final aircraft accident report 04 december 2014

FINAL AIRCRAFT ACCIDENT REPORT

04 DECEMBER 2014

MASWINGS DHC-6-310 TWIN OTTER, REGISTRATION 9M-MDM CRASH AT KUDAT, SABAH

10 OCTOBER 2013

AIR ACCIDENT INVESTIGATION BUREAU OF MALAYSIA

MINISTRY OF TRANSPORT MALAYSIA

Air Accident Investigation Report 9M-MDM De Havilland DHC-6-310

___________________________________________________________________AAIB MALAYSIA Page 1 of 32

The Air Accident Investigation Bureau of Malaysia The Air Accident Investigation Bureau (AAIB) is the air accidents and incidents

investigation authority in Malaysia responsible to the Ministry of Transport. Its

mission is to promote aviation safety through the conduct of independent and

objective investigations into air accidents and incidents.

The AAIB conducts the investigations in accordance with Annex 13 to the Chicago

Convention and Civil Aviation Regulations of Malaysia 1996.

In carrying out the investigations, the AAIB will adhere to ICAO’s stated objective,

which is as follows:

“The sole objective of the investigation of an accident or incident shall be the

prevention of accidents and incidents. It is not the purpose of this activity to

apportion blame or liability.”

Accordingly, it is inappropriate that AAIB reports should be used to assign fault or

blame or determine liability, since neither the investigation nor the reporting process

has been undertaken for that purpose.



Contents SYNOPSIS

1 FACTUAL INFORMATION

1.1 History of the flight

1.2 Injuries to persons

1.3 Damage to Aircraft

1.4 Other Damage

1.5 Personnel information

1.6 Aircraft Information

1.7 Meteorological Information

1.8 Aids to Navigation

1.9 Communications and Radar Data

1.10 Aerodrome Information

1.11 Flight Recorders

1.12 Wreckage and Impact Information

1.13 Fire

1.14 Tests and Research

1.15 Organisation and Management

2 ANALYSIS

2.1 Crew Qualifications

2.2 Airworthiness Certificate of the Aircraft

2.3 Flaps

2.4 Propellers

3 CONCLUSION

4 RECOMMENDATION



SYNOPSIS

On 10th October 2013, a Maswings DHC6-310 Twin Otter aircraft bearing

registration number 9M-MDM and flight number MH 3002 took off from Kota

Kinabalu International Airport on a scheduled flight to Kudat. At approximately 14:50

(2:50 PM – Local Time) whilst attempting to make a second approach to land into

Kudat on runway 22, the aircraft went out of control and crashed outside the

perimeter of the airfield hitting some trees and a residential compound about 165

meters to the right of the runway centerline and the house along its flight path.

At the time of the accident there were 16 people on board, consisting of the Captain,

First Officer and 14 passengers (including 1 infant). There were 2 fatalities, one

elderly passenger and the First Officer. The Captain survived the crash with injuries.

The aircraft was badly damaged with significant serious damage to the cockpit, right

wing, undercarriage, engines and propellers.

Department of Civil Aviation Malaysia (DCA) was promptly notified of the accident

via telephone by the Operator. DCA then notified Air Accident Investigation Bureau

Malaysia (AAIB) of the accident. A Mandatory Occurrence Report (MOR) was also

raised by the Operator, ref MW/MOR/DHC6/0313.



1. FACTUAL INFORMATION 1.1 History of the flight

On 10th October 2013 the crews of flight MH 3002, a DHC6-310 Twin Otter

was scheduled to operate the MIRI-LAWAS-KINABALU-KUDAT-SANDAKAN-

KUDAT-KINABALU sectors, a total of 6 sectors. The scheduled departure

time for flight MIRI-LAWAS (the first sector) was 1200 hrs local time (LT). The

Captain reported for duty at about 1050 LT, 25 minutes earlier than the

scheduled reporting time at 1115 LT.

The flight MIRI-LAWAS-KINABALU was uneventful. On the KINABALU-

KUDAT sector, the aircraft took off at about 1410 LT. 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 provided the crew on

the weather conditions with wind at 270kts gusting 31kts.

The aircraft continued the approach on runway 04 and leveled off at 500ft

with flaps set at 10°. At this point the crew noticed that the approach for

runway 04 had strong tail wind. This was evident from the indicated airspeed

observed by the crew which indicated 100kts 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 cannot make a

landing they will return to Kota Kinabalu.



The aircraft was aligned to the centerline of runway 22 and a 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 experienced 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 (based on

GPWS callout) from 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 left high situation.

Note: The aircraft veering to the right is a common tendency in a

weathercock situation where the aircraft turns into the wind (wind is

coming from the right gusting) unless a cross control technique is

applied in order to maintain the aircraft on a straight path.

As the aircraft left wing was high and not level with the horizon, the aircraft

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 the tree top (see Figure 1, Figure 2) at the airfield perimeter

fencing, disappeared behind the row of trees, hit another tree close behind

the right aft of the house.

It hit the right rear roof of the house, ploughs 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 swing back onto

the direction of the runway and rested on the ground with its left engine still

running.

The right undercarriage was dislodged from the aircraft and was left behind

on the left side of the house (see Figure 3) after it hit the concrete structure of

the house. The right main wheel was dislodged from the aircraft and was

thrown off and found lying on the left middle side of the house.

The right wing was also dislodged from the aircraft. The right engine was

dislodged from the wing and dropped on the left side of the house seen from

the rear of the house (see Figure 4, Figure 5). The nose wheel was found by

the side of the four wheel drive parked in the garage (see Figure 6).

The Captain regained consciousness and found out the left engine were still

running and the propeller spinning. He initiated an engine shut down but could

not locate the power lever and fuel shut off as the top portion of the cockpit

where those levers were situated was torn off and missing.

The Captain and First Officer were rescued by the Fire and Rescue

personnel. The passengers escaped to safety when one of the passengers

opened the rear exit door. However, one elderly passenger who is believed to

have sat at the rear of the cabin was flung off from his seat when the seat was

dislodged from the cabin floor and he succumbs to his injuries. The crew and



all passengers were rushed to the Kudat Hospital and later transferred to the

Queen Elizabeth II Hospital Kota Kinabalu.

1.2 Injuries to Persons 1.2.1 Table below shows the breakdown of the 16 injuries.

Injuries Crew Passengers Total Fatal 1 1 2

Serious 1 5 6

Scratches / Bruises - 8 8

Total 2 14 16 1.2.2 The injured First Officer was rushed to Kudat Hospital and he succumbed to

his injuries at the hospital on 10th October 2013. Based on doctor’s report, the

cause of death is polytrauma due to or as a consequence of aircraft crash.

1.2.3 The Captain was placed in the Intensive Care Unit (ICU) at Queen Elizabeth II

hospital. He was released on the 18th October 2013 to recuperate at his

house in Miri.

1.2.4 One elderly passenger who is believed to have sat at the rear of the cabin

was flung off from his seat when the seat was dislodged from the cabin floor

and he succumbs to his injuries.

1.2.5 Among the remaining 13 passengers on board, a total of 8 with minor injuries,

and 5 with serious injury were warded and transferred to Queen Elizabeth II

hospital. Based on doctor’s report, common injuries were compression

fractures of different parts of the vertebrae. They have since been discharged.



1.3 Damage to Aircraft Listed below is the significant damage to the aircraft:

a) Radome and forward cargo compartment section crushed and ripped.

b) Instrument Panel/Cockpit Area

Generally cockpit was crushed with the cockpit crown area and pulled

rearward. Both windshields were broken with the center post missing.

Main instrument panel distorted and some instruments found migrated

and detached. Left hand crew seat was distorted and the right hand crew

seat was distorted and crushed. The control column yoke was found

slightly bent.

c) Nose landing gear dislodged from the forward bulkhead.

d) Left Wing and Engine

All propeller blades were bent, distorted and were in ‘feathered’ position.

The propeller lever was in the ‘minimum’ position. There was evidence of

cracks on nacelle longeron. The outboard wing including the aileron and

flaps were wrinkled, bent and damaged with the flaps in full down

position.

e) Right Wing and Engine

The wing was sheared and dislodged from the fuselage at the wing root

area. The outboard flap and aileron were dislodged from the main wing

assembly. The engine was dislodged from the wing together with the

nacelle. There was evidence of cracks on nacelle longeron. The

propeller blades were bent, distorted and were in ‘towards fine’ position.

The propeller lever was in the ‘maximum’ position.

f) Left hand main wheel was punctured with timber.

g) Right hand main landing gear was sheared and detached.

h) Aircraft empennage lower section was torn, punctured and distorted.

i) A possible damage to the fuel cells, as the presence of fuel was evident.



1.4 Other Damage A bricked residential house in Kampung Sin San identified as House

No.1094, Kilometre 6, Post Box 315, 89058 Kudat was badly damaged. The

house was located at the outer perimeter of the Kudat Airport runway.

Two motor vehicles, a Toyota Fortuner bearing the registration number SK

5955 and a NazaRia bearing registration number SS 5955 which were parked

within the house compound were badly damaged as well.

1.5 Personnel Information

Details Captain First Officer

Gender Male Male

Age 56 years 22 years

Citizen Malaysian Malaysian

DCA Licence Number ATPL – 3986 CPL – 5318

Licence Expiry 12th March 2014 04th April 2014

Initial Date of Operating Twin Otter 11th March 2013 01st February 2013

Total Operating Hours on Twin Otter 807:35 400:40

Total Flying Hours 4740:33 651:05

Rest Period Since Last Flight 17:40 45:50

Last Base Check 12th September 2013 04th October 2013

Last Line Check 13th March 2013 01st February 2013

Last Instrument Rating Check 13th March 2013 04th October 2013



1.6 Aircraft Information 1.6.1 Details

Aircraft Owner Penerbangan Malaysia Berhad Aircraft Operator MASwings Sendirian Berhad Air Operator Certificate No 38

AOC Expiry 31st March 2014 Aircraft Type De Havilland DHC-6-310 Aircraft Serial Number 804 Nationality Malaysian Aircraft Registration 9M-MDM Flight Number MH 3002

Flight Sector Miri-Lawas-Kinabalu-Sandakan-Kudat-Kinabalu

Type of Flight Scheduled passenger flight Persons on board 16 The aircraft was purchased new from De Havilland Incorporated, Canada.

The aircraft model is De Havilland DHC-6-310, high wing, twin turboprop with

Serial Number 804. It was manufactured in 1983 and registered in Malaysia

as 9M-MDM on 30th June 1983 and has been put into active service since

then.

The aircraft was maintained by Malaysian Airline System Engineering and

Maintenance Division. The maintenance base for this aircraft type is Kota

Kinabalu as per DCA Approved Maintenance Schedule. 9M-MDM had

clocked-in 56,828 hours and 108,882 cycles as of 09th October 2013.

The aircraft had undergone an Equalized Maintenance for Maximum

Availability (EMMA) Check Number 08 on 30th September 2013 at Kota

Kinabalu.

The aircraft technical log book, airframe, engines and propellers log books,

are quarantined at MAS Kota Kinabalu Quality Assurance Office. They were



thoroughly reviewed with no significant defects to the aircraft, engines and

propeller systems, ref Technical Log (MR1) pages 61195351 to 61195361.

1.6.2 Certificates

The following aircraft certificates are available in the Aircraft Certificate File.

They are current and valid:

a) Certificate of Registration Number M.0127 b) Certificate of Airworthiness Number M.0408 c) Certificate of Airworthiness Expiry Date 02nd October 2014 d) Radio License Expiry Date 31st December 2014 e) Certificate of Maintenance Review No. 6876 f) CMR Last Reviewed 15th August 2013 g) Next CMR Review Due 13th February 2014 h) Certificate of Release to Service Scheduled

Maintenance Inspection (CRS-SMI) No. 25059

i) CRS-SMI Issue Date 30th September 2013 j) Aircraft Weight Schedule Reference APS-MDM-8

1.6.3 Engines

Details of the engines that were fitted on 9M-MDM at the time of incident are

as follows:

ENGINE SERIAL NUMBER / POSITION

PCE-42228(LH) PCE-42475(RH)

Time Since New 44,357 Hrs 34,717 Hrs Time Since Overhaul (TSO) 3,352 Hrs 202 Hrs Time Since Fitted (TSF) 3,352 Hrs 202 Hrs Cycles Since Overhaul (CSO) 4,974 331 Cycles Since Fitted (CSF) 4,974 331 Date Fitted 12th June 2012 9th September 2013 Time Between Overhaul (TBO) 4,500 Hrs 4,500 Hrs



1.6.4 Propellers

Details of the propellers that were fitted on 9M-MDM at the time of incident

are as follows:

PROPELLER SERIAL NUMBER / POSITION

BUA26053(LH) BUA20430(RH)

Time Since New 18,147 Hrs Unknown Time Since Overhaul (TSO) 2,523 Hrs 620 Hrs Time Since Fitted (TSF) 2,523 Hrs 620 Hrs Date Fitted 19th October 2012 15th July 2013 Time Between Overhaul (TBO) 4,000 Hrs 4,000 Hrs

1.6.5 Weight and Centre of Gravity

Basic Weight 3,636 Kg Crew Weight 150 Kg (75 Kg x 2 crew) Passenger Weight (include hand carry) 987 Kg Baggage Weight (checked in) 87 Kg USL Equipment Not Applicable Fuel Weight 771 Kg Take-Off Weight on Departure 5,481 Kg Maximum Authorised Take-Off Weight 5,669 Kg



1.7 Meteorological Information On the day of the accident the following weather information was obtained

from the Meteorological Department:

METAR WBKT 100600Z 27015G25KT 230V320 9999 FEW015 BKN280

31/24 Q1008 RMK F01 P00.0 R64

“Kudat’s weather on 10th October 2013 at 1400 hours (local time), wind

direction 270 degrees, wind speed 15 knots gusting to 25 knots, wind

direction vary from 230 degrees to 320 degrees, visibility more than 10 km,

cloud condition 1-2 octas at 1500 feet, 5-7 octas at 28,000 feet, temperature

31 degrees Celsius and dew point 24 degrees Celsius, mean sea level

pressure 1,008 Hectorpascal.”

“METAR WBKT 100700Z 27017G31KT 210V300 9999 SCT 014 BKN280

30/24 Q1008 RMK F03 POO.0 R67”

“Kudat’s weather on 10th October 2013 at 1500 hours (local time), wind

direction 270 degrees, wind speed 17 knots gusting to 31 knots, wind

direction vary from 210 degrees to 300 degrees, visibility more than 10 km,

cloud condition 3-4 octas at 1,400 feet, 5-7 octas at 28,000 feet, temperature

30 degrees Celsius and dew point 24 degrees Celsius, mean sea level

pressure 1,008 Hectorpascal.”

1.8 Aids to Navigation

Kudat Airport does not have any navigation aids. As such, all departures and

approaches are by visual reference only.

1.9 Communications and Radar Data Kudat Airport Tower is equipped with HF Radio System. The radio is operated

by Malaysia Airports Berhad (MAB) personnel.



Prior to the accident, there was no distress or emergency call received by Air

Traffic Control or by any other aircraft on the frequency.

The emergency call was transmitted to Kota Kinabalu Tower by Kudat Tower

personnel upon witnessing the accident.

1.10 Aerodrome Information

Runway Direction 04 / 22 Runway Length 730 Meters Runway Width 18 Meters Elevation 03 Meters (10 feet) Wind Socks Available 02 (01 each at runway ends) Airport Fire and Rescue Services (AFRS) Nil

1.11 Flight Recorders The aircraft was not installed with Flight Recorders as they are not mandatory

to this aircraft; reference DCAM Airworthiness Notice No. 83.

1.12 Wreckage and Impact Information The aircraft stood park on the ground towards the left side of the house with

the right wing dislodged from the aircraft. The right engine was dislodged from

the wing and was found on the left side of the house. The right hand landing

gear was also dislodged from the aircraft and found on left side of the house.

The right main wheel was found lying on the middle side of the house.The

nose wheel was found by the side of the four wheel drive parked in the

garage.

Based on the Captain’s statement, he tried to initiate an engine shut down but

could not locate the power lever and fuel shut off valve as the top portion of

the cockpit where those levers were situated was torn off and missing.



1.13 Fire

There were no reports of in-flight or post impact fire.

Note: The left hand engine was running post-accident in excess of 1 hour.

The right hand engine had sheared off from the aircraft wing.

However, both the engine Fuel and Shut Off Valves were selected to the

‘OFF’ position and the fire handles were pulled. Pulling of the fire handle on

the DHC6 aircraft would initiate the firing of engine fire bottles to start

extinguishing the engine compartment.

Note: The selection of the Fuel Shut Off Valve to Off and the discharging of

the engine fire bottles were performed by the Airport Fire Rescue

Services (AFRS) team at the site upon obtaining clearance from Chief

Inspector, Aircraft Accident Investigation Bureau (AAIB), Ministry Of

Transport Malaysia.

1.14 Tests and Research a) Detail Examination of Components

The aircraft wreckage had been removed from the crash site and kept at a

secured warehouse approximately 5km from Kota Kinabalu International

Airport.

b) List of Components Removed:

The entire aircraft build inclusive of its airframe, engines, propellers and

avionic components are quarantined together with the wreckage.

c) List of engine component removed.

Pratt Whitney of Canada and AAIB Malaysia conducted a joint

examination after the tear down of the engine. Based on the Pratt

Whitney of Canada report, it is summarised that the both engines were

operating normally/satisfactorily above idle power. The actual power



setting cannot be determined due to the absence of FDR and CVR on the

aircraft.

1.15 Organisation and Management Based on discussions with the aircraft operator and meteorological report, the

aircraft have operated beyond company policies;

a) Operating crew has flown beyond its aircraft operating limitation i.e

maximum aircraft wind capability.

b) Operating crew did not identify threats and manage possible errors when

operating into Kudat airfield as stated in the company policies.

c) There is no in-house DHC6-310 aircraft simulator training facilities or

improved training aids for the flight crew to handle abnormal situations.

d) Operator’s operating policies and procedures were not consistent and not

well defined.

e) Based on discussion with the Airport Operator, the Air Traffic Service

personnel did not receive adequate training and the airport itself did not

have adequate facilities to handle aircraft operating into Kudat Airfield.

2. ANALYSIS

2.1 Crew Qualifications Both the Captain and the First Officer were recently qualified i.e. between 7

and 8 months as Twin Otter Captain and First Officer.

2.2 Airworthiness Certificate of the Aircraft The aircraft has a valid Certificate of Airworthiness and maintained by

Malaysian Airline System Engineering and Maintenance Division. The

maintenance base for this aircraft type is Kota Kinabalu as per DCA Approved

Maintenance Schedule. 9M-MDM had clocked-in 56828 hours and 108,882

cycles as of 09th October 2013.



The aircraft had undergone an Equalized Maintenance for Maximum

Availability (EMMA) Check Number 08 on 30th September 2013 at Kota

Kinabalu.

2.3 Flaps

The left-hand flap position conformed to the position of the flap actuator that

was in the aircraft cabin. With reference to the DHC6 Twin Otter Aircraft

Maintenance Manual, a full flaps down position would be indicated by a 3.4

inches exposure of the flap actuator ram inside the aircraft cabin roof area.

During the investigation, the actuator ram was found at approximately 3.3

inches. The right wing was detached together with the flap push rods during

the incident/ impact. As a result of the right-hand wing’s detachment, the

right-hand flaps no longer corresponded to the movement of the flap actuator

and were ‘floating’ freely.

The selector lever was found in the full up i.e. ‘0’ position in contrary to the

position of the left hand flaps which was still intact following the

impact/incident. The discrepancy noted could not be established for certain.

However, two possible reasons to this is either the flap selector was selected

to the full up position by the crew during the ‘go around’ that was being

executed or the flap selector lever had slid up to the ‘0’ position due to the

impact. The flap selector lever moves on a corrugated plate. The corrugation

on the plate allowed the movement of the selector lever towards the flaps

up/retracted position without the need to depress the plunger on the selector

lever handle itself. The movement of the selector lever towards the flaps

down/extended position is not possible under normal condition without the

plunger on the selector lever being depressed.

The position of the flap selector valve which had the selector pulley and the

follow-up pulley were inspected during the investigation. The flap selector

pulley which moves in conjunction with the flap selector lever in the cockpit

was found to indicate a ‘flap up’ position which conforms and tallies with the

position of the flap selector lever. The flap follow up pulley however was



found at the flap fully down position which conforms and tallies with the

position of the left hand flap which indicated a full down position.

Under normal operation, when the flap selector lever is moved to a pre-

determined position during the flap selection, through the flap selection cable

system, the flap selector pulley is moved from the ‘null’ position to a new null

position. With the availability of hydraulic pressure, the hydraulic ports within

the selector valve are opened to allow pressure to move the actuator. The

movement of the actuator in turn would reposition the follow-up pulley

towards the ‘new null’ which was initially selected. The flap actuator

movement would stop when the follow-up pulley has reached the ‘new null’

position as selected in the selector pulley.

The DHC6-310 Twin Otter aircraft does have a system accumulator which to

a certain extent allows and assist in the operation of the hydraulic system

user i.e. flaps, brakes and steering. However, following the impact, the

hydraulic bay was completely damaged with broken plumbing and tubing thus

making the hydraulic accumulator pressure depleted and the system pressure

not available.

2.4 Propellers The left hand propeller was found in the ‘feathered’ position, which is the

normal condition when the engine is not in operation i.e. no oil pressure. The

propeller blades were actuated to the ‘feathered’ position by feathering spring

that is located within the propeller hub itself. The normal operation of the

propeller as described was observed on the left hand propeller correctly.

However, the same was not observed on the right hand propeller assembly.

The right hand propeller hub was inspected during propeller removal and the

propeller pitch change sliding ram was found pried out of the hub housing.



This is suspected to have been caused by extreme impact during the engine

and propeller free fall on to the ground upon the right hand engine nacelle

being liberated from the right hand wing.

The difference in the propeller lever position i.e. left hand propeller lever

being in the minimum position and the right hand propeller lever being in the

maximum position was suspected to have been caused by the migration of

the levers during the aircraft impact where the cockpit crown was ripped

upward and rearwards of the aircraft.

3. CONCLUSIONS

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 tail-

wind 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.

4. RECOMMENDATION

Based on the evidence gathered, the Accident Investigation Team

recommends the following to be implemented to prevent future air accidents:

a) Operation of Aircraft Outside Adverse Weather

Aircraft operating into Kudat when encountering adverse weather such

as gusty winds should be avoided. The current company policy on

adverse weather operation should be complied with.

b) Operation of Aircraft Within Aircraft Limitations

Flight Crew operating DHC6-310 Aircraft should be made more aware

and reminded of DHC6-310 Aircraft operating limitations like maximum

aircraft wind capability.

(Note: These company policies and procedures are already available)

c) Human factors

Flight Crew operating DHC6-310 Aircraft into new airfields should

identify threats and managing possible errors as stated in the company

policies. The threats identified during this accident were firstly,

Captain’s first in-command flying into Kudat airfield, secondly, the gusty

wind conditions at Kudat airfield and thirdly, the Captain was under

stress to land the aircraft safely after the first go-around.

d) Flight Crew Training



The Operator should include DHC6-310 aircraft simulator training or

improved training aids to enable flight crew to handle abnormal

situations, for example, strong or gusty wind conditions.

e) Operator’s organisation aspects

The Operator’s management should review Operator’s operating

policies and procedures to be consistent and well defined.

f) Flight Service provider

Kudat Airport should have adequately trained Air Traffic Service officer

and adequate facilities to handle aircraft operating into Kudat airfield.



Appendix

Photographs of Aircraft Wreckage



Figure 1: The first impact on the tree top

Figure 2: Blow up of the chopped tree

FFIRST IMPACT ON THE TREE TOP

BLOW UP OF THE CHOPPED TREE



Figure 3: The right main wheel found behind the house

Figure 4: Right engine found behind the house

THE RIGHT MAIN WHEEL



Figure 5: Right engine found behind the house

Figure 6: The nose wheel found in the garage

THE NOSE WHEEL



Figure 7: The aircraft crashed and lay rested on the ground

Attachment 1 – Captain’s LH Instrument Panel

AIRCRAFT FACING BACK TOWARDS RUNWAY AFTER IT RESTED ON THE GROUND



Attachment 2 – First Officer’s Instrument Panel

Attachment 3 – Cockpit Overhead Panel (Flap Lever,

Power Lever and Propeller Lever

Position)



Attachment 4 – LH wing (Flap Position)

Attachment 5 – RH Wing (Flap Position)

Attachment 6 – RH Wing (Flap Position)



Attachment 7 – Power Lever / Propeller Lever /

Fuel Lever (panel removed)

Attachment 8 – Flap Actuator (inside aircraft cabin)



Attachment 9 – LH Engine Assembly with Propeller



Aerial view of crash site with reference to Kudat Airport Runway

final aircraft accident report 04 december 2014

Documents