ZS-CAR: Minister calls for fresh investigation

20 hours ago

6 min read

By Garth Calitz

The ZS-CAR story has taken another significant turn, with Transport Minister Barbara Creecy asking Justice Minister Mmamoloko Kubayi to initiate a judicial inquest into the January 2020 crash of South African Civil Aviation Authority (SACAA) Cessna Citation S550 ZS-CAR near George. The move comes after more than six years of controversy surrounding the accident, during which the crash has been investigated, re-investigated, disputed and subjected to increasingly intense scrutiny. It also follows the disclosures made by former SACAA airworthiness inspector and accident investigator Jeremiah Visser, whose concerns about the handling and findings of the investigation were highlighted in Flightline Weekly in our previous report.

The Minister's request is potentially one of the most important developments in the ZS-CAR saga since the Ethiopian Aircraft Accident Investigation Bureau was asked to conduct an independent investigation following dissatisfaction with the original findings. It does not mean that any individual or organisation has been found responsible for the accident, nor does it automatically invalidate the investigations already conducted. What it does do is create the possibility of an independent judicial examination of the circumstances surrounding the deaths of the three people on board and, importantly, the opportunity to test some of the questions that have remained unanswered.

ZS-CAR crashed on 23 January 2020 while conducting a calibration flight in the George area. Captain Thabiso Tolo, First Officer Tebogo Lekalaka and Flight Inspector Gugu Mnguni were killed when the Citation struck mountainous terrain. The accident immediately raised questions because of the nature of the operation and the organisation involved. SACAA was not only responsible for regulating the aircraft and the operator; ZS-CAR was itself a SACAA aircraft being operated by the authority. That unusual relationship became an important issue as questions began to emerge about the aircraft's maintenance history, the circumstances of the flight and the subsequent investigation.

The initial investigation placed considerable emphasis on the actions of the flight crew and concluded that pilot error was central to the accident. The families of the deceased were not satisfied with that explanation and continued to pursue an independent investigation. The then Transport Minister subsequently appointed the Ethiopian Aircraft Accident Investigation Bureau to examine the accident, which released a report in January 2022. While the Ethiopian investigation broadly concluded that the crew lost control of the aircraft after entering an unusual attitude in cloud and mountainous terrain, it also identified several issues concerning the aircraft's airworthiness, maintenance and regulatory oversight.

Those findings were particularly uncomfortable because they involved SACAA itself. The Ethiopian investigators identified problems associated with the aircraft's flight data recorder, including the absence of a required annual inspection and limitations in the parameters being recorded. The investigation also raised questions about inspections carried out before the aircraft was returned to service following an earlier engine-related serious incident. These findings did not necessarily establish a direct link between the regulatory shortcomings and the crash, but they raised legitimate questions about the systems surrounding an aircraft operated by the very authority responsible for regulating aviation safety in South Africa.

The Ethiopian investigation also highlighted a broader structural issue that has remained relevant throughout the ZS-CAR controversy: the need for independence when investigating an accident involving an aircraft owned or operated by the regulator itself. The principle is straightforward. Accident investigation should be sufficiently independent to allow investigators to examine the actions of pilots, operators, maintenance organisations and regulators without being influenced by the interests or reputation of any of those parties. The ZS-CAR case presented an obvious challenge because SACAA had several roles connected to the aircraft and its operation.

It was against this already complicated background that Visser began raising further concerns. A former accident investigator and SACAA airworthiness inspector, Visser examined the available material surrounding the crash and eventually prepared a detailed manuscript setting out what he believed were shortcomings and inconsistencies in the way the accident had been investigated. Among the issues he raised was whether sufficient consideration had been given to the possibility that another aircraft was operating in the area during the critical stages of the flight and whether a possible near mid-air collision should have been investigated more thoroughly.

Those claims remain allegations and have not been established as fact. That distinction is important, particularly in a case involving a fatal accident, because neither Visser's manuscript nor the claims contained within it should be regarded as a substitute for a formal investigation. The significance of his disclosures is that they identify questions which he believes warrant further examination, and the Minister's latest intervention provides a mechanism through which those questions can potentially be tested against the available evidence rather than being resolved through an argument between the whistle-blower and his former employer.

The dispute between Visser and SACAA has, in fact, developed into a separate controversy. After raising his concerns through SACAA's internal whistle-blowing process and bringing them to the attention of other authorities, including the Transport Minister, Visser was suspended and subsequently subjected to disciplinary proceedings. He was eventually dismissed by SACAA. The authority has rejected suggestions that his dismissal was retaliation for whistle-blowing and has maintained that the disciplinary action related to alleged breaches of internal policies, confidentiality obligations and employment conditions. Visser disputes that characterisation and maintains that his actions were motivated by genuine safety concerns.

The matter escalated further when SACAA approached the Gauteng High Court in Pretoria in an attempt to prevent the publication or distribution of Visser's manuscript. The urgent application was ultimately struck from the roll with costs. That legal battle did not determine whether the technical allegations contained in the manuscript were correct, but it added another dimension to an already highly contentious affair and ensured that the questions surrounding ZS-CAR received considerably more public attention.

Creecy's request for a judicial inquest now potentially moves the debate away from the employment dispute and back to where it belongs — the evidence surrounding the accident. An inquest would provide an independent forum in which the circumstances of the deaths could be examined and the available evidence assessed. It would not automatically endorse Visser's allegations, nor would it necessarily overturn the conclusions reached by previous investigators. Instead, it would provide an opportunity to establish whether the existing evidence supports those conclusions and whether information that may have emerged subsequently warrants further investigation.

That distinction is particularly important for South African aviation. Accident investigations are not intended to protect institutions or individuals from criticism. Their purpose is to establish what happened, why it happened and what can be done to prevent a recurrence. Sometimes the conclusions are straightforward, and sometimes they reveal uncomfortable failures in an organisation, an aircraft's maintenance programme, operational procedures or regulatory oversight. The credibility of the entire safety system depends on investigators being able to follow the evidence wherever it leads, even when that evidence raises questions about the regulator itself.

The ZS-CAR case therefore has significance well beyond the accident itself. If the original findings withstand independent scrutiny, then the aviation community and the families of those who died should have greater confidence in those conclusions. If the evidence reveals that important questions were overlooked, those questions need to be addressed. Neither outcome should be regarded as a threat to aviation safety. In fact, the willingness to revisit an investigation when credible new information emerges is one of the characteristics of a mature safety system.

For the families of Captain Tolo, First Officer Lekalaka and Flight Inspector Mnguni, however, the issue is much more personal. More than six years after the crash, they are still dealing with the loss of people who went to work and never returned home. Their interest is not in institutional politics or the reputational concerns of an aviation authority. They want to know what happened and whether everything that could reasonably have been done to establish the truth has been done.

A judicial inquest will not necessarily provide the dramatic answers that some may expect, and it should not be prejudged. Its value will depend entirely on the evidence placed before it and the willingness to examine that evidence objectively. But after years of competing findings and unresolved questions, an independent examination may be the best opportunity yet to establish which questions have substance and which do not.

Now, with the Transport Minister calling for a judicial inquest, there is a possibility that those questions can finally be put before an independent process. Whatever the eventual findings, that can only be good for South African aviation.