KUALA LUMPUR – Deviations from standard procedures, inadequate training, and poor decision-making have been identified as contributing factors to last year’s fatal plane crash in Bandar Elmina, Shah Alam.
The Air Accident Investigation Bureau’s (AAIB) final report on the incident on August 17 last year reveals that the primary cause of the crash was the inadvertent extension of the lift dump spoilers by the flight crew during the Before Landing checklist.
“Contributing factors included deviations from standard operating procedures, inadequate crew training, regulatory grey areas and deficiencies in communication as well as decision-making,” stated the report released today.
The report further indicated that the unintended extension of the lift dump spoilers was “most likely” carried out by the second-in-command of the Hawker Beechcraft Model 390 (Premier 1) aircraft. This action led to a sudden loss of lift, resulting in a “catastrophic loss of control” and the subsequent crash.
Additionally, the seating arrangement of the crew deviated from established protocols, with the pilot occupying the right-hand seat while the co-pilot sat in the left-hand seat, contrary to the Airplane Flight Manual.
This deviation, according to the AAIB report, likely contributed to ineffective crew resource management and communication.
The incident was coded by the AAIB as an inflight loss of control.
Based on personnel information available in the report, the pilot Shahrul Kamal Roslan, 41, had a total of 36.72 flying hours with the plane type, while his co-pilot Heikal Aras Abdul Azim, 44, possessed 3.15 flying hours for the same plane type.
While the co-pilot’s “unfamiliarity” with the specific risks associated with the lift dump system led to the inadvertent extension of the spoilers, ineffective communication and decision-making processes were found to be evident during critical phases of the flight.
“The absence of specific briefings or warnings about the lift dump system operation and the decision to deviate from standard seating protocols underscored deficiencies in communication and decision-making.”
Besides that, the AAIB also determined that regulatory grey areas and organisational practices compromised safety oversight and compliance.
“The aircraft operator’s failure to obtain necessary approvals for non-scheduled air services and comply with Malaysian regulations highlighted gaps in operational oversight.”
In its concluding statement, AAIB emphasised that while its investigation had revealed instances of non-compliance and errors, its findings are not intended for the purposes of apportioning blame or liability.
“Rather, (the findings) are solely for the purpose of preventing accidents in the future and improving aviation safety on the whole.”
The plane, which crashed on August 17 last year and claimed the lives of both crew members, six passengers as well as two bystanders, was operated by private operator Jet Valet Sdn Bhd.
Among the victims of the crash were Pahang Local Government, Housing, Environment and Green Technology exco Datuk Seri Johari Harun. The two bystanders consisted of one motorcyclist and a motorcar driver.
The flight crashed two minutes before it was due to land at Sultan Abdul Aziz Shah Airport in Subang after its departure from Langkawi International Airport. – August 16, 2024