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“This action led to a sudden loss of lift, resulting in catastrophic loss of control and the subsequent crash,” the AAIB said in its final report on the crash, adding that it believed the co-pilot made the fatal error.
The report released today also highlighted a number of other contributing factors that led to the crash which killed 10 people including Pahang executive councillor and Pelangai assemblyman Johari Harun.
These included the flight crew sitting in the wrong seats, which the AAIB said would have likely contributed to ineffective crew resource management and communication.
“(There was) insufficient crew training and awareness about the operation of the lift dump system. The co-pilot’s unfamiliarity with the specific risks associated with the lift dump system led to the inadvertent extension of the spoilers,” the report said.
“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,” the report said.
The AAIB recommended that aircraft operator Jet Valet Sdn Bhd should enhance training programmes for all crew members with an emphasis on proper checklist procedures, crew resource management and adherence to protocol.
“Special attention should be given to unfamiliar systems and the operation of critical functions such as the lift dump system.
“Jet Valet Sdn Bhd should review and update operational procedures to include clear warnings and briefings on critical systems, such as the lift dump system, to ensure all crew members are fully aware of associated risks and procedures for safe operation,” the AAIB said.
It also highlighted regulatory grey areas and organisational practices, which compromised safety oversight and compliance.
“The aircraft operator failed to obtain necessary approvals for non-scheduled air services and comply with Malaysian regulations.
“Jet Valet Sdn Bhd must ensure full compliance with civil aviation regulations, including obtaining necessary approvals for non-scheduled air services and adhering to seating protocols outlined in aircraft manuals.
“Ineffective communication and decision-making processes were evident during critical phases of the flight.”
The board said Koperasi Amanah Pelaburan Berhad and Jet Valet should implement a robust safety management system, promoting a culture of transparency, accountability and continuous improvement, including clear lines of responsibility, improving communication channels, and conducting regular safety audits and assessments.
The report concluded by saying that the Civil Aviation Authority of Malaysia should review the current regulatory framework to provide an appropriate level of oversight of foreign aircraft by licensed foreign aircrew to ensure safe operations.
“This review should include an assessment of licensing requirements, training standards and operational protocols,” the AAIB said.
On Aug 17, 2023, the business jet with eight people on board crashed off the Guthrie Corridor Expressway in Bandar Elmina. Among the 10 killed were two road users.
The aircraft, a Beechcraft Premier 1, was flying from Langkawi to Subang airport. It had been cleared to land at 2.48pm but crashed two minutes later.
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