ASN Aircraft accident British Aerospace 4121 Jetstream 41 ZS-NRM Durban International Airport (DUR)
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Status:Accident investigation report completed and information captured
Date:Thursday 24 September 2009
Time:07:57
Type:Silhouette image of generic JS41 model; specific model in this crash may look slightly different
British Aerospace 4121 Jetstream 41
Operator:SA Airlink
Registration: ZS-NRM
MSN: 41069
First flight: 1995
Total airframe hrs:27429
Engines: 2 Garrett TPE331-14GR-805H
Crew:Fatalities: 1 / Occupants: 3
Passengers:Fatalities: 0 / Occupants: 0
Total:Fatalities: 1 / Occupants: 3
Aircraft damage: Damaged beyond repair
Location:1,4 km (0.9 mls) E of Durban International Airport (DUR) (   South Africa)
Phase: Takeoff (TOF)
Nature:Ferry/positioning
Departure airport:Durban-Louis Botha Airport (DUR/FADN), South Africa
Destination airport:Pietermaritzburg Airport (PZB/FAPM), South Africa
Flightnumber:8911
Narrative:
A BAe Jetstream 41 turboprop plane, registered ZS-NRM and operated by SA Airlink, was destroyed when it crashed immediately after takeoff from Durban International Airport (DUR), South Africa. The crew consisting of two pilots and a flight attendant were seriously injured; the captain eventually died on October 7.
The aircraft was on a positioning flight, SA8911, from Durban International Airport (DUR) to Pietermaritzburg (PZB). The crew received takeoff clearance at 07:56. The aircraft commenced its take off roll from runway 06 and shortly before it became airborne a catastrophic failure occurred in the no. 2 (right hand) engine due to a fatigue failure of the second stage rotating air seal. Smoke was seen trailing from the aircraft as the airplane began to climb. Flaps were raised as the no. 2 engine torque rapidly dropped. At 07:57:25 the captain notified the Tower "Okay we’ve lost an engine". The associated pressure altitude was approximately 480 feet with an indicated airspeed of 120 knots. It continued to climb to an altitude of about 500 feet AMSL. Immediately after raising the undercarriage, at 07:57:30, the left engine spooled down from 100% to zero within 7 seconds. The aircraft then descended and the stick shaker activated.
The airplane force landed in a small field within the Merebank residential area, 1.4 kilometers from the end of runway 06. The aircraft struck the ground with the tail cone first in a wings-level attitude with the landing gear retracted. It skidded for approximately 25 meters before impacting an electrical pole and crossing a tarmac road. The aircraft then collided with a concrete palisade fence and came to rest with the fuselage broken in two and detached from the wings.
A member of the public was also injured when he was struck by the wing of the aircraft as it landed.

Probable Cause:

PROBABLE CAUSES:
Engine failure after takeoff followed by inappropriate crew response, resulting in the loss of both lateral and directional control, the misidentification of the failed engine, and subsequent shutdown of the remaining serviceable engine.
Contributing factors:
- Separation of the second-stage turbine seal plate rim;
- Failure of the captain and first officer to implement any crew resource management procedures as prescribed in the operator’s training manual;
- The crew’s failure to follow the correct after take-off engine failure procedures as prescribed in the aircraft’s flight manual.

Accident investigation:

cover
Investigating agency: CAA SouthAfrica
Status: Investigation completed
Duration: 2 years
Accident number: CA 12-12a
Download report: Final report

Classification:
Shutdown of wrong engine

Loss of control

Sources:
» SKYbrary 
» Airlink


Follow-up / safety actions

CAA S.A. issued 3 Safety Recommendations

Show all...

Photos

photo of BAe-4121-Jetstream-41-ZS-NRM
accident date: 24-09-2009
type: BAe 4121 Jetstream 41
registration: ZS-NRM
photo of BAe-4121-Jetstream-41-ZS-NRM
accident date: 24-09-2009
type: BAe 4121 Jetstream 41
registration: ZS-NRM
 

Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Durban-Louis Botha Airport to Pietermaritzburg Airport as the crow flies is 64 km (40 miles).
Accident location: Exact; deduced from official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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