Pilot "Errors" and Harsh Conditions Blamed for Malawi VP's Plane Crash
The Commission's recommendations, released alongside its detailed findings on the probable cause of the crash, focus on addressing the systemic failures that contributed to the tragedy.
LILONGWE, Malawi—A devastating plane crash that killed Malawi's Vice President Saulos Chilima and eight others in June was likely caused by a combination of pilot “error” and challenging weather conditions, according to a government-instituted Commission of Inquiry report released on December 14, writes Winston Mwale.
The report highlighted that the pilots, though experienced, were flying with expired licenses and medical certificates.
The Malawi government’s Commission of Inquiry investigated the crash of a Malawi Air Force Dornier 228 aircraft, registration number MAF-T03, that crashed at Nthungwa, Nkhata Bay, on June 10, killing all on board.
The report concluded that the probable cause was “a combination of environmental factors and human factors.”
The commission stated in the report that “spatial disorientation occurred in this marginal weather condition when the crew using visual flight rules lost visual reference to maintain their orientation due to low clouds, fog, strong winds, and breezes, thereby contributing to the accident.”
Key Findings of the Report:
● Pilot Credentials: The investigation discovered that both pilots, Colonel Owen Sambalopa and Major Flora Selemani Ngwilinji, were operating the aircraft with expired medical certificates and licenses. This alarming revelation raises serious concerns about oversight and safety protocols within the Malawi Air Force.
● Pilot Error: The report determined that the crew failed to obtain a formal weather briefing for the flight from Lilongwe to Mzuzu despite knowing the potential for difficult weather conditions along the route. In addition, the pilots chose a direct flight path rather than the standard route, further increasing the risks associated with the adverse weather.
● Weather Conditions: The report indicated that the crash was significantly influenced by bad weather, including low clouds, fog, and strong winds. It is likely that the challenging weather conditions hampered the pilots’ visibility and contributed to spatial disorientation.
● Last Known Location: The commission found that the last reported position of the aircraft, provided as 20 nautical miles north of Mzuzu, was “not credible.” This inaccurate information caused significant delays in the initial search and rescue efforts.
Details of the Final Flight:
Data recovered from the aircraft's GPS indicated that the plane deviated from its planned course, ascending and descending while still a considerable distance from its destination. This unusual activity began after 09:50.
The report also revealed that the aircraft "made one full cycle orbit before performing two more full 360-degree turns while descending between 500 feet and 200 feet above the ground level."
This activity was confirmed by witnesses on the ground who saw the aircraft flying at low altitude. However, despite the unusual flight activity, the crew did not issue a distress call.
The commission determined that the crew’s decision to descend to a low altitude was probably an effort to maintain visual contact with the ground due to the poor weather conditions.
However, this risky tactic proved fatal when the plane collided with the ground with its landing gear down and flaps extended.
Search and Rescue Efforts:
The report documented that the initial search and rescue efforts were negatively impacted by the incorrect information regarding the aircraft's last reported location.
It was only after receiving accurate data that the search was redirected to the actual crash site.
In addition, the challenging terrain, adverse weather, and a lack of appropriate equipment hindered search and rescue teams.
Rescuers faced difficult conditions, including dense forest, low visibility, and the risk of snake bites and hypothermia.
Procurement Irregularities:
The report noted irregularities in the process of procuring the aircraft for the vice president's flight. The standard process required written authorisation from the president, acting as the Commander-in-Chief of the Malawi Defence Force.
This authorisation was sought via the Office of the President and Cabinet (OPC).
However this step was bypassed. While the intention was reportedly to obtain this authorisation later as a formality, the commission noted this deviation from protocol.
The commission also observed that the “hybrid” approach, in which requests for aircraft use were sometimes made directly to the President, bypassing the established procedure, had not been formally communicated, which suggested an informal shift in protocol.
Additional Findings:
The commission expressed concerns about the handling of photographic evidence from the crash site, criticising the circulation of graphic pictures on social media, which demonstrated a lack of respect for the victims and their families.
The report also highlighted inconsistencies in the aircraft’s call sign during the flight. While it was identified as "Malawi 2" under the control of the Kamuzu International Airport tower, it used the call sign "AF88M" when communicating with the Mzuzu tower.
Inquiry Calls for Sweeping Changes After Fatal Malawi Plane Crash
The Commission's recommendations, released alongside its detailed findings on the probable cause of the crash, focus on addressing the systemic failures that contributed to the tragedy.
These recommendations cover a wide range of areas, from pilot training and aircraft maintenance to search and rescue operations and the regulation of social media.
Key recommendations include:
● The Malawi Defence Force (MDF) must upgrade its ageing fleet of aircraft and acquire modern equipment in adequate numbers to meet the needs of both military and civilian missions. This includes investing in helicopters, fixed-wing aircraft, and maritime vehicles. The Commission stressed the need to maintain all aircraft equipment in good working order and to ensure timely upgrades of obsolete technology.
● The Air Force should be adequately funded to discharge its mandate effectively. This funding should cover aircraft maintenance, equipment upgrades, insurance, and comprehensive training for pilots and ground crew. The report recommends that the Air Force be given its own budget line under the MDF.
● Stringent regulations and procedures must be implemented for Air Force operations in challenging weather conditions. This includes mandatory weather briefings for all flights, including civilian missions, and clear guidelines for determining minimum weather conditions for safe operation.
● The Air Force should enforce a strict ban on the use of any equipment that could interfere with aircraft navigation during flights. This includes mobile phones and other electronic devices. The ban must be strictly enforced, especially when carrying civilian passengers.
● The Air Force should immediately implement a mandatory terrain awareness refresher training program for all flight crews. This program should consist of both ground-based instruction and simulator sessions.
● All Air Force flight crews should undergo regular simulator tests and medical examinations to maintain their licenses and ensure proficiency.
● The Malawi Police Service should be equipped with the necessary aerial, ground, and marine resources to effectively fulfill its constitutional mandate and meet the needs of society. This includes acquiring unmanned aerial vehicles, aircraft, speedboats, rescue boats, and appropriate search and rescue equipment.
● The Police Service should establish a comprehensive in-house forensic pathology service, staffed by qualified pathologists, forensic scientists, forensic photographers, and other relevant specialists. This service would play a vital role in law enforcement and national disaster response.
● The Department of Civil Aviation and the Civil Aviation Authority (CAA) should develop a comprehensive national search and rescue plan, aimed at strengthening the Rescue Coordination Centre.
● The CAA must ensure continuous monitoring of the entire Malawi airspace and the provision of uninterrupted air traffic and flight information services.7
● The CAA should develop and implement clear guidelines for preserving aircraft accident scenes, including protocols for taking photographs and determining who is authorised to take photographs at the scene. The guidelines must also specify how these photographs should be stored and under what circumstances they can be released.
● The Airport Development Limited (ADL) must ensure that all airports, aerodromes, and airstrips in Malawi are secure and operational, enabling aircraft in distress to land safely. All airports, particularly those with urgent needs, should be equipped to handle takeoffs and landings in all weather conditions.
● The Department of Disaster Management Affairs should have immediate access to all necessary information and services, including telecommunication data, to facilitate a swift and effective response to emergencies. This access will enable the activation of prompt search and rescue operations.
● The search and rescue cluster operating under the national disaster response plan should conduct mandatory search and rescue drills regularly.
● The Office of the President and Cabinet (OPC) should develop clear guidelines for the procurement of military equipment used for non-military missions, particularly when civilians are involved. These guidelines should be publicly available and updated periodically.
● The OPC should ensure that government guidelines are strictly adhered to before releasing military equipment for civilian use. The OPC should also ensure that Very Important Persons (VIPs) are transported in aircraft suitable for their intended routes and destinations.
The Commission's report has been met with widespread calls for swift action from the government. Many hope that the implementation of these recommendations will prevent future tragedies and improve aviation safety across Malawi.
Aftermath and Implications:
The report’s release is likely to lead to a thorough examination of safety protocols and training procedures within the Malawi Air Force.
It is anticipated that the government will implement stricter measures to guarantee the safety and airworthiness of its aircraft.