Final Elmina crash finds pilots were in wrong seats, pre-landing action cause of accident

Final Elmina crash finds pilots were in wrong seats, pre-landing action cause of accident

A file photograph show Fire and Rescue Department personnel putting out the fire at the crash site in Elmina, Shah Alam, August 17, 2023. — Bernama pic

Friday, 16 Aug 2024 3:55 PM MYT


KUALA LUMPUR, Aug 16 — The fatal plane crash last year in Bandar Elmina near Shah Alam, Selangor, was caused by the flight crew’s accidental or unintended action before the aircraft could land, and factors such as the two pilots being in the wrong seats, Malaysia’s air accident investigators said today.

In the final report released just a day before the one-year anniversary of the crash which killed all eight people on board, the Air Accident Investigation Bureau (AAIB) concluded that this accident is coded as “Loss of Control – Inflight (LOC-I)”.

The report said the main cause of the crash was due to the flight crew’s “inadvertent” extension of the lift dump spoilers, while performing the “Before Landing” checklist. It said this action was most likely by the pilot who was second-in-command.

“This action led to a sudden loss of lift, resulting in catastrophic loss of control and the subsequent crash,” it said.

The report also listed four contributing factors, including the two pilots not sitting according to the airplane’s flight manual:

• Not following seating protocols: The Pilot-in-Command was supposed to be sitting in the left-hand seat, according to the flight manual. But during this flight, the Pilot-in-Command was sitting in the right-hand seat, and his Second-in-Command was sitting in the left-hand seat. “This deviation likely contributed to ineffective crew resource management and communication,” the report said.
• Inadequate crew training and awareness
• Regulatory grey areas and oversight gaps
• Ineffective communication and decision-making

Recommended reading:

Elmina crash: Early report finds no evidence of flight crew being incapacitated or affected physiologically

MORE TO COME

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kt comments:

I had the sad misfortune of viewing the video (probably taken by a phone camera on the ground) showing the final moments of the plane, as it turned onto the final approach (for landing). 

What I saw was the aeroplane kept on "rolling" as well as turning to line up on the final approach. Yes, the plane "rolled" HORRIBLY towards an inverted position and presumably would have kept on "rolling" (to upright) if there was enough airspace BUT alas in an almost or virtually inverted position it met (crashed onto) the ground.

Only 3 controls could have caused that fatal irrecoverable "roll', namely:

(a) as I had originally suspected, the landing flaps lowing in an asymmetric configuration, causing a 'roll' more humongous that that by activation of ailerons,

(b) activation (raising) of lift dump spoilers in an asymmetric configuration, which effect would have been the same as that of ailerons being activated or asymmetric flaps being lowered

In above diagram, the "roll" (resultant motion) to the right is caused by asymmetric spoilers activated in "right spoiler deployed & left spoilers stowed", whilst the accident case under discussion was probably the other way around.

Spoilers are usually fitted to high speed jet aircraft as they are more effective and efficient than ailerons themselves (no adverse aileron yaw, more instantaneous response to input), but the spoilers as a "rolling" control would NOT normally be used during the landing phase. During a landing phase, spoilers are activated symmetrically (not asymmetrically) to reduce speed rapidly during the landing roll,

(c) pilot's input to ailerons to "roll" the aircraft, but the degree and magnitude of that fatal "rolling' was way beyond normal pilot's input - anyway which pilot would be that suicidal to input such a fatal roll?

Secondly, the pilots being not in the expected-normal positions would not be a fatal mistake, as experienced pilots who have been "right-hand seat" qualified could be in the copilot seat whilst supervising a new pilot (training for command) in the left-hand seat. The report's “This deviation likely contributed to ineffective crew resource management and communication” is nonsense, as are the other "vague" kerbau's.

I am NOT satisfied with the vague non-informative report - MOST unhelpful, and sadly in saying so, as expected in Bolihland.