What happened
On the night of 15 August 2015, a Cessna 441, registration V5-NRS, departed Oranjemund Airport, Namibia, on a medical evacuation mission. The flight, operated by Westair Aviation, was transporting a patient and a companion to Cape Town International Airport.
During the approach to Cape Town, air traffic controllers notified the crew of a total radar failure at the facility. Consequently, the aircraft was directed to perform a VOR approach for Runway 19. At 0429Z, while attempting the approach, the aircraft ceased all radio communication. A search was initiated, and the wreckage was discovered approximately 8 nm north of the airport on the Maastrecht farm. The impact and subsequent fire resulted in 5 fatalities, claiming the lives of the two crew members and three passengers.
The investigation
SACAA AIID investigators examined the flight path, aircraft maintenance records, and meteorological conditions at the time of the accident. The investigation confirmed that the aircraft's engines and navigational equipment, including the Garmin GPS units, were fully functional. However, the investigation also scrutinized the operational procedures of the operator and the oversight provided by the Namibian CAA.
Findings
- The primary cause of the accident was the aircraft colliding with terrain while operating in instrument meteorological conditions (IMC) during the VOR approach.
- The crew failed to execute the published approach procedure correctly, leading to a descent that placed the aircraft below safe altitudes and outside of protected airspace.
- Meteorological conditions included low-level cloud cover with a base of 500ft and significant winds, which obscured the surrounding terrain.
- The investigation identified several organizational deficiencies, including a lack of formal procedures for fatigue management, crew pairing, and flight planning.
- There were notable discrepancies in training documentation and a lack of evidence regarding the competency of certain flight personnel.
Safety action
- The operator is advised to implement a comprehensive safety management system (SMS) to better identify hazards and mitigate risks, specifically regarding human performance and fatigue management.