. The flight, carrying two crew members and 17 passengers, was conducted under instrument flight rules.
As the aircraft approached Runway 08 at the mine airfield, the crew performed their landing checklists. The aircraft was flying in a flapless configuration, with flaps set to the up position. During the final approach, the aircraft touched down heavily on a gravel area approximately 3 metres before the runway threshold. The impact caused the left main landing gear drag brace bolts to shear, leading to a partial collapse of the gear. Despite the aircraft lowering on its left side, the pilot maintained directional control and brought the plane to a stop approximately 900 metres down the runway. The incident resulted in minor damage to the aircraft, but there were no injuries to the passengers or crew.
The investigation
An investigation by the SACAA AIID examined the flight's technical and operational history. Investigators discovered that the aircraft's flaps were unserviceable prior to departure from Gauteng. However, this defect had not been recorded in the aircraft's technical logs, nor was there any evidence of a deferred maintenance entry. The investigation also noted that the crew was aware of the inoperative flaps but had not followed regulatory procedures to document the deficiency.
Findings
- The primary cause of the incident was an incorrect approach speed for a flapless configuration, which led to an excessive sink rate and the subsequent hard landing.
- The crew failed to recognize an unsafe approach profile and did not execute a go-around.
- There was evidence of poor airmanship regarding the management of the approach.
- A significant maintenance oversight occurred as the known flap defect was not documented in the aircraft's technical logs, contrary to regulatory requirements.
Safety action
- It is recommended that the SACAA Director exercise increased oversight of the operator to address the practice of failing to document aircraft deficiencies.
- The regulator should conduct comprehensive audits of the operator's Safety Management System (SMS) to ensure all safety risks are effectively identified and mitigated.