Malu SH36 at Ndola on on Oct 24th 2021, landed at wrong airport
Last Update: January 8, 2023 / 21:04:18 GMT/Zulu time
Zambia's AIB released their final report concluding the probable causes of the serious incident were:
The cause of this incident from submitted reports and all related documentation gathered indicate that this aircraft was flown on route with a wrong way point (Ndola Airport). All the briefing offices were unable to pick up this mistake by the crew of 9S-GAP. The aircraft was operated by experienced pilots who were very familiar with the route operated via Ndola Airport. Their surprise landing at Peter Zuze airport also confirms that they did not receive the Notams issued with regards to the closure of Ndola Airport and transfer to Simon Mwansa Kapwepwe International Airport.
Human Factors is the cause of this incident mainly due to both organizational arrangements put in place prior to the flight and also service providers who missed the stop gaps by not noticing that a wrong way point had been indicated on the filed flight plan i.e. Ndola Airport (FLND) instead of Simon Mwansa Kapwepwe International Airport (FLSK).
The investigation team notes that both pilots did not observe updated notams and as such missed critical information required for the safe navigation without incident.
Peter Zuze Military Airport used to be the "Simon Mwansa Kapwepwe International Airport" of Ndola until October 2021. The new airport had been planned to open for operation in 2020, however, it's opening was delayed and officially confirmed on Aug 5th 2021 taking two more month until the airport went into operation. A similiar but reciprocal event had occurred in April 2021, see Incident: Ethiopian B738 at Ndola on Apr 4th 2021, landed at airport under construction. A final report for the Ethiopian occurrence has not yet been released.
The AIB analysed:
Human Factor Elements
There was a series of Human Factor related events that were not put into consideration by both the crew of 9S-GAP and Service Providers which can be broken down as follows:
a) Crew – It is very unlikely that this crew of 9S-GAP navigated the traditional way using maps, computer Appleyard scale following principles of Degrees, Distances and fixes.
It can be deduced from the pilot account that the crew navigation was supported by GPS backed navigation equipment. The fact that this aircraft was on a path to Ndola from Goma can only be as result of the following: -
- It is very much possible that the route was planned via Ndola and as such since airport data existed as published, an entry of waypoint Ndola validated this planned route as followed by crew.
- It is very unlikely that FLSK was selected as waypoint by 9S-GAP crew and as such the GPS information was used to navigate the aircraft as planned to Peter Zuze Military Airport (FLND).
b) Crew Resource Management – At least the PIC indicated that he had flown through Ndola Airport before and as such should have raised questions as to why the runway had shifted from 10/28 to 09/27(This is evidenced in reports from all Air Traffic Controllers who repeated the runway in use as 09 and the Pilots being familiar with Ndola’s runway 10 should have realized that there was an indication that they were being cleared to a runway that they were not familiar with. A simple request for clarification could have been made and 9S-GAP was going to receive updated information to navigate to the correct airport.)
c) Goma Airport, Democratic Republic of the Congo (DRC) – had not updated Notams on Ndola Airport closure and opening of Simon Mwansa Kapwepwe International Airport.
d) Goma Airport, DRC – There was no scrutiny or interrogation of Flight plan by Goma Airport briefing office for 9S-GAP filed as FZNA-FLND-FVJN-FALA
e) Lubumbashi Airport, DRC – There were no updated Notams on Ndola /Simon Mwansa Kapwepwe International Airport
f) Lubumbashi Airport, DRC – Lumumbashi Airport did not scrutinize the Flight plan by Briefing office for 9S-GAP filed as FZNA-FLND-FVJN-FALA
g) The 9S – GAP crew applied for an airspace flight permit to fly from Goma (FZNA) in DRC, make a stopover at Ndola Airport (FLND) (Now Peter Zuze Airport) then to Joshua Nkhomo (FVJN), finally Lanseira (FALA) in Republic of South Africa and it was approved by the Zambian Government through the Zambia Air Force. ZAF Operations did not notice the error on route via Ndola instead of Simon Mwansa Kapwepwe International Airport (FLSK).
h) Simon Mwansa Kapwepwe International Airport – Visibility was less than 10Km due to reported haze within the Airport traffic pattern and hence the tower controller failing to see the aircraft at the expected distance to sight the aircraft on final approach.
i) The Tower controller cleared the aircraft to land despite not physically seeing the aircraft.
Hand over/take over formalities between Zambia Airports Corporation Limited and Zambia Air Force Command
j) It is very much evidenced from the reports that Zambia Air Force Command at Peter Zuze Military Base were not prepared for this incident. The situation on ground at the time indicated that there were personnel manning the tower and monitoring radio transmissions between aircraft within SMKIA traffic pattern. The situation on ground at the time indicated Peter Zuze staff were conducting “fire drills” which was okay within the ZAF mandate. Further, the airport was not fully prepared with Rescue and Fire Services to match the airport category at the time of hand over from Zambia Airports Corporation Limited.
k) Despite the Peter Zuze Military Airport being handed over to ZAF, there were no published interim airspace restrictions to keep unsuspecting Civil Traffic from mistakenly flying into the Peter Zuze Military Airport.
l) The location Indicator and all the published procedure for FLND were still very much active at the time of incident.
m) The Risk analysis conducted by both the CAA and ZACL teams was not availed to indicate the mitigation that was put in place looking at the pertinent air space management regarding the two airports.
n) Zambia Air Force was unable to update investigators with any existing Standard Operating Procedures.
o) There was no evidence of an agreement or Memorandum of Understanding with regards the two airports (Peter Zuze Military Airport and Simon Mwansa Kapwepwe International Airport) between Zambia Air Force and Zambia Airports Corporation Limited.
The planned routing was Goma-Ndola-Joshua Nkhomo-Lanseria, and cruising flight level was FL125 VFR (Visual Flight Rules). This was the exact flight path followed by the pilots of 9S-GAP which was a wrong flight plan as it should have been Goma-Simon Mwansa Kapwepwe-Joshua Nkhomo-Lanseria, and cruising flight level was FL125 VFR (Visual Flight Rules). It was discovered that AFTN communication link between DR Congo and Zambia is very unreliable. However, the crew had applied for an airspace flight permit to fly from Goma (FZNA) in DRC, make a stopover at Ndola Airport (FLND) (Now Peter Zuze Airport) then to Joshua Nkhomo (FVJN), finally Lanseira (FALA) in Republic of South Africa and it was approved by the Zambian Government through the Zambia Air Force. Hence the crew homed for the old Ndola Airport. The crew claimed they did not receive prior notification through a NOTAM or Aeronautical Information Chart (AIC) regarding the new Simon Mwansa Kapwepwe International Airport.
Human factor events indicated above show that a number of safety nets had been breached both by the crew and service providers as follows:
a) The crew did not adequately plan as expected as there was no mention of updated Notams in their planning.
b) The nav data for Ndola Airport was still valid and as such GPS information did not bring out any questions of suspicions as expected of a non-existing airport data.
c) The Pilots kept receiving runway in use as 09 but were not raising a red flag that their situational awareness was affected by this runway discrepancy.
d) There were breaches in safety when an aircraft was cleared to land on a visual approach when it was not physically identified by the controller on duty.
e) There was no existing Airport Emergency Response plan availed by Zambia Air Force, Peter Zuze Command.
The aircraft documents availed indicated a fully serviceable aircraft with no known outstanding maintenance issues.
The weather was relatively clear skies in Haze through with moderate easterly winds and reported by Air Traffic Controllers as surface wind 140 at 09 kts, CAVOK, temperature +32ºC and QNH 1019.
Even though the reported weather indicated CAVOK, all the controllers interviewed did indicate a presence of moderate Haze.
Observations by the Investigation Team
The investigation team did observe that in as much as ZACL handed over Ndola Airport (now Peter Zuze Military Base) to ZAF following the opening of Simon Mwansa Kapwepwe International Airport, the Human Factor gaps indicated above also exposed a number of inconclusive reasons such as:
a) None existence of Memorandum of Understanding between Zambia Air Force Peter Zuze Command and Zambia Airports Corporation Ltd, Simon Mwansa kapwepwe Management.
b) FLND (Ndola Airport) Nav data for arrivals, approach, departure procedures were still available as published to international airways publishers.
c) Simon Mwansa Kapwepwe International Airport had incomplete Arrival and Departure procedures.
d) Simon Mwansa Kapwepwe International Airport had an Instrument Landing
System installed but not published as there was no procedure in place.
e) The Risk Analysis conducted by teams from the CAA and ZACL excluded CAA Operations inspectors.
f) The Risk analysis conducted by ZACL and the closure of Ndola Airport and opening of Simon Mwansa Kapwepwe International Airport was not availed to indicate how the mitigation was put in place to prevent traffic infringements between the two airports as in this incident.
g) There are no meteorogical visibility markers published for SMKIA by the MET department for use by ATM staff.
h) ATM staff were at times using nonstandard ICAO phraseology as noted in the tape transcript.
i) ATM staff have no met observation rating hence their inability to correct weather reports as promulgated from the Meteorological Department.
j) All ATCOs have no letters of authority written to them by the Minister through the Director of Civil Aviation Authority so that they can be empowered to enforce the law on the air regulation offenders. Hence they are unable to demand for licences, medicals and any other documents deemed necessary for from the offending crew themselves.
k) ATM staff did not use visual communication procedures.
l) ATM staff has adopted the wrong procedure for aircraft landing in Visual Meteorological Conditions (VMC). Aircraft approaching to land are cleared to land even when ATC has not sighted them.
m) No audio tape transcript were availed to the investigation team. Only a written one which the controllers refuted as not being correct.
n) They are no avoidance procedures (SIDs and STARs) put in place for Peter Zuze Military airport for either landing or departing aircraft.
o) Some ATM staff at Peter Zuze Airport are operating without civil aviation licences hence civil aircraft cannot be handled by them.
p) Some ATM staff at Peter Zuze Airport did not know how to use the Aldis Lamp for visual communication with non-radioed aircraft despite having the facility in the control Tower.
q) SMKIA management insisted that the onus of sighting SMKIA lies the with VFR pilots themselves since they are a lot of airstrips surrounding the said airport and not the controllers to guide them even when visual landing procedure have not been put in place by ATM.
This article is published under license from Avherald.com. © of text by Avherald.com.
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