What happened
On January 23, 2020, a Cessna S550, registration ZS-CAR, was operating a flight near George Aerodrome (FAGG) when it collided with a mountain. The aircraft was performing a flight inspection mission, specifically intended for VOR calibration. During the flight, the aircraft entered a steep dive and an overbanked maneuver while traversing terrain. The impact occurred on an upslope at an elevation of 2,192 feet. The collision resulted in the destruction of the aircraft and three fatalities.
The investigation
The investigation, conducted by the Ethiopian AAIB in delegation from the South African AIID, examined flight recorder data, wreckage distribution, and meteorological conditions. Investigators analyzed the flight path, which involved a 17 nautical mile arc passing over mountainous terrain. The study included an evaluation of the crew's training, the aircraft's equipment, and the operational procedures of the Flight Inspection Unit (FIU). The investigation also reviewed the meteorological reports from SAWS, which indicated significant cloud coverage below 1,500 feet at the time of the accident.
Findings
- The crew experienced an unusual attitude during the transition from VFR to IFR flight conditions without adequate preparation.
- The aircraft was flying through an area where mountain tops were obscured by clouds.
- The crew was unable to recover from the steep dive and overbanked maneuver before impacting the terrain.
- There was a lack of sufficient Upset Prevention and Recovery Technique (UPRT) training.
- The aircraft was not equipped with a Cockpit Voice Recorder (CVR), which prevented the recording of crew communications and terrain warnings during the impact.