What happened
On 24 September 2009, a Jetstream 4100, registration ZS-NRM, departed Durban Airport for a repositioning flight to Pietermaritzburg. During the takeoff roll on runway 06, the aircraft's right-hand engine began emitting heavy smoke, which was observed by other pilots on the ground. As the aircraft became airborne, the crew was alerted by air traffic control and another aircraft that the landing gear had not yet been retracted.
Shortly after takeoff, the aircraft climbed to approximately 500 feet before losing altitude. During the emergency, the crew mistakenly identified the failed engine and proceeded to shut down the remaining serviceable engine. This loss of power caused the aircraft to descend into a residential area in Merebank. The aircraft struck a field, slid across a road, and hit a concrete fence at a local high school. The accident resulted in one fatality (the captain) and two serious injuries to the remaining crew members. Additionally, a road worker was seriously injured when struck by the aircraft's wing.
The investigation
An investigation by the SACAA AIID examined the wreckage and flight data. Technicians determined that the right-hand engine had suffered a catastrophic failure caused by the fatigue failure of a second-stage turbine seal plate. Crucially, the investigation established that the left-hand engine was actually functional throughout the event. The investigators found that the pilot in command had manually moved the fuel-condition lever for the working engine, effectively disabling the aircraft's only remaining source of thrust.
Findings
- The primary cause of the accident was an engine failure following takeoff, which was followed by an inappropriate crew response.
- The crew misidentified the failed engine, leading to the shutdown of the only serviceable engine.
- There was a significant breakdown in Crew Resource Management (CRM), characterized by a failure in leadership, decision-making, and interpersonal communication.
- The crew failed to adhere to the operator's standard operating procedures (SOPs) and the aircraft's flight manual regarding engine-inoperative procedures.
- The mechanical failure originated from a fatigue failure of the second-stage rotating air seal in the engine.