Its Controlled Flight Into Terrain, The Board Says

KUALA LUMPUR: The investigation into the Nuri crash, without saying out loud, basically stated that the crash was due to the pilots mistakes.

Although, they were kind enough not to say it out loud that it was CFT, from what was reported it is clear that the board believes that the helicopter crash due to that reason and not to technical reasons.

However, without the benefit of cockpit and aircraft data recorders, it remained to be seen whether or not the families of the crew and RMAF pilots would contest the investigation. Nonetheless, Malaysian Defence believes the board had done its best even with its limitations.

Below is the Bernama story. Malaysian Defence hopes the report would be made available for the public just like the Auditor General report and not kept in a dark corner somewhere, so we all could learn from the incident and how the board investigate the crash.

–Malaysian Defence

Ill-Fated Nuri Copter Hit Canopy Of Trees Before Crash

General

September 27, 2007 20:52 PM

KUALA LUMPUR, Sept 27 (Bernama) — The Royal Malaysian Air Force (RMAF) Nuri helicopter which crashed in Genting Sempah in July hit the canopy of trees thrice while flying low over the area before going down, according to the report on the investigation into the incident released today.

Deputy Air Force Chief Lt Jen Datuk Bashir Abu Bakar said the investigation also found that bad weather, which had reduced visibility to less than two kilometres, and the hilly terrain in the area had also contributed to the mishap.

“The primary factor for the helicopter crash was that it hit the canopy of trees before crashing during the attempt to get across the Genting Sempah area,” he said when disclosing the report here.

The July 13 crash took the lives of the pilot, Capt Nor Azlan Termuzi, 29, co-pilot Capt Nor Intan Asykeen Moh Arof, 27, Flight Sergeant Khusnizaim Ariffin, 34, and Mohd Azmi Md Yassin, 35, Senior Airman Saifulizam Alias, 28, and Muhammad Ridzuan Ahmad, 27.

The helicopter was flying from the RMAF airbase in Sungai Besi to Kuantan when the accident happened.

Bashir said there was no evidence pointing to any technical fault in the helicopter, and that the investigation did not show up evidence of the engine and gearbox having caught fire.

“The probe team conducted various tests and analyses on several important components, such as the engine and gearbox. Analyses were also done of oil samples, and hydraulic fluid and lubricants.

“The analyses and engineering reports showed that there was nothing wrong in the samples and there was no evidence of any technical problem with the aircraft,” he said.


He also said that two witnesses had seen the ill-fated helicopter flying low.


“At 9.35am, an officer of the Orang Asli Affairs Department in Gombak saw the helicopter flying low in heavy mist. The other witness, an RMAF officer, saw the Nuri making a left turn at bearing 280 degrees,” he said.


Bashir said the pilot of the helicopter had decided to continue flying despite being aware of the bad weather.

He said the pilot should have checked on the weather and sought a safe altitude and not fly low in the heavy mist.

“The pilot should have turned back in such weather and there should have been awareness. The RMAF has decided to provide situational-awareness training for pilots to enable them make (the right) decisions during flights and emergencies,” he said.

The RMAF investigation panel was led by Lt Col Syed Islam Shahajam with Lt Col (Dr) Zuki Othman, Major Yee Ching Choy and Major Muhd Noorafzanidzam Frienney Salleh as the members.

— BERNAMA

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2 Comments

  1. The recent Nuri accident created public interest because of wide media coverage.

    The inability to immediately locate (not the first time) the ill-fated aircraft has resulted in the decision to install ELT in RMAF aircraft.

    A wise decision.

    It’s now known that the accident was a CFIT (Controlled Flight into Terrain). Considering that the weather (low clouds covering parts of the main range) was known to the pilot and his decision to undertake the trip to Kuantan at low level, it’s is correct for the Investigation Board to say that Commander of the flight made the wrong decision when he could have flown at a minimum safe altitude (10,000 ft) for that journey. The pilot was also blamed for his poor situation awareness. He could have turned around and returned to base when he experienced adverse weather near the main range.

    The RMAF has decided to provide situational-awareness training for pilots to enable them make (the right) decisions during flights and emergencies.

    Another good decision.

    My criticism is why must the pilots pay in blood before the RMAF decide to implement corrective actions? It’s a case of fighting fire instead of preventing fire. Could their management be more proactive in safety matters?

    There were a few Nuri crashes earlier in Sarawak, where the crew could not be located until a few days later. Different places but similar situation to that of the latest Nuri crash.

    You see, a more powerful aircraft-fitted gravity-activated ELT could have been installed long ago instead of relying on the less powerful personal SARBE, which is useless anyway if all the crew are dead on impact.

    Why must there be several crashes before the decision to equipped aircraft with ELTs.

    Decision Making and Situational Awareness are two of the important subjects taught in CRM (Crew Resource Management) courses.

    CRM training is a Civil Aviation Authority mandated course for all commercial airline pilots, not only here in Malaysia but worldwide, as recommended by the International Civil Aviation Organization (ICAO). It came about after research by NASA indicated that 80% of aircraft crashes were “Human Error” related and only 20% were attributed to the weather, aircraft design, aircraft systems and automation.

    CRM training will not prevent accidents from happening, for as long as there is human performance there will ever be human errors. The main aim of CRM training is the reduction of accidents due to human errors.

    Here in Malaysia, CRM training has been available for the last 15 years or so.

    The RMAF is not subjected to regulations of the Civil Aviation Authority; therefore attending CRM courses is not a must for their aircrew. It would be entirely up to their Management to evaluate the worthiness of such a course. If they have been proactive, perhaps they could have discovered the value of such course for their organisation a long, long time ago, ages before the latest Nuri accident.

    Is the Nuri accident a tip of the iceberg? Are there many more aircraft accidents or incidences in the RMAF, which are ‘human error’ related and unknown to the general public?

    If there are, then it’s high time that remedial action be taken to save the unnecessary waste and destruction of assets paid for by the tax-payers.

    Lastly, it’s only human that the parents of the unfortunate aircrew do not agree with the Investigation Board’s findings, especially when the ill-fated crew are not around to tell their story.

    If there had been a black-box (FDR-CVR) installed on the Nuri, recorded data with regards to the performance of the aircraft itself, the functionality of its engines, aircraft systems, etc, at the time of impact, would be made available to the investigators. The analysis of the accident would perhaps be more precise and accurate than what had been reported. Additionally, the Cockpit Voice Recorder would reveal the conversation of the crew during the last 30 minutes before impact. What really transpired in the cockpit? What were the crew discussing before the impact?

    It’s doesn’t cost much to install FDR/CRV in the relevant RMAF aircraft, especially those that are passengers carrying. It’ll definitely enhance the accuracy of their investigation in pinpointing the real cause of an accident or incident.

    We pray for the well-being of all RMAF aircrew and passengers and we hope that aircraft accident would be a rare occurrence in the RMAF soon.

  2. As far as I know most of the crashes involving Hawks off Kuantan the last three years were quietly attributed to CFT. The jets crashed into the sea while flying at low level, it must be noted that the aircrew were junior pilots trying to get more hours on the planes and moving off to other aircraft.

    On the CVR/CDR I was informed that the reason for deleting it during the upgrade in the late 80/90s was cost, the Nuri was not even fitted with auto-hover to save money. Now it apart from the ELT, with the Nuri being retired soon, I do not think anyone in RMAF would dare to ask that the CVR/CDR be installed in the active fleet.

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