South West Aviation L410 at Yirol on Sep 9th 2018, impacted lake on approach to Yirol City
Last Update: October 23, 2019 / 16:38:35 GMT/Zulu time
Incident Facts
Date of incident
Sep 9, 2018
Classification
Crash
Airline
South West Aviation
Departure
Juba, South Sudan
Destination
Yirol, South Sudan
Aircraft Registration
UR-TWO
Aircraft Type
Let L-410 Turbolet
ICAO Type Designator
L410
Initial information reported the aircraft had impacted Yirol River (sources including Radio Miraya absolutely ruled out the aircraft was in Yirol Lake) about 1.75nm south of the aerodrome while on approach to the runway at approximate position N6.53 E30.49.
The Information Minister in Eastern Lakes State reported the aircraft carried 23 people. 19 bodies were recovered, 4 survivors were taken to a hospital. The rescue and recovery was done by local fishing boats present at the accident site. Low visibility may have contributed to the accident. A domestic carrier named Southwest (editorial note: there is no evidence of that carrier on the Internet) had chartered the aircraft to carry out a passenger flight from Juba to Yirol City. South Sudan's Civil Aviation Authority have opened an investigation.
On Sep 10th 2018 the Minister stated, that 20 people died as result of the crash, three passengers survived. Eastern Lake State declared three days of national mourning.
In the evening of Sep 9th 2018 The Aviation Herald received a passenger manifest showing the operator of the flight was South West Aviation, the aircraft operated was UR-TWO. The handwritten manifest lists 17 adults and 3 children as passengers, one of the adults is listed as Ugandan Citizen, one an Ethiopian Citizen, all others as South Sudan Citizens.
Italian Media report an Italian citizen, working as doctor for a NGO in South Sudan (the name appears on the manifest as South Sudan Citizen), is amongst the survivors and has been taken to Juba with serious injuries.
According to Russian databases (who updated their information on Sep 9th 2018 after the accident, initially the aircraft's owner was shown unknown since 2017) the aircraft, MSN 841328, was operated by Ukrainian company "Universal-Avia" tail number RA-67102 until 2008, then was put into storage. In 2017 the aircraft is being owned by "SlavAir" based in Kiev (Ukraine). the tail number changed to UR-TWO. Pictorial evidence shows the airframe being restored to flying condition in Rivne (Ukraine) in 2016, the paint scheme already carries the operator name "South West" with South Sudanese Mobile Phone Number on it (Country Code 211, mobile phone provider 91). According to Ukrainian trade registers "SlavAir Company LLC" is based at Kiev Borispil Airport and engages in aircraft maintenance, rental and leasing of transport aircraft and passenger air transport, according to Ukrainian trade databases the company has less than 10 employees. According to a protocol certified on Jan 9th 2018 new partners joined the company in a meeting of Dec 11th 2017. In September 2018 the domain of SlavAir slavair.com is however expired and offered for sale, the last Facebook entry by the airline, showing a photo of Let L410 UR-ONE as one of their aircraft, was made in 2016, and there is no current sign of life by the company (past Apr 2018). No information about "South West" or their phone numbers is available online.
According to Ukraine's Aircraft Registry the L-410 MSN 841328 was assigned tail number UR-TWO on Apr 11th 2018, the owner is named SlavAir Company with no operator mentioned. UR-ONE on the other hand, identified as one of SlavAir's aircraft by the company on their Facebook account in 2016, has officially been registered to Nigerian N.S. in Kiev (Ukraine) on Mar 24th 2016.
On Nov 19th 2018 Ukraine's NBAAI reported SlavAir's L-410 registration UR-TWO suffered an accident at Yirol falling into the lake. 20 people were killed, 3 received injuries. South Sudan's Civil Aviation Authority is conducting the accident investigation. The NBAAI have assigned an accredited representative to the investigation, between Oct 29th 2018 and Nov 2nd 2018 the NBAAI read out and decrypted the parametric data.
No weather data for Yirol are available.
On Oct 23rd 2019 Ukraine's NBAAI published the final report released by South Sudan's Ministry of Transport (SSMOT) concluding the probable causes of the crash were:
The committee for the investigations of Slav Air Let410 aircraft registration UR-TWO has finally concluded that the cause of the accident at Yirol Eastern Lake State Republic of South Sudan was caused by a combination of the following factors:
- Severly bad weather in the morning of the accident. ( Not making a decision to return to Juba or diverting to the nearest Airport Rumbek)
- Pilot incompetency and error in setting the altimeter for Yirol airstrip before the crash. (Causing variations in altitude flying at false altitude below the actual flight level)
- Replacement of a faulty propeller in Pibor and not informing the safety department of the changes and not being given the release documents for operations.
The SSMOT reported the captain (57, ATPL, total flight hours and flight hours on type lost with pilot logbook) was assisted by a first officer (27, ATPL, total flight hours and flight hours on type lost with pilot logbook). The SSMOT annotated: "According to the Director of Safety and Flight Operation, the crew members from Republic of Sudan who flew the aircraft on the day of the accident were not inspected by the South Sudan Safety and Flight Operation Department of Airworthiness. Their currency status, licenses and qualifications were unknown to South Sudan Civil Aviation Authority until after the crash."
The SSMOT reported with respect to weather:
TAF/ YIROL 090500Z 0906/1012 VRB03KT 8000 FG FEW030 SCT140
The terminal weather Forecast(TAF] for Yirol area was reported as follow:
On the 9th of September 2018, at 5:00 Zulu( 8:00am local], and at 6:00Zulu ( 9:00am- local time, the wind was blowing from 100° at 12 nautical miles variable at 3 nautical miles. 8000 meters fog reported. Few clouds at 3,000 feet and scattered clouds at 14,000 thousand feet.
The weather forecast, during the flight was clearly visible and the visibility deteriorated when they entered the clouds. The visibility was less than a few meters that one could hardly see anybody in front (heavily fogged according to ground witnesses that day] and disabled the crew to clearly see the runway or the airport.
The crew circled several times over the town trying to locate the runway. As a result, the crew miscalculated and crash landed the plane into the Lake Yirol.
This incident was confirmed by the local fishermen when they heard a plane circling and later heard a bang just close by.
The SSMOT reported the laboratory analysis of the FDR, which recorded on a photosensitive film, resulted in the NBAAI reporting: "As a result of analysis performed by the laboratory experts, it was found that the accident data is missing on the photosensitive film because, by the time of the accident, the photosensitive film inside the cassette had come to its end. As a result of the analysis, experts concluded that the lack of flight data information does not provide a chance to determine the cause of the accident by this flight data recorder."
The SSMOT analysed:
After recovery of the wreckage from lake Yirol, the aircraft instrument panel was recovered together with most of the aircraft instruments.
It was analyzed that most the aircraft instruments frozen in the impact according to the instrument panel read as follws:
- The altimeter reading was 1,780 ft.
- Airspeed Indicator was 300 km/hr.
- Attitude Indicator was showing -25°( decent]
- Vertical speed was reading -4° [descent],
- Revolutions per minute (RPM) reading was 190hp.
- Heading Indicator reading was at 280° degrees.
- Barometric Altimeter reading was 290°
- Fuel indicator reading was (Left tank showing 400 ltrs and Right showing 3201trs].
- Turn coordinator reading was 3°Left.
The SSMOT released following findings:
1. The aircraft is owned by a Ukrainian company called Slav Air company and was leased to Southwest Aviation and entered into Republic of South Sudan in May 2018.
2. The aircraft was issued a ferry flight permit from Khartoum- Sudan to Juba- South Sudan by a Captain from Slav-Air plus two crew from The Republic of Ukraine for repositioning on the 17th of May 2018 and the insurance coverage was valid.
3. Weather report was not good; visibility was very poor due to fog at destination airport.
4. The crew which crashed were different than those who brought the aircraft to South Sudan, and before the crash the aircraft was flown by the two pilots brought from Khartoum by Southwest, and were not inspected by the SSCAA according to inspectors from Flight Safety Department.
5. Previously, a week before the crash, the aircraft had undergone some power plant maintenance in Pibor due to propellers malfunction, were not issued a Certificate of released to service from CAA inspectors but just started operations without informing the SSCAA about this incident which is a must procedure.
6. The South West company crew did not check the weather briefing at Meteorology department before their departure. This was proved in the sign-in log book which had not been signed by the crew and when asked by the investigators to provide the aircraft load sheet, it was missing and the operator could not provide one.
7. Baby Air Tours and Travel Company chartered the airplane from the South West Aviation company and put their passengers travelling to Yirol the day of the accident.
8. The company operation manager indicated that the engineer dispatched the aircrafton 9/09/2018 and then he returned to Ukraine on the same morning of the accident day.
Incident Facts
Date of incident
Sep 9, 2018
Classification
Crash
Airline
South West Aviation
Departure
Juba, South Sudan
Destination
Yirol, South Sudan
Aircraft Registration
UR-TWO
Aircraft Type
Let L-410 Turbolet
ICAO Type Designator
L410
This article is published under license from Avherald.com. © of text by Avherald.com.
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