Region

Crash of a Raytheon 390 Premier I in Kuala Lumpur: 10 killed

Date & Time: Aug 17, 2023 at 1449 LT
Type of aircraft:
Operator:
Registration:
N28JV
Survivors:
No
Schedule:
Langkawi - Kuala Lumpur
MSN:
RB-97
YOM:
2004
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
6275
Captain / Total hours on type:
36.00
Copilot / Total flying hours:
9298
Copilot / Total hours on type:
3
Aircraft flight hours:
3142
Circumstances:
N28JV departed WMKL with eight persons on board at approximately 1408 LT, heading to WMSA. At around 1446 LT, N28JV contacted the WMSA air traffic tower controller to report it was established on the NBD Runway 15 approach and requested landing clearance. At 1448:36 LT, N28JV was cleared to land on Runway 15. The flight acknowledged the clearance at 1448:41 LT. No further radio transmissions were heard from the flight. Automatic Dependent Surveillance–Broadcast (ADS-B) data indicated that at 1447:24 LT, at an altitude of 2,600 feet, the aircraft began a speed reduction and descent. At approximately 1449:06 LT, at an altitude of 1,025 feet, the aircraft initiated a right turn, continuing until about 1449:14 LT, when it was at an indicated height of 550 feet. This was the last recorded data transmission from the accident flight, which was near the accident location. The ground speed during the right turn ranged between 146 and 154 knots. The aircraft crashed at Persiaran Elmina, Elmina, Shah Alam. The airplane was destroyed following the ground impact and subsequent fire. All eight occupants and two ground bystanders were fatally injured.
Probable cause:
The accident was primarily caused by the inadvertent extension of the lift dump spoilers by the flight crew while performing the Before Landing checklist.
The following contributing factors were identified:
- Inadvertent Extension of Lift Dump Spoilers: The primary cause of the accident was the inadvertent extension of the lift dump spoilers, most likely by the Second-in-Command, during the Before Landing checks. This action led to a sudden loss of lift, resulting in catastrophic loss of control and the subsequent crash.
- Deviation from Seating Protocols: The seating arrangement of the crew deviated from established protocols, with the Pilot-in-Command occupying the right hand seat and the Second-in-Command in the left-hand seat, contrary to the Airplane Flight Manual. This deviation likely contributed to ineffective crew resource management and communication.
- Inadequate Crew Training and Awareness: Insufficient crew training and awareness regarding the operation of the lift dump system were contributing factors to the accident. The Second-in-Command's unfamiliarity with the specific risks associated with the lift dump system led to the inadvertent extension of the spoilers.
- Regulatory Grey Areas and Oversight Gaps: 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.
- Communication and Decision-Making: Ineffective communication and decision-making processes were 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.
Final Report:

Crash of a Beechcraft B200T Super King Air at Butterworth AFB: 1 killed

Date & Time: Dec 21, 2016 at 1718 LT
Operator:
Registration:
M41-03
Flight Type:
Survivors:
Yes
Schedule:
Kuala Lumpur – Butterworth
MSN:
BT-37
YOM:
1993
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The crew was completing a training flight from Kuala Lumpur-Subang Airport when on final approach to Butterworth Airbase, the twin engine aircraft went out of control and crashed, coming to rest against the perimeter fence. The aircraft was partially destroyed by impact forces and one crew member was killed while three other occupants were injured. Weather conditions were considered as good at the time of the accident.

Crash of a Casa CN-235M near Kuala Selangor

Date & Time: Feb 26, 2016 at 0840 LT
Operator:
Registration:
M44-07
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Subang - Subang
MSN:
N055
YOM:
2005
Flight number:
Sintar Sakti 02
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Kuala Lumpur-Subang-Sultan Abdul Aziz Shah Airport at 0835LT on a local training flight. Ten minutes later, the left engine caught fire and failed, forcing the captain to attempt an emergency landing. The aircraft crash landed in the sea, few metres off the beaches of Taman Malawati Utama, south of Kuala Selangor. The copilot was injured (broken arm) while seven other occupants escaped unhurt. The aircraft was destroyed by a post crash fire.

Crash of a De Havilland DHC-6 Twin Otter 310 in Kudat: 2 killed

Date & Time: Oct 10, 2013 at 1450 LT
Operator:
Registration:
9M-MDM
Survivors:
Yes
Schedule:
Kota Kinabalu - Kudat
MSN:
804
YOM:
1983
Flight number:
MWG3002
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4700
Aircraft flight hours:
56828
Aircraft flight cycles:
108882
Circumstances:
A de Havilland Canada DHC-6 Twin Otter 310, operated by MASwings, sustained substantial damage in an accident at Kudat Airport (KUD), Malaysia. The copilot and one passenger died, four others were injured. MASwings flight MH3002 operated on a domestic flight from Kota Kinabalu Airport (BKI) to Kudat. The captain was the pilot flying for this sector and the first officer was pilot monitoring. As the aircraft was approaching Kudat Airfield, Kudat Tower reported the weather conditions to be: wind at 270 degrees at 17 kts gusting 31 kts. The aircraft continued the approach on runway 04 and leveled off at 500 feet with flaps set at 10°. At this point the crew noticed that the approach for runway 04 had a strong tail wind. This was evident from the indicated airspeed observed by the crew which indicated 100 kts where the airspeed for flaps 10° should be 65kts. The windsock also indicated a tail wind. Noticing the approach for runway 04 was a tail wind condition, the crew decided to go around at a height of 500ft. Maintaining runway heading, the crew initiated a go around climbing to 1,000ft making a left tear drop and reposition for runway 22. On the approach for runway 22 the captain informed the first officer that if they could not land they would return to Kota Kinabalu. The aircraft was aligned with the centerline of runway 22 and 20° flaps was set. The aircraft continued to descend to 300ft. At this point the wind appeared to be calm as the aircraft did not experience any turbulence and the captain told the first officer that he was committed to land. Upon reaching 200ft the captain called for the flaps to be lowered to full down. As they were about to flare the aircraft to land, approximately 20ft above the runway, the aircraft was suddenly hit by a gust of wind which caused the aircraft to veer to the right with the right wing low and left wing high and the nose was pointing 45° to the right of runway 22. The crew decided to go around by applying maximum power; however the aircraft did not manage to climb successfully. The flaps were not raised and were still in the full flaps down position as the crew thought the aircraft was still low hence the flaps were not raised. The aircraft continued to veer to the right with right wing low and managed to only climb at a shallow rate. The aircraft failed to clear the approaching trees ahead and was unable to continue its climb because the airspeed was reducing. The presence of a full flaps configuration made it more difficult for the aircraft to climb. As the aircraft was on full power on both the engines, it continued to fly almost perpendicularly in relation to the runway and at a low height above the ground. The aircraft hit a tree top at the airfield perimeter fencing, disappeared behind the row of trees, hit another tree behind a house. It hit the right rear roof of the house, ploughed through the roof top of the kitchen, toilet and dining area, hit the solid concrete pillars of the car garage and finally hit the lamp post just outside the house fence. It swung back onto the direction of the runway and came to rest on the ground with its left engine still running. A woman and her 11-year old son who were in the living room at the time escaped unhurt.
Probable cause:
Based on the information from the recorded statements of witnesses and Captain of the aircraft, it clearly indicates that the aircraft was attempting to land on Runway 04 with a tail-wind blowing at 270° 15kts gusting up to 25kts on the first approach, contrary to what was reported by the Captain to the investigators. The demonstrated cross wind landing on the DHC6-310 is 25kts and tailwind landing is 10kts. The aircraft was unsettled and unstable until it passed abeam the terminal building which was not the normal touch down point under normal landing condition. The flap setting on the first approach with the tail-wind condition was at 10°, which is not in accordance with company’s procedures. A tail wind landing condition that will satisfy the criteria for the DHC6-310 is not more than 10kts tail-wind and a flap setting of not more than 20°. One of the stabilized approach criterias for visual conditions (VMC) into Kudat is landing configuration must be completed by 500ft Above Ground Level (AGL) for the DHC6-310 where else if the above conditions could not be met, a go-around should be initiated. Hence, the Crew should have initiated a go-around earlier before the aircraft reached 500ft AGL on the first approach. The aircraft should be in the correct landing configuration at or below the stabilized approach altitude of 500ft AGL, since the aircraft was not stable due to the tail wind and gusting weather. The procedure carried out on the approach for Runway 04 was not consistent with MASwings’ Standard Operating Procedure (SOP) for a tailwind condition. Nonetheless, the first approach for Runway 04 though was uneventful. On the second approach from Runway 22, the wind condition was still not favorable for landing, and gusting. The aircraft was believed to be slightly low on the initial approach and was still unstable. The flap setting for the second approach for Runway 22 was at full flap (37°). As the wind was gusting, a flap setting to full-down should be avoided for the landing as stated in company’s DHC6-310 SOP. With the full-flap configuration, the aircraft had difficulty to settle down on the runway thus dragging the aircraft until abeam the tower which is way beyond the normal touch down zone.
At the point where the aircraft was approaching to land it was reported that the aircraft was hit by a sudden gust, several factors, including the following, have been looked into:
a) Why was the aircraft unable to climb after initiating the go-around?
The full flap setting would require a zero degree pitch attitude to ensure the aircraft speed is maintained. With go-around power set, the zero degree pitch would ensure a climb without speed loss. A pitch above zero degree can cause the aircraft speed to decrease and induce a stall condition resulting in the aircraft being unable to climb.
b) Was the go-around technique executed correctly, taking into consideration that the wind was blowing from 270° and gusting?
The Captain had said that "I applied maximum power and expected the aircraft to climb. At this point, the aircraft was still in left-wing high situation. I noticed the aircraft did make a climb but it was a shallow climb. I did not retract the flaps to 20°, as at that time, in my mind, the aircraft was still low."
c) Under normal conditions, the rule of thumb for initiating a go-around procedure is to apply maximum power, set attitude to climb, confirm airspeed increasing and reduce the flap setting. This procedure was found not to be properly synchronized between MASwings Manuals and DHC6-310 Series 300 SOP.
d) Were the pilots in control of the aircraft?
Based on the Captain’s statement and other associated factors, the pilots were not in total control of the aircraft.

Crash of a Boeing 737-230C in Kuching

Date & Time: Jan 13, 2007 at 0552 LT
Type of aircraft:
Operator:
Registration:
PK-RPX
Flight Type:
Survivors:
Yes
Schedule:
Kuala Lumpur - Kuching
MSN:
20256
YOM:
1970
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful mail flight from Kuala Lumpur, the crew initiated a night approach to Kuching Airport. After touchdown on a wet runway due to recent heavy rain falls, the aircraft deviated to the left and veered off runway. While contacting soft ground, both main gears collapsed, the left engine was torn off and the aircraft came to rest 1,500 metres past the runway threshold. All four crew members escaped uninjured while the aircraft was damaged beyond repair.

Ground accident of a Boeing 747-368 in Kuala Lumpur

Date & Time: Aug 23, 2001 at 2208 LT
Type of aircraft:
Operator:
Registration:
HZ-AIO
Flight Phase:
Survivors:
Yes
Schedule:
Kuala Lumpur - Jeddah
MSN:
23266
YOM:
1985
Flight number:
SV3830
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following technical problems with the engines, the aircraft was transferred to a hangar at Kuala Lumpur for maintenance. In the evening, a team of six technicians was dispatched to convoy the aircraft to the main terminal where 319 passengers should embark on a flight to Jeddah. While on a taxiway, the engineers attempted to turn to another taxiway when control was lost. The aircraft veered off taxiway and came to rest, nose first, in a drainage ditch. All six occupants were injured and the aircraft was damaged beyond repair. At the time of the accident, only the engine n°2 and 3 only were running and it is believed that the auxiliary hydraulic pump switches were in the OFF position. Thus, the nosewheel steering system was inoperative as well as the brakes.

Crash of a De Havilland DHC-4 Caribou in Kuching: 5 killed

Date & Time: May 24, 1999 at 1315 LT
Type of aircraft:
Operator:
Registration:
M21-05
Flight Type:
Survivors:
No
Schedule:
Kuching - Kuching
MSN:
270
YOM:
1969
Location:
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The crew was completing a local training flight at Kuching Airport. On final approach, one of the engine failed. The aircraft lost height and crashed in a swampy area near the airport. All five occupants were killed.
Probable cause:
Engine failure for unknown reasons.

Crash of a De Havilland DHC-6 Twin Otter 310 in Limbang

Date & Time: Jan 8, 1998 at 1744 LT
Operator:
Registration:
9M-MDJ
Survivors:
Yes
Schedule:
Miri - Limbang
MSN:
791
YOM:
1982
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft landed a little too far down the runway and bounced twice. Out of control, it skidded and overran the runway before coming to rest in a ditch. All eight occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Dornier DO228-212 near Miri: 10 killed

Date & Time: Sep 6, 1997 at 1942 LT
Type of aircraft:
Operator:
Registration:
9M-MIA
Survivors:
No
Site:
Schedule:
Labuan – Bandar Seri Begawan – Miri
MSN:
8217
YOM:
1993
Flight number:
BI238
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
The twin engine aircraft departed Bandar Seri Begawan Airport at 1903LT on a regular schedule flight to Miri, Sarawak. At 1936LT, the crew was cleared for an approach to runway 02 but failed to acknowledge. Six minutes later, while descending by night, the aircraft struck the slope of Mt Lambir (500 metres high) located 13,7 km from the airport. The wreckage was found the next morning at 0710LT. All 10 occupants were killed.
Probable cause:
Controlled flight into terrain after the crew descended below the minimum safe altitude for unknown reasons.

Crash of a Fokker 50 in Tawau: 34 killed

Date & Time: Sep 15, 1995 at 1222 LT
Type of aircraft:
Operator:
Registration:
9M-MGH
Survivors:
Yes
Schedule:
Kota Kinabalu - Tawau
MSN:
20174
YOM:
1990
Flight number:
MH2133
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
49
Pax fatalities:
Other fatalities:
Total fatalities:
34
Captain / Total flying hours:
4892
Captain / Total hours on type:
427.00
Copilot / Total flying hours:
1162
Copilot / Total hours on type:
962
Aircraft flight hours:
10848
Aircraft flight cycles:
17483
Circumstances:
Flight MH2133 A Fokker 27 mark 050 bearing registration 9M-MGH was a scheduled domestic flight from Kota Kinabalu to Tawau, Sabah. The departure from Kota Kinabalu was delayed by approximately 30 minutes due to late arrival of the aircraft operated by a different set of flight crew from Labuan. The flight took off from Kota Kinabalu at 0419 hrs on an Instrument Flight Rules (IFR) flight plan via Airway W 423 direct to Tawau Very Omni Range (VOR) at flight level (FL) 170 with 53 persons on board. The departure out of Kota Kinabalu was uneventful and the weather en-route was insignificant. At 0442 hrs the flight established radio contact with Tawau Tower “MH 2133 we are maintaining FL 170, TMA 40, VTW 0505, presently at 94 DME VTW”. The controller then passed the weather for Tawau which was, “surface wind calm, visibility more than 10 km, rain north to north east, scattered 1600 feet and scattered 2700 feet, broken at 14000 feet, Temperature 30 degree C and QNH 1009 mb, Runway 17”. At 0443 hrs another aircraft call sign TSE 809 (a Cessna 206) flying along the same route as MH2133 but at 9500ft established radio contact with Tawau Tower, TSE 809 then reported that the flight was 65 DME from Tawau VOR. This was immediately followed by Tawau Tower asking MH2133 to report position from Tawau VOR which MH 2133 replied “57 DME and requested descent”. The controller then cleared MH 2133 to descend to 10500 feet. At this point in time there was also another aircraft MH2135 (a Boeing 737) heading towards Tawau cruising at FL 230 and cleared by the TOWER to descent to FL 180. MH 2135 was also notified by the TOWER of the Expected Approach Time (EAT) of 0530 hrs. At 0457 hrs TSE 809 reported that the flight was 44 DME from Tawau VOR. On hearing this transmission, MH 2133 requested a lower descend clearance, as it was 30 DME from Tawau VOR. It must be noted that at this juncture, MH 2133 was ahead of TSE 809 but at a higher altitude. The controller then asked TSE 809 whether there was any objection for MH2133 to descent through its level and become number One (1). Despite the fact that TSE 809 had no objection for MH 2133 to become number One (1), MH 2133 was asked by the controller to still maintain 10500 feet. At 0458:23 hrs, MH 2133 asked “MH 2133 confirm maintain 10500 feet?”. TOWER then replied “Affirm maintain 10500 number 2 in traffic”. At 0458:36 hrs MH 2133 again asked “MH 2133, 26 DME confirm we are still number 2?” TOWER then replied- “Station calling…. say again - MH 2133 then repeated “2133 Maam, and are 25 DME maintain 10500, confirm we are number 2?”. TOWER – responded “That’s affirm 2133, Expected Approach Time 0520 hrs”. At 0459:05 hrs MH2133 asked TSE 809 to check position and whether there would be any objection for the aircraft to descend through its level. TSE 809 replied that they had no objection and MH 2133 was subsequently cleared to descend to 7000 feet. The descent into Tawau by MH 2133 from the cruising altitude of 10500 feet was initiated at about 21 DME. The flight crew discussed the descent technique they were going to use and were aware of all their action. At 0501:15 hrs, as the flight reported leaving 9000 feet and passing 16 DME, the flight crew advised the controller that they had the airfield visual. MH2133 was then cleared for visual approach runway 17. At 0502:48 hrs, MH 2133 reported passing 3500 feet. The aircraft was then configured for landing where landing gears were selected down and flaps set at 25 degrees. The aircraft speed was still fast and since it was also high on the approach, the commander assured the co-pilot “Runway is long so no problem Eh”. On passing 2000 feet and on short final, the copilot reminded the commander “speed, speed check, speed check Ah”. The rate of descent was in excess of 3000 feet per minute and its pitch angle was around minus 13 degrees. The excessive rate of descent triggered the aircraft Ground Proximity Warning System (GPWS) sink rate and pull up warnings. The commander ignored these warnings and insisted that he should continue with approach for a landing. The aircraft first touched down on the runway at 0505 hrs. Its first tyre marks (nose wheel) on the runway was at approximately 3400 ft from the threshold. It then bounced and at 4500 ft point, its left main wheel made a light contact with the runway surface. It subsequently bounced up again and its main wheels made a firm contact at 4800 ft point, thus leaving only 800 ft of runway remaining. The aircraft continued onto the grass verge, momentarily left the ground and hopped over the runway perimeter fence. It subsequently crashed at 571 feet from the end of the runway at almost right angle to the runway. There were a number of explosions followed by a fire. The aircraft was totally destroyed.
Probable cause:
The most probable cause of the accident was due to the commander’s insistence to continue with an approach despite the fact that the runway available after touchdown was not sufficient enough for the aircraft to stop. The perception regarding economic consideration which put pressure on him to save fuel and adhere to schedules was a contributing factor.
Final Report: