BUSIA CRASH REPORT
Pilots' error and runway caused crash
Muthoga commission recommends action against air company and aviation authority
By DAVID MUGONYI
Human error plus the poor condition of the runway at Busia caused the crash in which Labour minister Ahmed Khalif and both pilots were killed.
"The accident occurred as a result of a premature take-off leading to a stall from which the pilot could not recover," says the report of the team appointed to probe the February crash, in which three other Cabinet ministers, an assistant minister and an MP were also injured.
One of the pilots of the heavily laden twin-engine Gulfstream was unqualified to fly from rough country airstrips like the one at Busia, the report states.
The runway was too short for the type of plane – and the pilot was not experienced in flying it in such conditions, says the report, presented to Transport and Communications Minister John Michuki three weeks ago.
The poorly maintained runway was only 1,000 metres long, 300 metres of which were unusable, leaving the pilots with a mere 700 metres compared with the 1,200 metres the plane needed to take off successfully.
The 69-page report is harshly critical of the air charter company, African Commuter Services Limited, and concludes that the Busia flight was "ill conceived, negligently planned and carelessly executed".
It recommends that the firm's licence be withdrawn until it complies with all aircraft regulations.
It accuses the firm's chief pilot, Captain Mary Louise Anning of passing on the flight to another pilot because it was impossible for a big plane like the Gulfstream G159, carrying such a load, to take off from such an airstrip.
The inquiry found that though the pilots were medically fit and licensed, they were unqualified to fly into and out of rough airstrips with the G-159.
"The pilots were inadequately trained and not experienced in this type of operation," says the report.
"The flight to Busia, the chief pilot, like everyone else, agreed was ill-advised and dangerous," says the report, a copy of which the Nation has obtained.
Captains Abdi Kuno and Samuel Mungai died at the scene.
The plane, 5Y-EMJ, crashed on January 24 this year killing Mr Khalif and the pilots and injuring several dignitaries among them three Cabinet ministers, Mr Raphael Tuju, Ms Linah Kilimo and Ms Martha Karua, among others.
They were returning to Nairobi after attending an election victory party at the home of Cabinet colleague Mr Moody Awori.
Mr Michuki instituted a public inquiry into the crash two days later, on January 26, and appointed senior counsel Lee Muthoga to chair it.
The report is also highly critical of the Kenya Civil Aviation Authority which it recommends should strictly enforce air traffic regulations to avoid mistakes which contributed to the accident.
The inquiry report says although the plane's certificate of airworthiness was current, it did not comply with all the conditions required by the regulations.
For instance, the certificate of maintenance inspections, which is undertaken after a specified number of flight hours, could not be accurately tracked because documents were falsified.
Defects were not recorded in the technical log book as regulations require, uncertified parts were fitted into the aircraft and maintenance personnel were not trained and licensed.
The flight was also not conducted in accordance with approved flight regulations because it was negligently planned and executed.
It lacked many documents and those available were not approved by the Department of Civil Aviation, now Kenya Civil Aviation Authority.
The pilots should never have attempted to take-off, the report says and notes that their logbooks were "deliberately falsified" and did not tally with hours recorded in the technical logs of aircraft log books.
Since the chief pilot declined to fly the plane, the report says, the pilot in command who was told of the trip at the last minute may have been unhappy.
Both pilots might also have been under pressure because of the high profile passengers on board and they appeared apprehensive about the ability of the aircraft to take off from the airstrip.
In addition, the aircraft was not maintained in accordance with required airworthiness regulations.
The plane, the inquiry learnt, had a long history of accidents. On February 28, 1997, it hit a hut on take-off and damaged the left wing and on April 6, 1997, at Goma, Zaire, it killed one person on take-off.
In August 2000, while operating in Southern Sudan, it suffered a nose gear collapse, which damaged both propellers, both engines, nose gear and belly. It was repaired and reregistered.
Tests done to the Cockpit Voice Recorder in United Kingdom found that it was defective and the plane was not fitted with a Flight Data Recorder.
The Inquiry team recommended that the African Commuter Services Limited be suspended until it complies with all KCAA requirements for issue of an Air Operator Certificate (AOC).
Efforts to contact the operators of the aircraft were unsuccessful.
Busia Crash Report: Plane landed on house soon after take-off
The Nation (Nairobi)
May 26, 2003
The 24-seater 5Y-EMJ Gulfstream 1 plane crashed after it lost power and nose-dived seconds after takeoff.
The plane, weighing 16,000 kg, hit trees, electric poles and landed on top of a house.
Labour minister Ahmed Khalif and the pilots - Captains Abdi Kuno and Samuel Mungai - died at the scene. Ministers Raphael Tuju (Information and Tourism), Linah Kilimo (Office of the Vice-President) and Martha Karua (Water Resources) were injured and taken to the local district hospital before being airlifted to Nairobi Hospital.
Assistant minister Njeru Githae, Hamisi MP George Khaniri, former Fida chairperson Martha Koome, Abantu executive director Wanjiru Kihoro, former Saku MP Jillo Falana and air hostess Josephine Mwangi were also injured. Dr Kihoro is still in hospital.
They were returning from an election victory party for Home Affairs minister Moody Awori in Funyula.
Transport and Communications minister John Michuki ordered an inquiry into the matter. The report on the crash gives detailed medical and pathological information. Mr Tuju fractured two ribs and hand.
Mrs Kilimo was conscious and suffered bruises on the hip and abdomen, while Ms Karua suffered several cuts on the
face, scalp and injuries behind the neck. She was admitted to the High Dependency Unit and was in a brace for several weeks after the crash.
Mr Khaniri was conscious but injured on the left eye and suffered a strained neck, bruises to the left elbow and abdomen.
Mr Githae, who walked from the crash scene but later collapsed, fractured his wrist and his spine was slightly hurt.
Ms Koome fractured the right arm, while Mr Falana fractured his right leg and had chest and scalp injuries. Ms Mwangi's left leg was also injured.
Dr Kihoro suffered a severe head injury and has been unconscious to date although her state has improved.
The report says Minister Khalif and Captain Kuno could have died of severe internal head injuries. No post mortem was done as they were buried a day after, in accordance with the Islamic religion.
Captain Mungai's death was caused by severe head injuries after he was thrown out of the aircraft.
The licence of Commuter Air Services was immediately suspended and investigations launched. The inquiry was chaired by Mr Lee Muthoga and sat for 31 days at Charter Hall, Nairobi.
Some 74 witnesses testified in Busia and Nairobi.
African Commuter Services was represented by Mr Mohammed Ibrahim and Mr Fred Athuok while State counsel Horace Okumu and Norah Odingo acted for the government.
Among those who gave evidence at the inquiry were Mr Gakweli Warrakah, the chairman of the Kenya Airline Pilots Association, Mr Adi Dastur, CMC Aviation managing director, Kenya Airways safety manager Peter Biwott, Nominated MP Julia Ojiambo and the director of Civil Aviation Chris Kuto.
A plane carrying members of Kenya's new government has crashed in the west of the country, killing one minister, the two pilots and injuring other ministers.
The 24-seat Gulfstream plane crashed shortly after it took off from Busia airport. It hit power lines, according to Local Government Minister Karisa Maitha.
Kenya TV is reporting that Labour Minister Ahmad Mohamed Khalif was killed.
Isaiah Kabira, head of the president's press service, said Mr Khalif could been dead, but it was not year clear. He said the plane was carrying 10 people when it crashed shortly after 6pm.
Trade Minister Mukhisa Kituyi said other government officials on the plane included the water resources minister, the minister of state in the office of the vice president, the information and tourism minister and the assistant justice minister.
The plane was taking the passengers from Busia to the Lake Victoria port of Kisumu where the government officials were to attend the commemoration of the death of one of the East African nation's leading opposition figures nine years ago.
Three ministers, including Mr Kituyi, the home affairs minister and the attorney general, got off the plane - which began its flight in Nairobi - at Busia.
A new government, led by President Mwai Kibaki, took office after winning elections last month that ended the 39-year rule of the Kenya Africa National Union, or Kanu, party.
Mr Kibaki, who took over from former President Daniel arap Moi, is currently in Nairobi Hospital, recovering from ankle and arm injuries sustained in December car crash.
He was readmitted to hospital last week suffering from a blood clot and slightly high blood pressure. He is expected to leave hospital next week.
Busia Crash Plane Had Defects, Inquiry is Told
The Nation (Nairobi)
26 Février 2003
The ill-fated Busia crash plane was allowed to operate with defective parts, an engineer charged with its maintenance said.
Pilots flying the aircraft did not bother to record the defects in the Tech-log, where such problems should be entered, Mr Alfred Onsongo said.
Instead, Mr Onsongo said, the pilots made verbal complaints to the plane owner, Africa Commuter Air Services. The plane would then be taken to the maintenance firm, Airworks Kenya Ltd, for repair.
Mr Onsongo, an engineer with Airworks Kenya Ltd, told the commission inquiring into the crash, that ACAS allowed the plane to operate as it awaited to have some parts changed.
"Even the ACAS managing director, Mr Ishmael Jibril, was not able to compel them to record these problems as required by the law," he said.
He further admitted that although he was responsible for fitting the aircraft with new parts, he was not aware that it did not have a flight data recorder.
Mr Onsongo was testifying for the second day before the commission in Nairobi.
He said it was possible for the plane to leave the hangar with undetected faults because some were never officially recorded. He added: "At times, the owner would have it released from the hangar with some defects as long as the plane was in a position to fly."
Mr Onsongo said the last maintenance on the plane was carried out on December 30 and 31 and the plane released from the hangar at Wison Airport on January 15 when he signed the clearance certificate. The plane then flew four times before it crashed at Busia airstrip killing Cabinet minister Ahmed Khalif and two pilots on January 24.
Mr Onsongo was taken to task by the commission, chaired by Mr Lee Muthoga, when he admitted that he had certified the cockpit voice recorder as functional even though it had been faulty for months. He said he signed the clearance certificate on the strength of maintenance done by a Mr James Makau.
Earlier nominated MP Julia Ojiambo said she had raised concerns about the bad state of the airstrip that morning. "I drove to the airstrip in the morning to meet the guests and I had a chance to discuss the condition of the airstrip with the district commissioner and the police boss," Dr Ojiambo said.
Mr Makau did not however, commit himself anywhere in writing that he had checked the equipment and the commission is likely to summon him to give his evidence.
Ask by the commission chairman Mr Lee Muthoga why he signed for work he had not personally supervised, Mr Onsongo said: "I didn't know I would finally land in this court, so I just signed."
Mr Muthoga described the action as dangerous warning the witness that it could get him into more problems.
Mr Onsongo said after raising the pilots negligence with his boss, Airworks Kenya designed a different form in which all faults on the aircraft were to be recorded when reported by ACAS. The form has no particular name neither is it a legal document.
The form was also to be used in making payments claims because ACAS failed to pay for some maintenance made on the aircraft.
Mr Onsongo admitted that his company did not record in the Tech-log any maintenance it carried out on the aircraft. He said other documents in which some defects were recorded were inside the aircraft when it crashed.
He said he had been servicing the aircraft and issuing maintenance certificates since 1999.
Busia Crash: 'Pilot Was Unhappy'
The East African Standard (Nairobi)
14 Mars 2003
A witness yesterday told the inquiry into the Busia Air crash that one of the pilots of the crash plane was "not very happy about taking the flight."
Transworld Safaris, Captain Kokoro Yongole Janda, a close friend of the late Abdikadir Kuno said the latter had confided in him, a day before the flight, that he needed to take an off because "he had not had a rest".
Janda said Kuno had further told him the Chief Pilot, Captain Louise Anning, was the one scheduled to take the flight but had requested him (Kuno) to take it for her because she was expecting some visitors.
He said Kuno had told him that the real reason why Anning did not take the flight was because "Busia was challenging".
Janda further told the inquiry that charter flights of the crash plane were normally done by Anning while his friend did Flamingo flights.
Also testifying, the Inflight Attendant Josephine Wangari tearfully narrated her experience to the inquiry.
Wangari, who is on crutches and still under medication after suffering leg fractures, said she made sure the passengers were comfortable and had their seat belts.
"After we took off, I don't know what happened and when I opened my eyes I saw the aircraft upside down," she said amid tears.
Wangari further said the pilots had noted that the run way was short and had measured it before take off and found out it was one kilometre long.