SOUTH AFRICAN AIRWAYS AIRBUS A340-600: 6 NOVEMBER 2018 LOSS OF CONTROL REPORT

On 17 July 2023 the final Board of Inquiry report by the German authorities into the loss-of-control experienced by an SAA South African Airways Airbus A340-600, registration ZS-SNF performing flight SA-260 from Johannesburg to Frankfurt, on 6 November 2018, which was enroute at FL380 climbing to FL390 over Switzerland, about 40nm south-south-east of Zurich, when the aircraft encountered overspeed and the subsequent actions by the crew (notably the PIC) led to a loss of control.

The report severely criticises the crew’s actions

During the conduct of the investigation by the German authorities they discovered that both SAA 2.0 and the SACAA, through their lack of oversight had allowed the Senior First Officer involved in this instance to fly for many years without holding an Airline Transport Pilot’s licence.

The findings:

The aircraft was in cruise flight at Flight Level (FL) 380 in Swiss airspace, when a change of wind conditions at high altitude caused the exceedance of the maximum operating Mach. The Pilot in Command deactivated the autopilot and steered the aircraft manually into climb. While reaching FL 400, the maximum angle of attack was reached several times and the stall warning activated. The PIC initiated a descent, stabilising the flight path again at FL 340. On 16 November 2018, the Swiss Transportation Safety Investigation Board (STSB) delegated the investigation to the German Federal Bureau of Aircraft Accident Investigation.

The investigation determined:

• A rapidly turning wind direction during cruise flight, unpredictable for the flight crew. This caused an overspeed condition.

• The flight crew did not respond to this overspeed condition with the procedure

Abnormal and Emergency Procedures / Misc / Overspeed Recovery

• The PIC had deactivated the autopilot and in the course of the incorrect application of the OEB No. 49, he had two ADRs of the three Air Data Inertial Reference Units (ADIRU) switched off. Subsequently, the A/THR was deactivated and flight idle thrust initially maintained.

• Temporarily, the aircraft was controlled in Alternate Law. • Due to the dynamic pitch-up control inputs of the PIC, the subsequent climb and the