Malawi Vice President Aircraft Accident Investigation Interim Report

Identification

• Type of Event: Accident
• Date: 10.06.2024
• Location: Chikangawa Forest (Republic of Malawi)

Aircraft

• Type: Airplane
• Manufacturer: General Atomics AeroTec Systems
• Model: Dornier 228–202(K)

Casualties

• Fatalities: 3 crew members and 6 passengers
• Damage to Aircraft: Destroyed
• Third-Party Damage: Ground damage
• File Number: BFU24–0508-DX

Summary

During a domestic passenger flight of the military aircraft Dornier 228–202(K) from Lilongwe-Kamuzu to Mzuzu (Malawi), the aircraft collided with the side of a hill under marginal visual flight weather conditions. At the request of the government of the Republic of Malawi to the Federal Republic of Germany, the BFU sent an investigation team to Malawi, supported by an expert from the aircraft manufacturer. The Republic of Malawi delegated the leadership of the investigation, conducted based on ICAO Annex 13, to the BFU and appointed an accredited representative and two advisers for the investigation.

Facts

Events and Flight Progress

According to the Flight Information Officer at Mzuzu Airport, the crew arrived at 06:00 local time. The plan was to fly to Lilongwe-Kamuzu, pick up the Vice President of the Republic of Malawi and five other passengers, and then fly to Mzuzu.

From the available GPS data, it was evident that the aircraft took off from runway 35 at 07:04 and turned to a southern course in a climbing left turn one minute later.

According to the controller in Lilongwe, he received a phone call from the Flight Information Officer in Mzuzu shortly after takeoff, informing him that the aircraft was expected to reach waypoint NALSA at 07:31 and the estimated landing time in Lilongwe-Kamuzu was 07:48.

The crew contacted Lilongwe Approach at 07:28 at flight level (FL) 100 with 3 crew members on board and fuel for a flight time of 02:30 hours. The estimated time to reach NALSA was 07:32, and the estimated landing time was 07:48. The controller cleared the aircraft for a direct approach to the non-directional beacon (NDB) KG and an ILS approach to runway 14, providing weather information. At 07:50, the aircraft turned into the final approach for runway 14, landed 2 minutes later, and taxied to stand 5. The aircraft was refueled there for the flight to Mzuzu and the planned return flight.

According to the air traffic control organization, the co-pilot filed a flight plan for the flight to Mzuzu at the crew briefing office at Lilongwe-Kamuzu Airport. The flight plan indicated an estimated flight time to the destination of 00:50 hours and a maximum possible flight duration of 04:00 hours.

At 09:05, the co-pilot requested departure information via radio and 3 minutes later requested start clearance. The controller issued the route clearance for a direct flight to Mzuzu at FL90 and the departure clearance at 09:12, transmitting the transponder code 2772. The aircraft took off at 09:16 with 3 crew members and 6 passengers on board from runway 14. The controller reported that the aircraft’s radar target appeared on the monitor when it reached an altitude of approximately 4,800 ft AMSL. At 09:17, during the climb, the aircraft began a left turn, which was completed 2 minutes later, turning to a northern direction.

The crew received clearance from the controller to climb to FL90. Later, the crew requested to remain at 7,000 ft AMSL. GPS data indicated that the aircraft reached a cruising altitude of approximately 7,300 ft (GPS altitude) around 09:23. About a minute later, it crossed the boundary of the airport’s control zone.

The crew informed the controller that they would reach the reporting point NALSA at 09:32 and the destination airport at approximately 10:05. The controller relayed this information to the Flight Information Officer at Mzuzu Airport by phone. At 09:30, the controller cleared the crew to switch to the frequency 118.1 MHz. According to him, there was no radar contact at this time due to the low altitude.

According to GPS data, the aircraft flying north was about 3 NM west of waypoint NALSA at approximately 7,500 ft at 09:32. At 09:37, it began to climb and reached an altitude of approximately 8,600 ft within 3 minutes. At 09:44, the aircraft began to descend. At 09:50, about 1.5 NM northwest of the village of Fumbawowa, it deviated from the direct course to the destination airport by turning left

In the left turn, at 09:52, at an altitude of 5,500 ft, the aircraft began to climb again. The left turn ended with a course of about 150° over the ground, and the aircraft then turned right to a westerly direction, reaching an altitude of 8,100 ft at 09:55 and descending again. At 09:56, the aircraft made a full left turn, continued southwest, and passed the settlement of Bokosi Kunga at 09:58. A minute later, it began to turn right, reaching an easterly course within a minute and then turning to a northeasterly course. The altitude decreased to about 5,400 ft (about 460 ft above ground). About 2 NM south of a wood industry facility, the aircraft turned left to a northerly direction while climbing. Between 10:06 and 10:09, about 3 NM northwest of the town of Chikangawa, the aircraft made 2 full left turns with a radius of about 600 m, flying at altitudes between 500 ft and 200 ft above ground.

From 10:09, the aircraft continued flying with changing courses in a northeasterly direction, descending to an altitude of 185 ft above ground, and then climbing again. At 10:12, it was about 25 NM southwest of Mzuzu Airport at an altitude of about 7,000 ft (about 1,500 ft above ground). Two minutes later, the aircraft reached an altitude of about 2,200 ft above ground. It then turned north and began to descend again. At 10:15, the aircraft turned left to a northwesterly direction. It last had a ground course of about 284° and crashed at 10:16.

All 9 occupants suffered fatal injuries, and the aircraft was destroyed. The crash site was found after a one-day search.

The Flight Information Officer at Mzuzu Airport stated that the weather at the airport was bad and conditions were deteriorating. Since the crew had not reported by 09:50, he called them on the radio, but this and a second attempt 5 minutes later were unsuccessful. He then called the Lilongwe Area Control Centre at 10:05 to confirm the aircraft’s planned arrival time.

At 10:12, the crew reported on the Mzuzu Tower frequency, stating that they were 20 NM away and approaching.

Here’s the translation:

The crew intended to approach from the north. The Flight Information Officer provided weather information and stated that runway 17 was in use. He informed the crew that visibility was about 5 km to the east, south, and west of the airport. The crew wanted to fly towards Ekwendeni to see if the weather conditions were better there. At 10:17, he called the crew on the radio to ask for their position and altitude, but received no response, as was the case with later attempts.

Personnel Information

Responsible Pilot

The 54-year-old responsible pilot held a commercial pilot license issued by the civil aviation authority of the Republic of South Africa and a military pilot license from the Malawi Air Force. The pilot was qualified as a flight instructor on the Do228 model.

His total flight experience was 2,367 hours, of which 2,006 hours were on the affected model. In the last 90 days, he had flown 24:40 hours, and in the last 24 hours, he had flown 02:40 hours.

Co-pilot

The co-pilot was 44 years old and held a commercial pilot license issued by the civil aviation authority of the Republic of South Africa and a military pilot license from the Malawi Air Force. The pilot served as the Base Safety Officer in the squadron.

She had a total flight experience of 722 hours, of which 472 hours were on the Do228 model. In the last 90 days, she had flown 23:50 hours, of which 02:40 hours were in the last 24 hours.

Documents indicated that the co-pilot and the responsible pilot had flown a total of 11:50 hours together since 16.04.2024.

Engineer

The 43-year-old aircraft engineer was responsible for assisting the pilots with the technical preparation and follow-up of the flights.

Aircraft Information

The Do 228–202(K) aircraft is a twin-engine, high-wing monoplane with a retractable tricycle landing gear. The aircraft is powered by two turboprop engines (see Fig. 3).

Here’s the translation:

Manufacturer: General Atomics AeroTec Systems
Model: Do 228–202(K)
Serial Number: 8148
Year of Manufacture: 1987
Maximum Takeoff Weight (MTOM): 6,200 kg
Engines: Honeywell TPE 331–5 (s/n P-39183 and P-39171)
Propellers: Hartzell HC-B4TN-5ML (s/n CDA4793 and CDA4794)
Total Operating Time: 3,492:56 hours

The aircraft had a registration in the Republic of Malawi as a military aircraft and was operated by the Malawi Air Force. It was equipped for instrument flight rules (IFR) flights and had a Garmin Aera 760 satellite navigation device with serial number 6HD001128.

According to the available refueling invoice, the aircraft was refueled with 483 liters of Jet A1 fuel at Lilongwe Kamuzu Airport before departing for Mzuzu.

Navigation Aids

The Department of Civil Aviation Malawi provided the BFU with the Aeronautical Information Publication (AIP) of the Republic of Malawi, edition 21.07.2017, for the investigation. According to the Department of Civil Aviation, this was the edition of the AIP valid at the time of the accident.

Airspace Structure in Malawi

According to the Ministry for Transport and Public Works, the Republic of Malawi had two major international airports: Lilongwe-Kamuzu International Airport and Blantyre-Chileka International Airport. Additionally, there were four airfields with paved runways, including the one in Mzuzu. There were also 26 airfields with unpaved runways in the country

The Lilongwe Flight Information Region (FIR) was structured as follows: Each of the two international airports was surrounded by a control zone (CTR) with a radius of 20 NM, extending from the ground up to an altitude of 7,500 ft AMSL. Above the control zones were the terminal maneuvering areas (TMA) of Lilongwe and Chileka. From FL145 to unlimited altitude was the Lilongwe Control Area (CTA). Mzuzu Airport was located north of the CTA Lilongwe boundary (Fig. 4).

Radar coverage by air traffic control existed in both CTRs, both TMAs, and the upper airspace.

In AIP Part 2 Enroute (ENR), among other things, Chapter “ENR 4 Radio Navigation Aids/Systems” Subchapter “ENR 4.1” listed radio navigation aids with information on their location coordinates, frequency, range, etc. This list included the VOR/DME VMZ northwest of Mzuzu Airport with a range of 100 NM and the NDB UU (range 50 NM). According to the Flight Information Officer in Mzuzu, the VOR/DME and the NDB had not existed for at least 15 years. Conversely, the NDB KG located 3.9 NM northwest of Lilongwe Airport was missing from the AIP list.

Radio Communication

Radio communication between the crew and the air traffic control posts in Lilongwe was not recorded. Radio communication between the crew and the Mzuzu Flight Information Service was also not recorded.

Airport Information

Lilongwe-Kamuzu Airport

According to the AIP Malawi, Lilongwe-Kamuzu International Airport (FWKI) is located 11 NM north of the capital city Lilongwe at an altitude of 4,029 ft AMSL. The airport has a 3,540 m long and 45 m wide asphalt runway

Runway 14 was in use at the time of departure.

Mzuzu Airport

Mzuzu Airport (FWUU) is located 1 NM northwest of the city of Mzuzu at an altitude of 4,117 ft AMSL, according to the AIP. The airport had a 1,300 m long and 18 m wide asphalt runway oriented 165°/345°. At the time of the accident, runway 17 was in use.

Flight Data Recording

The aircraft was not equipped with a Cockpit Voice Recorder or Flight Data Recorder. These recording devices were not legally required. The radar data from air traffic control in Lilongwe for the two flights on the day of the accident were not recorded.

The Garmin Aera 760 navigation device installed in the aircraft recorded position data (GPS position and GPS altitude over time). The BFU was able to retrieve the data. In addition to the accident flight data, position data from flights since 07.03.2024 were secured.

The recording of the accident flight began at 08:46:48 on the apron of the departure airport and ended at 10:16:14 near the crash site (see Fig. 1). Appendix 1 of the report shows the GPS altitude profile during the accident flight.

Using the “Garmin Basecamp” software, the internal memory of the device was accessed. It contained all “Waypoints” and “Flightplans” saved by the device user. The device’s Diagnostics Page was also evaluated, revealing that the GPS automatically shut down approximately 2:45 hours after the aircraft’s impact (time of accident) due to low battery.

Crash Site and Findings on the Aircraft

Search and rescue teams recovered the bodies of the occupants from the wreckage and crash site the day after the accident. Some wreckage parts were moved from their original positions. The crash site was then cordoned off and secured until the investigation team arrived.

The crash site was located about 34 km (18 NM) southwest of the destination airport in Chikangawa Forest in the Nkhata Bay District of Malawi’s Northern Region

The aircraft crashed about 2 km east of Highway M1 and approximately 700 m south of a settlement on the southeastern slope of a hill about 1,940 m (6,365 ft) high. The slope at the crash site had an incline of 25°-30°. The aircraft’s heading at the time of impact was approximately 283°.

The aircraft first collided with the trunk of a tree at a height of about 4.5 m above the ground with the outer part of the right wing. A part of the honeycomb structure of the wing was embedded in the tree trunk (see Fig. 5). Based on the marks on the tree trunk and the right wing, it was determined that the aircraft had no significant bank angle at the time of the collision.

About 12 m northwest of the tree, the aircraft impacted the ground with the underside of the fuselage. The tip of the right wing and the right aileron were located northwest of the fuselage impact site. Parts of the interior and some cockpit instruments were scattered over an area of about 60 m x 25 m.

The main wreckage came to rest uphill, about 80 m from the tree collision (see Fig. 6). The fuselage had disintegrated, and the engines were torn from the wings. The casings of both engines were broken at the first compressor stage. The propellers of both engines were torn from the shafts.

The flaps were set to position 1. The flap lever was deformed. The landing gear was extended, and the landing gear lever was in the “DOWN” position.

The Horizontal Situation Indicator (HSI) and the Radio Magnetic Indicator (RMI) on the co-pilot’s side showed a heading of 284°. The barometric altimeter on the left side of the instrument panel was set to a reference pressure of 1,029 hPa, and the one on the right side was set to 1,026 hPa.

The Warning and Caution Panel on the instrument panel was removed and secured by the BFU for investigation.

The Emergency Locator Transmitter (ELT) was found in the wreckage. The switch in the cockpit was in the “ARM” position, and the switch on the device itself was in the “OFF” position (see Fig. 7). The device was secured by the BFU.

The Garmin Aera 760 GPS was secured at the crash site by the BFU and later read out in the BFU laboratory.

Medical and Pathological Information

Eight of the nine aircraft occupants were autopsied. The BFU had the autopsy reports available for evaluation.

According to the autopsy reports, the occupants suffered fatal multiple injuries upon impact in the form of high-velocity trauma. Leading injuries were severe head and chest injuries, followed by multiple fractures of the arms and legs, or the pelvis.

Fire

There were no indications of a fire in flight or after the impact.

Survival Aspects

According to the Flight Information Officer in Mzuzu, after losing radio contact, he called the controller at the tower in Lilongwe-Kamuzu at 10:42. The controller informed him that there was also no radio contact with the crew there. The controller called the crew on the tower frequency but could not establish contact. The crews of two high-flying aircraft were asked to try to establish radio contact with the missing aircraft. All attempts were unsuccessful.

At 11:31, the Rescue Coordination Centre (RCC) was activated at Lilongwe-Kamuzu Airport. Surrounding airfields, both domestic and international, were contacted by phone to check if the aircraft had landed there. Around 14:30, search and rescue teams from Mzuzu Airport and others arrived in the Ekwendeni area to search for the aircraft. Later, witnesses reported a suspected crash near the Raiply cell tower. Search and rescue teams were then dispatched to this area. According to the RCC report, the search was hampered by poor visibility. Malawian RCC staff requested assistance from the Aeronautical Rescue Coordination Centre (ARCC) in Johannesburg (South Africa) to search for the aircraft’s ELT signal.

The following day, helicopters from Zambia, a US military aircraft, and several drones supported the search. Around 10:00, search and rescue teams located the crash site and found the wreckage.

Additional Information

Events on the Day Before the Accident

On 09.06.2024, the day before the accident, the aircraft’s crew started their duty at Zomba Airbase around noon. They were instructed to fly the remains of a person who had died two days earlier and some of his family members from Blantyre-Chileka to Mzuzu, where the burial was planned for the next day. At 12:53, the crew took off from Zomba on runway 27, flew a circuit, and then conducted the positioning flight to Blantyre-Chileka. The landing took place at 13:13 on runway 28. With the deceased and some family members on board, the aircraft took off at 16:05 from runway 10 for the flight from Blantyre-Chileka to Mzuzu. At 17:32, the aircraft landed on runway 17 there.

The three crew members stayed overnight in a hotel in Mzuzu. According to the Malawi Air Force, the crew received orders in the evening to pick up the Vice President of the Republic of Malawi and his entourage in Lilongwe-Kamuzu the next morning, fly to Mzuzu, and return to Lilongwe immediately after the burial, as the Vice President was to depart on an overseas trip with the President the same day.

Evaluation of Mobile Phone Data

Due to the lack of radar coverage in the lower airspace north of the TMA Lilongwe boundary, the BFU requested mobile phone data from the telecommunications company regarding the mobile phones of the aircraft occupants as part of the investigation. These data were provided. They showed that four mobile phones from three of the occupants were turned on and logged into different cell towers at various times during the accident flight.

Satellite-Based Search for ELT Signals

An Emergency Locator Transmitter (ELT) Narco Avionics ELT10 was installed in the aircraft cabin, on the left side of the fuselage next to the door. It was a device that transmitted a signal on the frequencies 121.5 MHz and 243 MHz. The ELT was examined and found to be non-functional because the battery had expired in 2004.

Safety Recommendations

At the time of the publication of this interim report, the BFU has issued two safety recommendations:

09/2024

The Minister of Defence of the Republic of Malawi should ensure that aircraft of the Malawi Air Force intended for passenger transport are equipped with a functional Emergency Locator Transmitter (ELT).

10/2024

The Minister of Transport and Public Works of the Republic of Malawi should ensure that aircraft crews always have up-to-date information on radio navigation aids in Malawi. The Department of Civil Aviation should check the functionality of the navigation aids and update the relevant information in the Aeronautical Information Publication (AIP) of Malawi.

Investigation Leader: Jens Friedemann
On-Site Investigation: Dr. Susann Winkler, Jens Friedemann

Attachments

Attachment 1: GPS Altitude and Elevation during the Accident Flight

The investigation is conducted in accordance with Regulation (EU) №996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation and the Law on the Investigation of Accidents and Incidents in the Operation of Civil Aircraft (FlUUG) of 26 August 1998.

The sole purpose of the investigation is to prevent future accidents and incidents. The investigation is not intended to determine blame, liability, or claims.

Publisher

Federal Bureau of Aircraft Accident Investigation
Hermann-Blenk-Str. 16
38108 Braunschweig
Phone: +49 531 35 48–0
Fax: +49 531 35 48–246
Email: box@bfu-web.de
Website: www.bfu-web.de