Report finds inadequately trained SAA flight crew lost control of plane

A report by a German aviation authority has found that SAA flight crew temporarily lost control of an Airbus 340-346 on a commercial flight from Johannesburg to Frankfurt with 259 people on board in 2018.

The German Federal Bureau of Aircraft Accident Investigation’s findings, released this week, found that the incident — caused by rare and unpredictable wind conditions at high altitude — caused the plane to exceed the maximum operating speed.

The investigation found the pilots to be experienced, but they applied the recovery procedures erroneously, leaving the plane close to stalling. 

Further investigation revealed that the Airbus A340 simulator they trained on was technically not able to correctly produce the type of conditions they experienced for the first time during the sudden wind change on the flight. The simulator training of the pilots was limited to explanations by the simulator trainers.

“The operator neglected to update the simulator software even though in 2006 the aircraft manufacturer had published an update. The training department should have noticed and remedied this deficit,” the report found.

The pilots also did not have any training material available to explain how to deal with such an incident. There were no injuries and no damage in the 2018 incident that occurred as the aircraft flew over Clariden, Switzerland.

The report labelled the incident as “serious” and that there had been a high probability of an accident. The probe found that the pilot in charge deactivated the autopilot and steered the aircraft manually into climb. The maximum angle was reached several times and the aircraft system’s stall warning was activated several times for a few seconds. The Airbus 340 is equipped with a high speed protection to prevent in-flight speeds which could cause structural overload or loss of control.

The pilot then initiated a descent and stabilised the flight path again. The Swiss Transportation Safety Investigation Board delegated the investigation to the German Federal Bureau of Aircraft Accident Investigation in November 2018. The German investigation found the rapidly turning wind direction was unpredictable for the flight crew and caused an overspeed condition.

The flight crew did not respond to this overspeed condition with the relevant “abnormal and emergency” and overspeed recovery procedures. “The control inputs by the pilot in charge during the active stall warning were insufficient and not energetic enough to stabilise the flight attitude in time,” states the report.

“Crew co-operation during the overspeed condition and the stall recovery was erroneous in regard to the analysis of the situation and the implementation of procedures.”

The report concludes that high-altitude overspeed training with drastic wind speeds would have better prepared the pilots for such an event and minimised the surprise. The investigation also found that the pilot in charge and co-pilot 2 held the required and valid aeronautical licences and ratings. However, the investigation determined a difference in the licence of co-pilot 1 and found he did not meet the licence requirements as a
co-pilot in commercial operations.

The report says SAA has implemented new processes to check pilots’ licences and the checklists of the training department and flight operations were adapted to ensure that the simulator software version and that of the real aircraft concur. The flight operations and training department now monitor pilots’ training.

SAA responded to the report, saying: “SAA is aware that the report in question was published on the German regulatory website of the German Federal Bureau of Aircraft and Accident Investigation. SAA has not officially received the report from the SACAA nor the German regulator.

“It must be noted that this safety report relates to an incident which occurred in November 2018, both SAA and the SACAA had previously completed and provided inputs to the German Investigative Authority prior to business rescue and subsequent restructuring of the airline.

“The company has been reorganised and relaunched under new management, and according to current management procedures and SAA’s Safety Management System, as soon as this report is officially received and confirmed, SAA will study the report judicially. A response on the findings and any possible remedial actions required will be communicated to all stakeholders and implemented internally.”