On 24 October 2021, a Shorts SD360 (9S-GAP) was being operated by Malu Aviation on a non revenue international positioning flight from Goma DR Congo to Lanseria South Africa with three company engineers as passengers. It was intended that the first of two en-route stops would be made at Ndola but the crew were unaware that the civil airport had recently moved to a newly built airport 8 miles away which had kept the same name (Simon Mwansa Kapwepwe International Airport) and radio frequencies of the old international airport which had been re-designated for military use. Whilst working ATC at the new airport, the flight routed in hazy day VMC to the old airport as flight planned and landed there without clearance.
A Serious Incident Investigation into the event was carried out by the Zambian Aircraft Accident Investigation Board (AAIB). It was noted that the Captain was a Belgian national who held an ATPL (airline transport pilot licence) issued by the Congolese Civil Aviation Authority and had a total of 22,000 hours flying experience of which about 5000 hours were on type and was familiar with the former Ndola International airport. The First Officer held a CPL (commercial pilot licence) issued by the Congolese Civil Aviation Authority and had a total of 500 hours flying experience including about 100 hours on type.
The flight was to position the aircraft from Goma to Lanseria where scheduled maintenance was to be carried out. Intermediate stops were planned at Ndola and Bulawayo and a VFR flight plan had been filed for each sector. In the case of Ndola, the former international airport ICAO identifier, FLND - which had been retained by the military - was used when filing the flight plan with the Goma authorities.
After almost four hours airborne after departure from Goma, the flight was transferred from Lusaka Control to the Ndola APP frequency and was cleared to continue to Simon Mwansa Kapwepwe International Airport (SMKIA). When 28 nm away, the flight requested descent from FL125 and was cleared to 5000 feet to report runway in sight.
Fifteen minutes later, the flight reported on left base leg for the runway in use (09) and was transferred to Ndola TWR where the controller cleared it to final and gave a spot wind and a caution on bird activity. The flight was subsequently cleared to land despite the controller not seeing the aircraft on final approach and making several unsuccessful attempts to contact it. The APP controller then called the TWR controller and advised that the aircraft was on ground at the Peter Zuze Military Airport, the former International Airport located 8nm to the South East of the new airport. The pilots only realised after landing that they had landed at a military base having not seen any NOTAM about the recent airport location change. The Captain expressed surprise that none of the Zambian controllers who had handled the flight had made mention that the airport had just moved to a new location with its old name radio frequencies. The aircraft was subsequently able to take off for the short flight to the new airport.
The Duty military controller at the airbase stated he had been surprised to see an aircraft not on his frequency landing but a call was received from the SKMIA Senior Air Traffic Control Officer (SATCO) asking if an aircraft which had been working their TWR frequency but had not landed had done so at the old airport and this was confirmed to have happened.
Why It Happened
It was considered probable that the en-route navigation of the flight was reliant on GPS-backed navigation equipment. Since the flight had been planned to the airport which the crew believed was (still) the Ndola International Airport and still had the ICAO airport code it had previously had, it can be assumed that this destination (FLND) rather than that the new locator code for the new airport (FLSK) was would have been entered into the navigation equipment on board the aircraft and followed.
The Investigation identified a long list of inadequacies in the process under which the relocation of the Simon Mansa Kapwepwe International Airport (SMKIA) had been managed. These included the following:
- Despite the old airport having been handed over to the Zambian Air Force, no interim airspace restrictions had been introduced to keep unsuspecting civil traffic from mistakenly landing there.
- The same location Indicator and all published procedures for the old airport under its civil locator code FLND were still active at the time of incident.
- Risk analysis in respect of the airport move conducted by both the CAA and the Zambia Air Ports Corporation teams was not used to examine the efficacy of air space management arrangements in respect of the two airports.
- The Zambian Air Force was unable to provide the Investigation with any Standard Operating Procedures for their newly-acquired air base.
- There was no evidence of any MoU or other agreement between the Zambia Airports Corporation (ZACL) and the Zambian Air Force as operators of the two airports once the changeover had begun.
The AIS provision in both DR Congo and Zambia on the matter of the changes at Ndola appeared to have been inadequate:
- the Goma airport authorities there had not made NOTAMs on the matter available and the flight plan filed, which specified the Ndola stop as FLND (the identifier for the old airport which had not been altered with the change to military only use).
- Lubumbashi airport also had no NOTAMs on the airport changeover and personnel there did not adequately check the flight plan filed at Goma.
- The flight crew applied for the necessary airspace flight permit to fly from Goma to Ndola (FLND) and it was approved by the Zambian Government through the Zambia Air Force.
- Zambian Air Force Operations did not notice the airport identification error during the approval process.
Provision of ATC at the new airport was not in accordance with applicable procedures there (and more generally) in that the VFR flight under investigation was given a landing clearance despite the fact that it had not been acquired visually - whilst it was reportedly hazy, the METAR for FLSK (SMKIA) was giving CAVOK (cloud and visibility OK).
The Performance of the Flight Crew was deficient in that despite several references to runway 09 for landing, they did not query what should have been recognised as anomalous as the landing runway at the old airport which the Captain was familiar with and intended to land at was 10 not 09.
Based on the various findings of the Investigation, a number of ‘Observations’ - some directly related to what happened or incidental discoveries not so related - were made including but not limited to the following:
- Navigation data for the old Ndola airport (FLND) for arrival, approach and departure were still available as published to international airways publishers.
- Arrival and Departure procedures for the new airport (FLSK) were incomplete.
- The new airport (FLSK) had an ILS installed but there was no published procedure for its use.
- The changeover risk analysis conducted by teams from the CAA and the ZACL excluded CAA Operations Inspectors.
- Tape transcripts consulted by Investigation found that controllers at FLSK were using non-standard phraseology.
- No SIDs or STARs had been published for FLND since it was re-designated as a military air base.
- Some controllers at FLND since it became a military air base were operating without civil aviation licences which means civil aircraft cannot be handled by them.
- Some controllers at FLND did not know how to use an Aldis Lamp for visual communication with non-radio aircraft despite the TWR VCR having that capability.
- In the absence of visual landing procedures at FLSK, the airport operator (ZACL) insisted that VFR pilots are solely responsible for correctly identifying the airport.
A total of 14 Safety Recommendations were made as a result of the Findings of the Investigation as follows:
- that the Zambia Airports Corporation Ltd (ZACL) conducts a course of refresher training for its staff. [AAIB/SR/2022/014]
- that the ZACL consider training some Tower ATCOs as MET observers for them to be able to advise on met information. [AAIB/SR/2022/015]
- that the ZACL urgently publish Standard Instrument Departures (SIDs), Standard Terminal Arrival Routes (STARs) and Visual approach and landing charts for the new Ndola International Airport (FLSK). [AAIB/SR/2022/016]
- that the ZACL urgently publish an Instrument Landing System (ILS) Chart for the new Ndola International Airport (FLSK). [AAIB/SR/2022/017]
- that the ZACL ensure availability of Audio Transcripts to assist investigations of incidents and accidents. [AAIB/SR/2022/018]
- that the ZACL ensure that communications concerning Aeronautical Information Services between Zambia and DR Congo are improved. [AAIB/SR/2022/019]
- that the ZACL ensure that there are specific procedures for verbally warning foreign VFR pilots of the proximity of the Ndola military airport to the new Ndola International Airport and provide action to ensure pilots do not misidentify them. [AAIB/SR/2022/020]
- that the ZACL revisit the Risk Analysis for the two Ndola airports i.e. the new International Airport (FLSK) and the former one (FLND) which is now a Zambian Air Force base. [AAIB/SR/2022/021]
- that the Zambia Air Force (ZAF) ensure accuracy of all flight plans filed for clearance. [AAIB/SR/2022/022]
- that the ZAF publish a new Location Indicator and coordinates for their military base with the ZACL when cancelling the expired location indicator for the former Ndola Airport including its associated navigation procedures with International aeronautical charts publishers. [AAIB/SR/2022/023]
- that the ZAF publish an Airspace Restriction from Ground to 2000 feet agl for the former Ndola civil airport now designated as a Military base. [AAIB/SR/2022/024]
- that the Civil Aviation Authority (CAA) ensure that the ZACL publishes Standard Instrument Departures (SIDs), Standard Terminal Arrival Routes (STARs), Visual approach and landing charts and Instrument Landing System (ILS) Charts for Ndola International Airport. [AAIB/SR/2022/025]
- that the Civil Aviation Authority carry out an ad-hoc audit of ZACL Aeronautical Information Services to ensure reliability and effectiveness of Aeronautical Information Services between Zambia and the DR Congo. [AAIB/SR/2022/026]
- that the Civil Aviation Authority must ensure that the ZACL and ZAF Command conduct a secondary Risk Analysis with regard to airspace management between the newly designated military base and the new International Airport. Mitigation measures should help in developing Standard Operating Procedures (SOPs) for use at both airports covering all aspects of aircraft operations as far as normal and abnormal flight operations. [AAIB/SR/2022/027]
Editors Note: Although the new SMKIA was officially opened on 5 August 2021, the changeover was reportedly not completed until mid October, shortly before the event under investigation occurred.
The Final Report was released on 16 March 2022.