CemAir CRJ2 at George on Aug 23rd 2021, takeoff without clearance

Last Update: October 13, 2022 / 15:10:34 GMT/Zulu time

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Incident Facts

Date of incident
Aug 23, 2021

Classification
Incident

Airline
Cemair

Flight number
KEM-125

Departure
George, South Africa

Destination
Johannesburg, South Africa

Aircraft Registration
ZS-CMG

Aircraft Type
Canadair Corporate Jetliner

ICAO Type Designator
CRJ2

A CemAir Canadair CRJ-200, registration ZS-CMG performing flight KEM-125 from George to Johannesburg (South Africa) with 38 passengers and 3 crew, was scheduled for departure at 05:45Z, was preparing for departure from runway 29 a few minutes prior to that time while the tower was still unstaffed, however, the crew knew the NOTAM that indicated the tower would open at 05:45Z. The aircraft taxied for departure and at 05:43Z radioed on tower frequency that they were taxiing to holding point A3. Approach control, who had opened 15 minutes earlier, informed the crew that tower would be open within the next 2 minutes, the crew decided to use the procedures for unstaffed aerodromes and radioed they were lining up for departure on runway 29, they would turn left early after departure. At 05:44:58 tower, now occupied, radioed they were in service, at that time KEM-125 was still holding on the runway. At 05:45:35z the crew radioed they were now rolling for takeoff. Approach needed to instruct a scheduled line flight (Embraer ERJ-135) on approach to George to level off to ensure separation. The CRJ departed and during initial climb turned left contacting approach, who then provided vectors to both the CRJ and the ERJ to ensure separation and permit the ERJ to continue their approach. After separation was ensured approach cleared the ERJ for a visual approach to George's runway 11.

South Africa's CAA rated the occurrence a serious incident and opened an investigation.

On Oct 13th 2022 the SACAA released their final report concluding the probable causes were:

The pilot-in-command (PIC) of the ZS-CMG elected to take-off from Runway 29 by following the unmanned aerodrome departure procedures (pilot’s discretion) before the tower officially opened at 0545Z. This was after he was advised by the Approach Controller that Runway 11 was in use and that there was an aircraft (ZS-ALJ) inbound for landing from the west. This resulted in the two aircraft being on reciprocal tracks. The Approach Controller instructed the ZS-ALJ aircraft to deviate by turning to the right of the track until they were clear of the departing conflicting traffic.

The SACAA analysed:

The aircraft departed FACT on a scheduled domestic air transport flight under instrument flight rules (IFR), destined for FAGG. The aircraft was scheduled to depart FACT at 0515Z but took off at 0520Z. The estimated flight time was 35 minutes. At 05:40:54Z, the crew establish communication with Approach Controller at FAGG whilst under radar control, who instructed them to descend to FL150 and to expect vectors for the ILS approach Runway 11.

At this stage, the aircraft was approximately 55nm from FAGG, which was just prior to entering the Terminal Manoeuvring Area (TMA) of FAGG. At 05:47:06Z, approximately 17nm from FAGG, the Approach Controller instructed the crew to turn right on a heading of 165° to avoid conflicting traffic (KEM125) that was departing from Runway 29 (pilot’s discretion). The crew was informed by Approach Controller at 05:48:49Z to join Runway 11 for a visual approach; the aircraft landed safely at 05:54:17Z.

The decision by the PIC of ZS-CMG (KEM125) to not wait for the official opening of the Tower at FAGG at 05:45:42Z after being advised by the Approach Controller resulted in this serious incident. By opting to take-off from Runway 29, which was the PIC’s discretion after being informed that a scheduled air transport flight carrying passengers was on approach for Runway 11 was a display of poor airmanship and a disregard for safe operating procedures.

The decision by the PIC to use Runway 29 for take-off placed the aircraft on a reciprocal track with ZS-ALJ (Link621). This decision by the PIC of ZS-CMG (KEM125) required the intervention of the Approach Controller who, in an attempt to avoid an accident, instructed ZS-ALJ (Link621) to turn to the right of the track on a heading of 165° and to descend to 6 000ft.

At no time, prior to take-off from Runway 29, did the crew members of ZS-CMG (KEM125) enquire from the Approach Controller about the distance the ZS-ALJ (Link621) was at from FAGG. Without this critical information, the PIC continued to take-off from Runway 29.

It should be taken into account that ZS-CMG (KEM125) was only issued a squawk code (# 3271) at 05:47:55Z whereafter the aircraft was identified on radar. By that time, the aircraft was passing through 4 800ft while in a left turn over the sea.

Approach Control at FAGG opened at 0530Z, which was 15 minutes prior to the Tower opening time. The Approach Controller was in radio communication with ZS-ALJ (Link621), which was inbound from FACT to FAGG. The crew was informed to expect vectors for the ILS approach Runway 11. Following the decision by the PIC of KEM125 to take-off from Runway 29, which placed them on a reciprocal track with ZS-ALJ (Link621), the Approach Controller had to instruct ZS-ALJ (Link621) to turn right on a heading of 165° to maintain adequate separation between the two aircraft.

Approach Control at FAGG provided the following weather information to ZS-ALJ (Link621); “The surface wind at the moment, northerly less than 5 knots, the temperature is 6°C, dew point 4°C, QNH 1018 and it is CAVOK.”

It should be noted that aircraft on approach for landing have priority over departing aircraft as stipulated in the International Civil Aviation Organisation (ICAO) Doc 4444, pg. 171. From the radar data available, ZS-ALJ (Link621) was 23nm from the threshold of Runway 11 and descending through 9 000ft when ZS-CMG (KEM125) commenced with their take-off roll. At no stage, prior to commencing with their take-off roll, did any of the crew members enquire with either the Approach Controller or the crew of ZS-ALJ (Link621) about the distance and the time the aircraft was from FAGG. The PIC made a decision without gathering essential information prior to electing to use Runway 29. Also, he did not take cognisance of the fact that he was informed of the aircraft that was on approach for Runway 11. Moreover, he did not wait for the Tower to open.

The pilot’s primary responsibility is to fly the aircraft safely. Pilots should remain alert to all other traffic movements within their vicinity. The performance capabilities of all aircraft are different in both speed and rate of climb/descent, resulting in high closure rates limiting the time available for detection, decision-making and evasive action. It is essential that the greatest degree of safety and vigilance are always complied with.
Incident Facts

Date of incident
Aug 23, 2021

Classification
Incident

Airline
Cemair

Flight number
KEM-125

Departure
George, South Africa

Destination
Johannesburg, South Africa

Aircraft Registration
ZS-CMG

Aircraft Type
Canadair Corporate Jetliner

ICAO Type Designator
CRJ2

This article is published under license from Avherald.com. © of text by Avherald.com.
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