Serious incident Shorts 360-100 9S-GAP, Sunday 24 October 2021
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Date:Sunday 24 October 2021
Time:07:20
Type:Silhouette image of generic SH36 model; specific model in this crash may look slightly different    
Shorts 360-100
Owner/operator:Malu Aviation
Registration: 9S-GAP
MSN: SH3612
Year of manufacture:1983
Fatalities:Fatalities: 0 / Occupants: 5
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Ndola-Peter Zuze Air Force Base -   Zambia
Phase: Landing
Nature:Ferry/positioning
Departure airport:Goma Airport (GOM/FZNA)
Destination airport:Ndola-Simon Mwansa Kapwepwe International Airport (NLA/FLSK)
Investigating agency: AAIB Zambia
Confidence Rating: Accident investigation report completed and information captured
Narrative:
On October 24, 2021, a Shorts 360 aircraft operated by Malu Aviation in DRC departed from Goma Airport for a scheduled maintenance check to Lanseria Airport in South Africa.
The aircraft made radio contact with Lusaka Area Control who handed it over to Ndola Approach at Simon Mwansa Kapwepwe International Airport. Ndola Approach then proceeded to hand the aircraft over to Ndola Tower for final approach. Ndola Tower did not see the aircraft on final approach Runway 09 and made several attempts to contact it but to no avail. Later, Ndola Approach called Ndola Tower reporting that the aircraft was on ground and had erroneously landed at Peter Zuze Military Airport.

The cause of this incident from submitted reports and all related documentation gathered indicate that this aircraft was flown on route with a wrong way point (Ndola Airport). All the briefing offices were unable to pick up this mistake by the crew of 9S-GAP. The aircraft was operated by experienced pilots who were very familiar with the route operated via Ndola Airport. Their surprise landing at Peter Zuze airport also confirms that they did not receive the Notams issued with regards to the closure of Ndola Airport and transfer to Simon Mwansa Kapwepwe International Airport.

Human Factors is the cause of this incident mainly due to both organizational arrangements put in place prior to the flight and also service providers who missed the stop gaps by not noticing that a wrong way point had been indicated on the filed flight plan i.e. Ndola Airport (FLND) instead of Simon Mwansa Kapwepwe International Airport (FLSK).

The investigation team notes that both pilots did not observe updated notams and as such missed critical information required for the safe navigation without incident.

Accident investigation:
cover
  
Investigating agency: AAIB Zambia
Report number: 
Status: Investigation completed
Duration:
Download report: Final report

Sources:

https://www.aaib.org.zm/pages/9S-GAP.php

Revision history:

Date/timeContributorUpdates
28-Oct-2024 09:09 Bandit Added
28-Oct-2024 09:15 ASN Updated [Aircraft type, Cn, Location, Nature, Destination airport, Source, Narrative, Accident report, ]
28-Oct-2024 09:16 ASN Updated [Destination airport, ]

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