With a crew that had been “worked to death”, tossed in an unfamiliar terrain at night and a pilot who could not fly in the dark, Botswana Police Service 2014 helicopter crash victims were operating on a wing and a prayer until their luck ran out.
A confidential report leaked to the Sunday Standard compared the three police officers who were killed in the crash to “a blind crew flying against the terrain.”
The report which was compiled by the Ministry of Transport and Communications has revealed that “crew of the occurrence aircraft were engaged in anti-poaching activities without option to mitigate chances of fatigue”.
The report corroborates an industry expert who in 2014 told Sunday Standard that blinding darkness may have resulted in the helicopter crash that killed Superintendent Keokeditswe Sobatha, Assistant Superintendent Shepherd Ntobedzi and Inspector Ricardo Mabotho.
The expert had explained that in Botswana pilots cannot fly at night unless they fly under night visual flight rules (VFR) with the assistance of illumination from streets lights or a full moon.
States the report: “The crew entered a state of spatial disorientation and in the process collided with the terrain. Lack of knowledge of the terrain, possible fatigue and apprehension could have led to spatial disorientation and as such cannot be ruled out as contributory factors in this occurrence. As a result of anti-poaching operations of the day, both flight crew members were exhausted.”
It further states that “… both crew members were exhausted; this was even evident earlier on during the anti-poaching operation when the Pilot in Command (PIC) stated that she was tired and handed over the controls to the Chief Pilot (CP).”
According to the report the helicopter was being piloted by Sobatha as the PIC.
The report states that it would have been much better to make sure that before attaining captaincy all crew members undertake familiarisation with certain parts of the country.
According to the report, it was apparent that this was the first time that these three crew members operated in and around Gumare.
“All the three flight crew members were not familiar with the area of operation,” states the report suggesting that it was like a blind crew flying a helicopter.
The report says that the PIC’s decision to depart Gumare for Maun that night was ill informed as she had no clue how the environment was like at night in the area.
“She was operating an aircraft that was approved only to fly day or night Visual Flight Rules (VFR). The flight duty time was, however, within the stipulated timeframe of 12 hours for two pilots,” reads the report.
The report suggests that accident occurred because the crew could not maintain altitude, track and heading. “The fact that the final flight path was in the general direction of Gumare could indicate two possible scenarios, deliberate or inadvertent action,” states the report.
Deliberate action, the report says, could mean that the crew members had chosen to return to Gumare upon encountering a situation whereby arrival at Maun was no longer guaranteed.
“Inadvertent action would be a situation whereby the crew had lost complete control of the aircraft. In the absence of any sign aircraft control malfunction, the investigation cannot rule out lack of situational awareness as a result of spacial disorientation,” the report says.
The report states that indications are that the PIC was incapacitated. “It cannot be discounted that the CP was also incapacitated. If not, the possibilities could be as follows; the CP was not aware of the danger on time, and his advice or attempt to assist was not effective,” reads the report.
The report says possible causes was collision with the terrain as a result of low level flying , loss of situational awareness compounded by probable spacial disorientation in an Instrument Flight Rules (IFR) environment.
Another possible cause for the accident, the report says, was the decision by the PIC (who lacked night currency) to fly back to Maun at night in an aircraft not approved for IFR.
The report found that all the three members of the crew were dully approved by ASB to operate the aircraft except that the PIC was not yet current on her night rating.
It also found that the Francistown-based aircraft which could have responded to the request for air support by Gumare Police was unserviceable, but it was not clear as to why the Francistown crew was not availed for the mission.
“The aircraft was approved for the day and night flying but only under VFR. The aircraft had been maintained according to Manufacturer’s instructions despite minor document lapses,” reads the report.
The report recommends that the Botswana police must formulate proper guidelines with unprofessional and unsafe conduct with its aviation personnel. Botswana Police must formulate airmen recruitment/selection policy to fully address issues of cockpit seniority versus general police rank.
The Botswana Police Service should also undertake a research and benchmarking drive with the aim of developing a clear policy on dealing with gender-related issues in aviation.
Botswana Police Service must, the report recommends, (with all other things being equal), review the ratio of the fleet between the two Air Wing Support Branch (AWSB) operational areas (i.e. Gaborone and Francistown).
The report also recommends that Civil Aviation Authority of Botswana (CAAB) must review and make clear policy with regards the flying a flight while operating controlled and uncontrolled flights.
“The Minister of Transport and Communications together with his affected counterparts(s) must, with a reasonable time-frame, organise a high level conference for relevant stakeholders to clearly define and decide on the roles of operators of state aircraft and civil aircraft with particular reference to accident/incident investigation,” the report says.