Accident description
Last updated: 3 September 2014
Status:Final
Date:Thursday 24 September 2009
Time:07:57
Type:British Aerospace 4121 Jetstream 41
Operator:SA Airlink
Registration: ZS-NRM
C/n / 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
Airplane damage: Damaged beyond repair
Location:1,4 km (0.9 mls) E of Durban International Airport (DUR) (   South Africa) show on map
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 nr.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 nr.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 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.

Classification:
Shutdown of wrong engine

Loss of control

Sources:
» Airlink

Official accident investigation report
investigating agency: Civil Aviation Authority (CAA) - South Africa
report status: Interim
report number: Interim report no.1
report released:22-DEC-2009
duration of investigation:89 days (3 months)
download report: Interim report no.1 in respect of the investigation into the cause of an accident involving a Jetstream 4100 aircraft shortly after take off from Durban International Airport on 24 September 2009 (S.A. CAA Interim report no.1)
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investigating agency: Civil Aviation Authority (CAA) - South Africa
report status: Final
report number: CA 12-12a
report released:03-OCT-2011
duration of investigation:739 days (2 years )
download report: Jetstream Aircraft 4100 ZS-NRM: Loss of control after engine failure and misidentified engine shutdown after take-off from Durban Airport, South Africa on 24 September 2009 (S.A. CAA CA 12-12a )
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Follow-up / safety actions

CAA SA issued 3 Safety Recommendations

Show all AD's and Safety Recommendations

Photos

photo of British Aerospace 4121 Jetstream 41 ZS-NRM
photo of British Aerospace 4121 Jetstream 41 ZS-NRM
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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).

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