Preliminary Report on the Serious Incident involving Beech Baron 58 aircraft

1.5.2 Co-Pilot (Student Pilot) Nationality: Nigerian Age: 31 License type: Commercial Pilot License (Aeroplane) License Valid till 7th March 2023 Aircraft ratings: Part 2: EMB-135/145 Beach Baron-58, Tampico Club TB-9 Medical certificate: Valid till 7th March 2023 Total flying time: 1972 h Total on type: 32:52 h Total on type (PIC): 344 h Last 90 days: 170 h Last 28 days: 40 h Last 7 days: 0 h Last 24 hours: 0 h 1.5.3 Engineer Nationality: Nigerian Age: 53 License type: Aircraft Maintenance Engineers Licence (AMEL) License validity: Valid till 13th June, 2027 Aircraft ratings: Beach Baron-58, SOCATA TB-9 Tampico Club, SOCATA TB20Trinidad, Diamond DA 40, Diamond DA 42 Preliminary report 5N-CAG 8 During post occurrence interview, it was discovered that the maintenance engineers were last trained in 2017. 1.6 Aircraft information 1.6.1 General information Type: Beech Baron 58 Manufacturer: Hawker Beechcraft LTD, Wichita, Kansas, USA Year of manufacture: 1995 Serial number: TH-1756 Certificate of Airworthiness: Valid till 25th April, 2023 Certificate of insurance: Valid till 3rd January, 2023 Certificate of registration: Issued on 30th April, 2007 Total airframe time: 2014:41 h Total Landing Cycles: 3209 Preliminary report 5N-CAG 9 Figure 1: 5N-CAG before the occurrence 1.6.2 Engines Engine Number 1 Number 2 Manufacturer Continental Motors, INC Continental Motors, INC Type/Model Continental IO-550-C1F Continental IO-550-C1F Serial number 1038268 1037709 Time Since New 315:55 h 315:55 h Preliminary report 5N-CAG 10 1.6.2 Propellers Propeller Number 1 Number 2 Manufacturer McCauley McCauley Type/Model 3AF32C512-C 3AF32C512-C Serial number 181086 951223 Time Since New 315:55 h 315:55 h Number of blades 3 3 Fuel Used: AVGAS 1.7 Meteorological information DNKA 0800z Wind: 070o/19 kt Visibility: 2000 m Weather: Haze Cloud: NSC Temp/Dew: 18/-01 oC QNH: 1020 DNKA 0800z Wind: 050o/15 kt Visibility: 2000 m Weather: Haze Preliminary report 5N-CAG 11 Cloud: NSC Temp/Dew: 20/-01 oC QNH: 1021 1.8 Aids to navigation The status of the navigational aids at Kaduna airport on the day of the occurrence were as follows: VHF 118.8 MHz Tower Main Frequency - ‘Serviceable’ VHF 118.5 MHz/121.7 MHz/122.3 MHZ/124.3MHZ - ‘Serviceable’ “KDA” VOR/DME 115.3 MHz - ‘Serviceable’ Met Information System/L.L.W.A.S - ‘Serviceable’ The status of the landing aids at Kaduna airport on the day of the occurrence were as follows: MOSE/INTERCOM PHONE/ITEL/HUAWEI/HUAWEI NEW - ‘Serviceable’ DIGITAL ANNEMOMETER/INFRA RED THERMOMETER - ‘Serviceable’ WIND DIRECTION/SPEED INDICATORS - ‘Serviceable’ ALDIS LAMP/ATC CLOCK/BINOCULARS - ‘Serviceable’ Preliminary report 5N-CAG 12 1.9 Communication There was effective communication between the aircraft and air traffic control up to the point of take-off. After the landing, 5N-CAG requested for fire truck. The ATC enquired for the nature of the emergency which there was no response from the crew. The ATC called again for the nature of the emergency, the crew responded that the right main landing gear was damaged. The Tower audio recording system was unserviceable at the time of the occurrence. 1.10 Aerodrome information Kaduna airport (DNKA) is located 29 km North-West of Kaduna with coordinates 10°41’39.4’’N 7°19’06.0’’E and has an elevation of 632 m. The aerodrome has a runway of an asphalt/concrete surface with orientation of 05/23. The length and width of the runway are 3000 m and 60 m respectively. The control tower in Kaduna airport is temporarily located at the ARFFS watch room at the time of occurrence. The watch room provides limited viewing of the extreme end of runway 05. Preliminary report 5N-CAG 13 ARFFS Watch room/ATC Tower Preliminary report 5N-CAG 14 ATC tower under construction 1.11 Flight recorders The aircraft was not equipped with a Flight Data Recorder (FDR) or Cockpit Voice Recorder (CVR). Neither of these was required by the regulations. 1.12 Wreckage and impact information During take-off and after lift-up the cockpit door opened on the right side. The SP reduced engine power then FI closed the throttle levers and landed the aircraft. The right main landing gear sheared off. The damages sustained by the aircraft include; Preliminary report 5N-CAG 15 1. The right main landing gear torque link sheared-off 2. The right main landing gear inner cylinder separated from the outer cylinder 3. The right wing lower section of the tank tore-off 4. Two of the propeller blades of the right engine bend outward and the other bend rearward 5. The aircraft step broke-off Figure 2: The aircraft after the occurrence Preliminary report 5N-CAG 16 Figure 3: The aircraft after the occurrence Figure 4: The sheared right main landing gear Preliminary report 5N-CAG 17 Figure 5: The remaining part of the landing gear attach to the aircraft Figure 6: The remaining part of the landing gear attach to the aircraft Preliminary report 5N-CAG 18 Figure 7: Bent propeller blade at the tip Figure 8: The broken step Preliminary report 5N-CAG 19 Figure 9: The torn right tank from the bottom Figure 10: The torn right tank from the bottom Preliminary report 5N-CAG 20 Figure 11: The unlatched starboard door handle On arrival of the safety investigators to the scene of the occurrence, it was discovered that the aircraft was moved away from its final position to another location 713 m along the runway. The distance from the threshold of runway 05 to the point, where the right main landing gear sheared off is 847 m. The distance from the point, where the right main landing gear sheared off to the final position of the aircraft is 203 m. 1.13 Medical and pathological information The post-incident medical examinations report (including physical, mental, psychology, and full toxicology) was carried out on the crew on the 31st December 2022 at about 14:00 h, at Mends Specialist Hospital and Aviation Medical Centre in Kaduna, Nigeria. Preliminary report 5N-CAG 21 The medical examination indicated that the assessment on both flight crew were within normal findings. 1.14 Fire There was no pre or post occurrence fire. 1.15 Survival aspect The incident was survivable. The structural integrity of the cabin was not compromised. The FI and the SP exited the aircraft through the cockpit door while the other two occupants exited the aircraft through the cabin door. The seats and seat belt harness were intact. There was no evacuation. At 10:19 h, Aerodrome Rescue and Fire Fighting Service (ARFFS) arrived at the scene of the occurrence and discovered fuel spillage from right wing tank and hydraulic fluid spill from the detached right main wheel. One charged hose of water was used to flush out the fuel spill and maintained a standby at the scene. Preliminary report 5N-CAG 22 2.0 INITIAL FINDINGS 1. The flight crew were licensed and qualified to conduct the flight. 2. The aircraft had a valid Certificate of Airworthiness. 3. The flight was an Airline Transport Pilot Licence (ATPL) training on instrument approach procedures. 4. The SP was the Pilot Flying (PF) and the FI was the Pilot Monitoring (PM). 5. The ATPL training was initially scheduled to be conducted in Mallam Aminu International Airport Kano with Diamond 42 (5N-CZA and 5N-BZE) due to the availability of Jet A1 fuel. 6. In the course of the training, DA-42 became unserviceable due to the Service Bulletin (SB) with reference number MSB 42-143/1 and MSB 42NG-086/1 requiring inspection of hole position and condition in the rudder steering bracket 7. The College decided to continue the training in Kaduna airport with Beech Baron 58 that uses AVGAS, which is readily available in Kaduna. 8. During taxi the SP reported that the throttle levers were stiff and the engine RPM of the engines were not synchronized. 9. The SP also observed red warning light on the left alternator and informed the FI. 10. At rotation speed, immediately after lift-off, the cockpit door on the right side opened. 11. The SP continued with the take-off while the FI attempted to close the door. 12. The FI tried to close the door, the SP reduced the throttle lever to 300 RPM. 13. With the door still open, the crew decided to land the aircraft straight ahead on the remaining runway Preliminary report 5N-CAG 23 14. On landing, the left main wheel touched the runway first then the right main wheel. 15. The right main landing gear sheared off. 16. The right wing impacted the runway and the aircraft veered to right of the runway. 17. The aircraft came to stop at the edge of the runway with the right wing dripping fuel. 18. The aircraft was moved to another location before the arrival of the safety investigators. 19. During post occurrence interview, the FI stated that there were previous instances of the door opening in flight. 20. There were no technical logbook entries for the previous incidences of door opening in flight. 21. The tower audio recording system was unserviceable at the time of the occurrence 22. During post occurrence interview it was discovered that the maintenance engineers were last trained in 2017. Preliminary report 5N-CAG 24 3.0 IMMEDIATE SAFETY RECOMMENDATIONS 1. The Nigerian College of Aviation Technology (NCAT), Zaria should not tamper with evidence of an aircraft occurrence which could lead to loss of evidence and adhere strictly to the provisions of Part 3 section 19 (1), (2) (a and b) Civil Aviation (investigation of air accidents and incidents) regulations 2019 . 2. The Nigerian College of Aviation Technology (NCAT), Zaria should ensure that its flight crew made entries in the Technical Logbook of the door opening in flight. 3. The Nigerian College of Aviation Technology (NCAT), Zaria should ensure that type rated engineer’s on the college fleet undergo refresher trainings as required by relevant sections of Nig.CARs 2015 4. The Nigerian Airspace Management Agency (NAMA) should ensure that the Tower audio recording system installed at Kaduna airport Tower is serviceable.