A review of crew training and the regulatory framework are among the five key safety recommendations made by the Air Accident Investigation Bureau (AAIB) following its investigation into the Elmina plane crash.
The final report released by the Air Accident Investigation Bureau (AAIB), under Ministry of Transport Malaysia, found that the primary cause of the accident was the inadvertent extension of the lift dump spoilers, most likely by the pilot who was the second-in-command, during the Before Landing checks.
In the final report released on the Transport Ministry's website today, Jet Valet Sdn Bhd is also advised to improve its compliance with regulatory requirements, enhance organisational oversight, and refine its operational procedures.
The Beechcraft Model 390 crashed in Elmina, killing all eight on board (six passengers and two flight crew members), as well as one e-hailing driver and a p-hailing motorcyclist on the ground.
Jet Valet is the company operating the ill-fated aircraft during the tragedy, and the report emphasized on the review and reinforce crew training.
"For review and reinforce crew training, Jet Valet Sdn Bhd should enhance training programmes for all crew members, emphasising proper checklist procedures, crew resource management, and the criticality of adhering to established protocols."
"Special attention should be given to systems unfamiliarity and the operation of critical systems such as the lift dump system," the report said.
The cockpit voice recorder transcript, released today as part of the Air Accident Investigation Bureau's (AAIB) final report on the tragedy, indicated that the pilots were in communication with the Subang control tower just prior to landing.
As the aircraft approached the Sultan Abdul Aziz Shah Airport on the ill-fated day, it was cleared for landing by the control tower.
The transcript from the CVR of the Beechcraft Model 390 was not included in the preliminary incident report issued on September 15 last year.
The 148-page final report said the aircraft had an L3Harris FA2100 CVR, which was recovered and its data was successfully downloaded with technical assistance.
The plane’s cockpit voice recorder transcript, which is almost five minutes long, starts at 2.44pm and 30.9 seconds, ending at 2.49pm and 11.5 seconds (which is also when the recording ended). The report stated the crash as being around 2.49pm.
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The report said the company must ensure full compliance with civil aviation regulations in terms of compliance with regulatory requirements.
This, it said, should include obtaining necessary approvals for non-scheduled air services and adhering to seating protocols outlined in aircraft manuals.
"Regular audits and oversight should be conducted to identify and rectify any regulatory compliance gaps," it said.
The report suggested enhancing organisational oversight, where Koperasi Amanah Pelaburan Bhd and Jet Valet should implement a robust safety management system, promoting a culture of transparency, accountability, and continuous improvement.
The report also calls for the Civil Aviation Authority of Malaysia to review the current regulatory framework and appropriate level of oversight of foreign aircraft operations in Malaysia by foreign licensed aircrew to ensure safe operation.
The review should include an assessment of licensing requirements, training standards and operational protocols to ensure compliance with international aviation safety standards and mitigate risks associated with foreign aircraft operations.
Earlier, in the report, AAIB said the cause of the Elmina air crash that occurred last year was due to loss of control inflight.
The investigation into the accident involving N28JV, a Hawker Beechcraft Model 390 Premier 1, revealed several key findings, which can be seen in below order:
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.
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.
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 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.
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.
It found that the primary cause of the accident was the inadvertent extension of the lift dump spoilers, most likely by the pilot who was the second-in-command, during the Before Landing checks.
The accident was primarily caused by the inadvertent extension of the lift dump spoilers by the flight crew while performing the Before Landing checklist.
Contributing factors included deviations from standard operating procedures, inadequate crew training, regulatory grey areas, and deficiencies in communication and decision-making.
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Post investigation, below are the exact words of the safety recommendations proposed by AAIB, Malaysia:
Jet Valet Sdn Bhd should enhance training programmes for all crew members, emphasising proper checklist procedures, crew resource management, and the criticality of adhering to established protocols. Special attention should be given to systems unfamiliarity and the operation of critical systems such as the lift dump system.
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. Regular audits and oversight should be conducted to identify and rectify any regulatory compliance gaps.
Koperasi Amanah Pelaburan Berhad and Jet Valet Sdn Bhd should implement a robust safety management system, promoting a culture of transparency, accountability, and continuous improvement. This includes establishing clear lines of responsibility, improving communication channels, and conducting regular safety audits and assessments.
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 Civil Aviation Authority of Malaysia should review the current regulatory framework to provide an appropriate level of oversight of foreign aircraft operation in Malaysia by foreign licensed aircrew to ensure safe operation. This review should include an assessment of licensing requirements, training standards, and operational protocols to ensure compliance with international aviation safety standards and mitigate risks associated with foreign aircraft operation.
In the accident, the six-seater Beechcraft Model 390 Premier 1 aircraft bearing the registration number N28JV, crashed near Elmina, Shah Alam during its approach into Subang Airport from Langkawi on Aug 17 last year.
