German investigators conclude cause of Chilima plane crash accident was due to flying at low altitude in marginal weather conditions

* The crew flew into instrument meteorological conditions during flight under visual flight rules and the aircraft collided with the ascending terrain

* The planned as well as the actual course of events on the day of the accident resulted in deadline pressure for the execution of the flight and a punctual landing in Mzuzu

* The lack of an effective emergency transmitter, as well as misleading information about the last position of the aircraft, made the search for the accident site more difficult

By Duncan Mlanjira

In its final report of the causes of the crash of the Malawi Defence Force (MDF) Dornier 228-202(K) military aircraft on June 10, 2024 — that killed the country’s Vice-President Saulos Klaus Chilima and eight others, German Federal Bureau of Aircraft Accident Investigation (BFU) concludes that the accident was due to:

* the decision of the crew to continue the flight to the destination at low level in marginal weather conditions;

* lack of situational awareness; inadequate flight preparation; and the planned as well as the actual course of events on the day of the accident resulted in deadline pressure for the execution of the flight and a punctual landing in Mzuzu.

“The accident occurred because the crew flew into instrument meteorological conditions during flight under visual flight rules and the aircraft collided with the ascending terrain,” says the report Maravi Express has in possession with.

Findings

Crew

* The investigation was unable to find aero-medical certificates for either pilot valid at the time of the accident;

* During the course of the investigation, no indications of possible health impairment of the pilots were found;

* The pilot-in-command was experienced both in terms of his overall flying experience and on type.

Aircraft

* The aircraft was equipped for flights under instrument flight rules and also had a navigation system with a terrain proximity function;

* No indications of accident-related technical defects were found on the aircraft;

* The plane had enough fuel on board for the flight to Mzuzu and back to Lilongwe.

* There was no evidence of a fire in flight or after the impact;

* The investigation of the Warning and Caution Panel revealed no indications of accident-relevant system failures.

Weather conditions

* Contrary to ICAO Annex 3 standards, the Meteorological Service did not provide meteorological information on the planned route;

* Testimonies provided evidence that poor weather conditions and partly instrument flight conditions prevailed on the route;

* The crew decided to fly the aircraft into marginal weather conditions close to the ground in order to reach the destination free of or below the clouds by sight. This tactic corresponded to the procedures used in the squadron;

* With this decision, the crew set themselves consciously at an increased risk of a CFIT event. Whether this decision was influenced, for example, by self-imposed pressure or pressure exerted by passengers could not be determined with certainty;

* The aircraft was for a long time at low altitude above ground in hilly terrain;

* The crew eventually flew into instrument meteorological conditions and the plane collided with the ascending terrain.

Survival aspects

* The ELT built into the aircraft was no longer functional for 20 years. This was known in the squadron and the copilot accordingly made no entry in the field ELT on the flight plan;

* The technical standard of the ELT was outdated and has not been supported for years. The Rescue Coordination Centre was not aware of this when coordinating the SAR operation for the aircraft;

* The lack of an effective emergency transmitter, as well as misleading information about the last position of the aircraft, made the search for the accident site more difficult;

* Due to the severity of the injuries sustained during the impact, the accident was not survivable for the aircraft occupants.

Organisational aspects

* The planned as well as the actual course of events on the day of the accident resulted in deadline pressure for the execution of the flight and a punctual landing in Mzuzu;

* The Malawi Air Force did not have up-to-date data on the validity aeromedical certificates of its flight crew;

* Contrary to ICAO Annex 11 standards and recommendations, radar and radio were not recorded in Lilongwe.