Accident Convair CV-340 ZS-BRV,
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Date:Tuesday 10 July 2018
Type:Silhouette image of generic CVLP model; specific model in this crash may look slightly different    
Convair CV-340
Owner/operator:Rovos Air
Registration: ZS-BRV
MSN: 215
Year of manufacture:1954
Total airframe hrs:18115 hours
Engine model:Pratt & Whitney R-2800-CB16
Fatalities:Fatalities: 1 / Occupants: 19
Aircraft damage: Destroyed, written off
Location:6 km ESE of Pretoria-Wonderboom Airport (PRY) -   South Africa
Phase: Approach
Departure airport:Pretoria-Wonderboom Airport (PRY/FAWB)
Destination airport:Sun City-Pilanesberg Airport (NTY/FAPN)
Investigating agency: CAA S.A.
Confidence Rating: Accident investigation report completed and information captured
On 10 July 2018 the private owner of the aircraft (ZS-BRV), Rovos Rail, entered into a sale agreement of this aircraft with the Luchtvaart Themapark Aviodrome from the Netherlands. As part of the agreement, the aircraft was to be kept in a serviceable condition and registered South Africa. The terms of the agreement included that the aircraft was being sold as is and all costs and responsibilities towards the aircraft were passed over to the Aviodrome. Though the arrangements were finalised between Rovos Rail and Aviodrome, the Certificate of Airworthiness (CoA) and the Certificate of Registry (CoR) were still registered under the current owners (Rovos Rail). The aircraft was to be ferried to the Netherlands on the 12th of July 2018 and expected to arrive in the Netherlands at Lelystad Airport (EHLE) on the 23rd of July 2018.
In preparation for ferrying the aircraft, the aircraft had to be painted, serviced, inspected and accepted by Aviodrome representatives. Prior to the accident flight in July 2018, the aircraft was last flown in February 2018. On 6 July 2018 maintenance checks (A, B & C) were performed on the aircraft. The accident flight was the first flight post maintenance.
On 10 July 2018 the aircraft took off for a scenic flight from Wonderboom Airport destined for Pilanesberg, with the intention to return back to Wonderboom. The passenger manifest indicates that there were 2 Australian pilots and 17 passengers on board. Among the passengers was a Licensed Aircraft Maintenance Engineer who acted as a member of the crew.
Unbeknownst to the crew, Pilanesberg Airport was closed for fixed winged aircraft as indicated in the Notice to Airmen (NOTAM) No. B0930/18, due to the runway being under construction. At the time of take-off (1439Z) the NOTAM had already been published and neither the crew nor Wonderboom ATC were aware of the NOTAM.
The captain, seated on the left seat, was the pilot flying (PF) and the first officer (FO), seated on the right seat, was doing the radio work. The engineer was operating the engine controls.
After all the run-up checks were concluded, the crew made a request for take-off. The request was acknowledged and granted by the ATC before the aircraft was taxied to runway 29 at 16:30.
The aircraft then entered the runway, accelerated down the runway and rotated. At the 50 kts call, the captain stated that the manifold pressure was low. After rotation, one of the passengers went to the cockpit and told the engineer that the left engine was on fire.
The Air Traffic Controller (ATC) stated that the aircraft then continued North West of the aerodrome over the Bon Accord dam at a distance of approximately 2 to 2.5 miles at about 800 feet, indicating a rate of climb of 600 to 700 feet per minute (fpm).
The aircraft continued with the left engine on fire throughout the flight and during the accident sequence. A cockpit GoPro recording also shows that the left engine RPM gauge was fluctuating and that later the left engine fire master caution light was illuminating and an audible warning sound was heard. The control wheel was deflected to the right and the captain indicated that they had lost aileron, and requesting rudder input from the FO.
The pilots indicated that they were not sure if they had retracted the landing gears. And although the pilots and engineer were informed of the left engine fire, they were asking each other which engine was on fire. At no stage did the pilots or the engineer discuss or attempt to extinguish the left engine fire, as the left engine fire extinguishing system was never activated.
The aircraft could not maintain altitude and first struck power lines spanned parallel Sakabuka street situated in Derdepoort industrial area, North of Pretoria. The aircraft continued for a further 71m before impacting a treetop with its left wing, and continued for a further 17m before impacting a set of treetops with its left wing. At 130m it impacted two commercial vehicles, before colliding with a building (Metal and Milk factories) resulting in the left outboard wing separating and coming to rest in the front of the building with which it collided . The collision destroyed the front and back wall of the building, with its roof together with the rear parameter wall fence, before the left horizontal stabiliser and inboard wing separating at 137m and 143m respectively. The inboard section of the left wing caught fire and continued burning. The main wreckage, right wing and engine came to rest found 250m further on, 6 km to the east of the airport.

Probable Cause:
During take-off, the left engine caught fire and the crew continued with the flight without securing the left engine as prescribed in the aircraft flight manual (AFM).
The crew declared an emergency and attempted to return to the aerodrome, however, they lost control of the aircraft and collided with power lines prior to crashing into a factory building.

Contributory Factors:
1. Pre-existing damage to the cylinder No 13 piston and ring pack deformation and, most probably, the cylinder No 7’s fractured exhaust valve head that were not detected during maintenance of the aircraft.
2. Substandard maintenance for failing to conduct compression tests on all cylinders during the scheduled maintenance prior to the accident.
3. Misdiagnosis of the left engine manifold pressure defect as it was reported twice prior to the accident.
4. The crew not aborting take-off at 50kts prior to reaching V1; manifold pressure fluctuation was observed by the crew at 50kts and that should have resulted in an aborted take-off.
5. Lack of crew resource management; this was evident as the crew ignored using the emergency checklist to respond to the in-flight left engine fire.
6. Lack of recency training for both the PF and PM, as well as the LAME.
7. Non-compliance to Civil Aviation Regulations by both the crew and the maintenance organisation

Accident investigation:
Investigating agency: CAA S.A.
Report number: CA18/2/3/9722
Status: Investigation completed
Duration: 1 year 1 month
Download report: Final report


Piloot en Vliegtuig



photo (c) SACAA; Pretoria-Wonderboom Airport (PRY); 10 July 2018

photo (c) Alan Wilson; Pretoria-Wonderboom Airport (PRY); 19 September 2014; (CC:by-sa)

Revision history:


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