Investigation Summary
The accident began when a fatigue failure of the second stage rotating air seal caused the right-hand (No. 2) engine to fail during the takeoff roll. Despite the failure, the aircraft successfully became airborne. Flight Data Recorder (FDR) analysis showed that the aircraft remained controllable initially, but the crew failed to follow standard operating procedures for an engine failure after takeoff. Instead of maintaining directional control and identifying the failed engine through instrument cross-checks, the crew raised the flaps and landing gear while the aircraft was in a deteriorating flight state. The captain, likely under high stress due to reports of smoke and a gradual loss of control, inadvertently shut down the left-hand (No. 1) engine, which was still producing power. This resulted in a total loss of thrust at an altitude of approximately 500 feet. With no power and insufficient airspeed to maintain flight, the aircraft descended rapidly, striking the ground tail-first in a small field before skidding into a concrete palisade fence at a local school.
Final Conclusions
The South African Civil Aviation Authority (SACAA) concluded that the primary cause was the engine failure after takeoff followed by inappropriate crew response. This response led to the loss of lateral and directional control, the misidentification of the failed engine, and the subsequent shutdown of the serviceable engine. Contributing factors included the fatigue failure of the turbine seal plate rim and a total breakdown in Crew Resource Management (CRM), as the pilots failed to implement prescribed emergency procedures or communicate effectively during the crisis.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Captain Allister Freeman. Died of injuries on October 7, 2009. Had a previous history of a similar accident in 2005 involving a BN-2 Islander.
First Officer
First Officer Sonja Bierman. Seriously injured. Was the Pilot Flying (PF) during the takeoff.
Systems & Failure Modes
Garrett TPE331-14GR Engine
The right-hand engine suffered a mechanical failure of the second-stage turbine seal plate rim, leading to a loss of thrust.
Stick Shaker
The stall warning system activated when the aircraft's airspeed dropped below safe limits following the shutdown of the second engine.
Propeller Feathering System
The captain attempted to feather the propeller of the failed engine but inadvertently selected the wrong engine's controls.
Interesting Facts
- 01The aircraft was on a ferry flight with no passengers on board.
- 02The captain had been involved in a similar engine-failure-related crash in 2005.
- 03The right-hand engine failed due to a fatigue failure of the second stage rotating air seal.
- 04The aircraft struck a concrete palisade fence at a primary school, but no students were present at the time.
- 05A ground worker was seriously injured after being struck by the aircraft's wing during the forced landing.
Safety Actions & Advisories
CRM Training Review
The investigation highlighted the need for improved Crew Resource Management training, specifically focusing on engine failure identification and verification procedures during high-workload phases.