Section/division Accident and Incident Investigations Division Form Number: CA 12-57

LIMITED INCIDENT INVESTIGATION

Reference Number CA18/3/2/1343

Classification Incident Date 10 May 2021 Time 1408Z

Type of Operation Flight Training (Part 141)

Location

Place of Departure Wonderboom Place of Intended Landing Wonderboom National

National Aerodrome Aerodrome
Place of Accident FAD 127 Wonderboom General flying Area

GPS Co-ordinates Latitude 25˚29’24.95” S Longitude 028˚14’25.80” E Elevation 7000 feet

Aircraft Information

Registration ZS-GDA

Registration ZS-PMX

Model/Make Cessna 172 P (Both)

Damage to Aircraft None Total Aircraft Hours 18 141.1

ZS-GDA
Damage to Aircraft None Total Aircraft Hours 6 362.5
ZS-PMX
Pilot-in-command

Licence Type ZS-GDA Commercial Gender Male Age 27

Pilot Licence
Licence Type ZS-PMX Airline Transport Gender Male 53
Licence
Licence Valid Both Valid

Total Hours on Type 980.0 for Total Flying Hours 1 010.0

ZS-GDA
Total Hours on Type 1 664.2 Total Flying Hours 13 350.3
ZS-PMX
People On- 1+1 Injuries 0 Fatalities 0 Other (On Ground) 0
board ZS-GDA
People On- 1+1 Injuries 0 Fatalities 0 Other (On Ground) 0
board ZS-PMX
What Happened

On Monday afternoon, 10 May 2021, a flight instructor accompanied by a student pilot on-board a
Cessna 172P with registration ZS-GDA took off from Wonderboom National Aerodrome (FAWB) at
1333Z. After take-off, the duo flew north to conduct aerial work at FAD 127 (Danger Flying Area
127), which is a designated flight-training area. Once they entered the general flying area, they
routed towards the centre field while climbing to 7 000 feet (ft) where they commenced with exercise
10 (Stalling).

At 1353Z on the same day, a Cessna 172P aircraft with registration ZS-PMX also departed FAWB
on a training flight to the same general flying area. On-board the aircraft were a flight instructor and
a student pilot. The intention of the crew was to conduct aerial work at the FAD 127. Although the
SRP date: 14 September 2021 Publication date: 15 September 2021
transponder code of 2000 was selected, no mode C (Charlie) was detected by air traffic control (ATC)
radar for this aircraft.

The ZS-PMX aircraft was tracked on Secondary Surveillance Radar (SSR); it entered FAD 127
general flying area at 13:59:29Z, flying in a northerly direction. Approximately 1 minute later, the
aircraft commenced a left turn, flying in a north-westerly direction. At 14:03:09Z, it commenced
another left turn flying in a south-easterly direction and was observed turning left again at 14:06:24Z,
flying in a north north-easterly direction towards the north-eastern corner of FAD 127. (The track that
the aircraft flew is depicted in Figure 1, indicated by the orange dotted line.) The flight instructor
stated that they communicated with ATC prior to and after take-off on radio 1 (Comm 1) without any
problem. Once at FAD 127 general flying area, the instructor allowed the student pilot to do radio
work using the same radio. The student pilot did numerous blind transmissions, but it seemed as
though they were not audible; they then changed to radio 2 (Comm 2) where they were able to
communicate with other traffic in the area. The flight instructor stated that while they were flying
towards the north-eastern corner of FAD 127, they saw another aircraft on their right-side just below
them turning right towards north-west. The instructor and the student pilot continued with their flight.
On their return to FAWB, they communicated with ATC, alternating between the two radios without
any communication problems.

The path of the ZS-GDA aircraft that took off 20 minutes prior to ZS-PMX from FAWB to carry out
aerial work in the north-eastern section of FAD 127 is depicted in Figure 1, (indicated by the yellow
dotted lines). According to the radar data, at 14:08:18Z, the two aircraft came too close to each other.
The ZS-GDA aircraft was flying at 6 900ft in a southerly direction at the time. The transponder mode
C on ZS-PMX aircraft was switched off or was not functional at the time as it was not possible for
radar to detect the height the aircraft was flying at while heading in a north north-easterly direction
towards the north-eastern corner of FAD 127. The red dotted line shows another training aircraft that
was flying within FAD 127 on the eastern boundary; the aircraft took off from FAWB approximately
4 minutes after ZS-PMX. From the statement of the flight instructor on-board ZS-PMX, their aircraft
was slightly higher than the ZS-GDA aircraft as he had observed the aircraft flying below theirs. The
flight instructor of ZS-GDA aircraft stated that he read the registration of ZS-PMX and made a radio
call as they were not aware of their intention at FAD 127.

During an interview with both flight instructors, they confirmed that the correct very high frequency
(VHF) mode for FAD 127 general flying area is 124.40 megahertz (MHz). Both these aircraft were
broadcasting their intentions and positions on this frequency. The radio work was mostly carried out
by the respective student pilots during the flights to get familiar with using it, as well as the procedures
that needed to be followed.

The serious incident occurred during the day at Global Positioning System (GPS) determined to be
25˚29’24.95” South 028˚14’25.80” East.

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Figure 1: The orange dots show the flight track of ZS-PMX aircraft while the yellow dots show the flight track
of ZS-GDA aircraft.

Probable cause:

The investigation revealed no evidence of avoidance manoeuvre from the radar records. It is likely
that when entering the FAWB GFA, the ZS-PMX aircraft did not correctly change the radio frequency,
resulting in them not being heard by other aircraft in the GFA. It is also possible that the two aircraft
may have flown very close to each other. It is always important for aircraft to make position reports
and intentions using the correct frequency.

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 Figure 2: Airspace map indicating the incident site within FAD 127 Flying Training Area.

Safety Action/s
None.

CA 12-57 Date: 18 June 2021 Page 4 of 6

Safety Message and/or Safety Recommendation/s

1 It is recommended that all aircraft flying in South Africa file a flight plan. This allows for all
aircraft to be allocated a squawk code as well as making it possible to be tracked by radar.
Should a distress situation arise, the last known position of the aircraft would be known in
case any search and rescue action is required. Pilots should view filing a flight plan as their
advantage. In this incident, neither aircraft filed a flight plan, therefore, none were allocated
a squawk code, which made it difficult to identify these aircraft on radar.

2 It is recommended that pilots always remain vigilant during flights as the general flying areas
can get congested quickly, especially in areas in and around Gauteng where there is a
substantial number of aircraft training organisations (ATOs). A proper lookout and frequent
radio transmission on the correct frequency in those areas is recommended.

3 It is recommended that pilots always ensure that the aircraft radios are in good working
condition. It is known that these devices can fail without any warning, therefore, hand-held
radios are recommended to be always carried with on-board aircraft.

Purpose of the Investigation

In terms of Regulation 12.03.1 of the Civil Aviation Regulations (CAR) 2011, this report was
compiled in the interest of the promotion of aviation safety and the reduction of the risk of aviation
accidents or incidents and not to apportion blame or liability.

About this Report

Decisions regarding whether to investigate, and the scope of an investigation are based on many
factors, including the level of safety benefit likely to be obtained from an investigation. For this
occurrence, no investigation has been conducted, and the Accident and Incident Investigations
Division (AIID) has relied on the information submitted by the affected person/s and organisation/s
to compile this brief report. The report has been compiled using information supplied in the initial
notification, as well as follow-up information to bring awareness of potential safety issues to the
industry in respect of this occurrence, as well as possible safety action/s that the industry might want
to consider in preventing a recurrence of a similar accident.

This report provides an opportunity to share safety message/s in the absence of an investigation.

All times given in this report are Co-ordinated Universal Time (UTC) and will be denoted by (Z).
South African Standard Time is UTC plus 2 hours.

Disclaimer

This report is produced without prejudice to the rights of the AIID, which are reserved.

CA 12-57 Date: 18 June 2021 Page 5 of 6

This report is issued by:

Accident and Incident Investigations Division

South African Civil Aviation Authority
Republic of South Africa

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