Description

On 17 August 2023, a Hawker Beechcraft 390 Premier 1 (N28-JV) being operated by Malaysian private company Jet Valet on a non-scheduled domestic passenger flight from Langkawi to Subang had been cleared to land at destination in day VMC when it departed controlled flight and crashed. The aircraft was destroyed by a high energy ground impact as it initially crossed over a busy road and a subsequent post crash fire which killed the two pilots, all six passengers and two people on the ground - a car driver and motor cycle rider- whose respective conveyances were also destroyed.  

Investigation

An Accident Investigation was carried out by the Malaysia Air Accident Investigation Bureau (AAIB). The damaged 30 minute duration CVR was recovered from the accident site and its data were eventually successfully downloaded at the CVR manufacturer’s USA facilities after initial assistance from the Singapore Transport Safety Investigation Bureau (TSIB). An FDR was not installed on the aircraft and was not required to be. ADS-B data was available to show the terminal descent.

The 41 year-old male Captain had a total of 6,275 hours of flying experience which included 36 hours on type and held a corresponding type rating. The 44 year-old male co-pilot occupying the left hand seat had a total of 9,298 hours flying experience of which 3 hours were on type and only held a second-in-command rating for the Gulfstream IV. The same crew had also operated two domestic flights in the same aircraft the previous day (Subang to Kuantang and Kuantang to Langkawi) but other than these flights, the co-pilot had not previously operated on the aircraft type and had not received any formal training on it.

What Happened

The 45 minute flight from Langwaki to Subang proceeded normally with the Captain acting as PF (but occupying the right hand seat) until shortly after it had established on the NDB approach to runway 15 at Subang and requested and received landing clearance. Less than half a minute after acknowledging this clearance, it suddenly turned right away from the final approach track at a recorded altitude of 1,025 feet and descended at an average rate of 3,500 fpm at a calculated ground speed of between 146 and 154 knots for 8 seconds before ground impact. This began as it crossed a busy road on a westerly track, colliding with a car and a motor cycle as it did so. The distance between the initial impact point and the position where the main wreckage came to rest was approximately 73 metres. The impact led to an immediate and “massive” post crash fire which completed the destruction the aircraft. 

The impact location with the impact ground track (260°) visible. [Reproduced from the Official Report]

Why It Happened

A comprehensive examination of all the available evidence was able to eliminate any aircraft airworthiness, flight crew incapacitation or intentional flight crew failure to control the aircraft. It was possible, with the assistance of CVR data to conclude that a loss of control with insufficient time to recover had followed an unintended in-flight deployment of the ground spoilers (lift dumpers). This had followed the Captain’s request to the left hand seated co-pilot as the aircraft passed 1,000 feet to run the ‘Before Landing’ checks which included unlocking (but not deploying) the lift dumpers. CVR evidence confirmed that the lift dumpers had been unintentionally deployed by the left hand seated co-pilot without this being recognised by either pilot until the consequences followed. The five-item checklist (see below) included a prominent warning not to extend the lift dump in flight and there was also a placard stating “WARNING - DO NOT EXTEND IN FLIGHT” adjacent to the selector.

The Before Landing Checklist. [Reproduced from the Official Report]

It was also noted that a video recording obtained of the aircraft's approach showed a glare a few seconds before the aircraft began turning right and descending rapidly and it was concluded that this glare was likely to have been caused by the lift dump spoilers reflecting sunlight as they extended.

The fact that the Captain had permitted the unqualified co-pilot to occupy the left hand seat was found to have been contrary to the AFM Limitations which mandate that the appropriately rated pilot must occupy the left seat because only that seat provides the “optimal access to controls and instruments necessary for single-pilot operation”. It was considered that the non type-rated co-pilot “would not have been adequately prepared to manage these responsibilities, raising concerns about the decision to deviate from standard protocol”. It was also considered that this non-compliance could have had “implications for the overall safety and decision-making process during the flight (and) contributed to ineffective CRM thus potentially impacting the crew's ability to handle critical situations”.

The accident aircraft was one of three operated by Jet Valet, the others being a Hawker Beechcraft 4000 and a Gulfstream IV. All the aircraft were US-registered but used exclusively for fights within Malaysia on behalf of the aircraft operator’s owner, Koperasi Amanah Pelaburan, which had 12,000 individual members and provided them with access to domestic flight service. It was considered that the aircraft operator’s and owner’s organisational and management practices “including their exploitation of regulatory grey areas and (their) failure to obtain necessary approvals” coupled with the large membership base and associated high number of passengers carried necessitated “stringent adherence to regulatory standards to ensure safety”.

The Investigation found that although the accident aircraft was “explicitly intended to be based in Malaysia long-term” and had been in the country since May 2023, there was no evidence that any application had been made to the Civil Aviation Authority of Malaysia (CAAM) for Malaysian registration of the aircraft as required for foreign-registered aircraft operating in the country for more than six months. Nor was there any indication that Jet Valet had or intended to apply for the necessary approval from CAAM for non-scheduled air services and the carriage of passengers for payment in a foreign-registered aircraft.

The Cause of the accident was formally recorded as “primarily the inadvertent extension of the lift dump spoilers by the flight crew while performing the Before Landing Checklist”.

Four Contributory Factors were summarised as follows:

• Deviation from Seating Protocols: 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 occupying the left-hand seat contrary to the AFM which likely contributed to ineffective crew resource management and communication.
• Inadequate Crew Training and Awareness: Insufficient crew training and awareness regarding the operation of the lift dump system and 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 Oversight Gaps: 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.
• Communication and Decision-Making: 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.

A total of five Safety Recommendations were made as a result of the findings of the Investigation as follows:

• that Jet Valet 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.
• that Jet Valet 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.
• that Koperasi Amanah Pelaburan (as the aircraft owner) and Jet Valet 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.
• that Jet Valet 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.
• that 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.

The 148 page Final Report was issued on 16 August 2024.

Related Articles

• Loss of Control
• Safety Oversight
• Spoilers and Speedbrakes
• Checklists - Purpose and Use
• Decision-Making
• Safety Management System