PILOST
3rd Mar 2001, 08:46
Posted below is the article from Star newspaper.
Agusta A 109E 9M - DRB helicopter Crash Tragedy at Kampung Sungai Damak, Jerangsang, Benta, Kuala Lipis, Pahang Darul Makmur on March 3 1997
Magistrate's Court Kuala Lipis Inquest No: 88-2-99
Magistrate's Court Kuala Lipis Inquest No: 88-1-99
Magistrate's Court Kuala Lipis Inquest No: 88-3-99
(LMM 3/97: TAN SRI YAHYA ÜAHMAD{M=¤
LMM 4/97 : AZLIZAN ABDUL ÜMANAS{M=¤
LMM 5/97 : PUAN SRI ROHANA ÜOTHMAN){M=¤
The Court's Decision:
This inquest is the result of the crash of Agusta A 109E Power helicopter at Kampung Sungai Damak, Jerangsang, Benta, Kuala Lipis, Pahang at 11.15pm on 3/3/1997 where all three victims perished.
Based on the facts of the case, Helicopter 9M-DRB Agusta A 109E Power, owned by Gadek Aviation Services Sdn Bhd commenced its flight from the "Segambut Helipad'' at 10.45pm carrying three (3) passengers and was scheduled to land in Kuala Terengganu at 11.45pm. According to the Flight Plan, the helicopter was using the Whisky 526 route with minimum altitude of 9,000 feet and a radial interception of 038 degrees from VBA Batu Arang. Based on the radar, the helicopter looked like it had veered right from the route at 11.11pm and disappeared from the radar screen at 11.13pm. The helicopter was recorded as having crashed at 11.15pm, on 3/3/1997 at Kg. Atong, Sungai Damak, Jerangsang, Benta, Kuala Lipis.
The purpose of this inquest, based on Section 333 (1) and 339 (1) Criminal Procedure Code is to identify:
(a) The cause and reason for the crash;
(b) Reason and nature of the deaths of the victims involved: and
(c) Whether the deaths and the crash were caused by any act or ommission contrary to the law.
In the air crash tragedy of Helicopter A109E, the Court is satisfied, based on the overall evidence, that all the victims involved and who were killed were Tan Sri Yahya Abroad, Mejar (B) Azlizan Abdul Manas and Puan Sri Rohana Othman.
In determining the cause of the deaths, the testimonies of SI 7, Dato Dr. Abdul Karim Tajudin including the post-mortem reports for each victim (P23, P24 & P25), showed clearly that all the victims were killed as a result of multiple injuries resulting from the crash. The injuries were also consistent with injuries sustained in a helicopter crash. From the evidence, the Court is also satisfied that the fatal injuries occurred after the helicopter crashed and exploded.
To ascertain the cause and reason for the crash, court was supplied with evidence from concerning various aspects, including the mechanical (equipment, component and engine), flight safety, flight cistern and the victims' and pilot's positions.
In investigating the cause of the tragedy, an investigative team was set up by the Department of Civil Aviation (DCA) as specified under the Malaysian Civil Aviation Regulations 1996 which was headed by Kapt. Yahya Abdul Rahman (SI9) and aided by Suhaimi Abdul Ghani (SI8) as well as other officers. The results of this investigation has been presented in Court as P35.
According to DCA investigations, the crash could have been largely caused by a combination of the following factors:
(a) The Commander was disoriented after the helicopter veered suddenly to the right and he was then unable to control the helicopter by referring to the flight instruments.
(b) The Commander was unable to veer the helicoper back to its course from the extraordinary height using the flight instruments.
(c) The use of the "override facility'' by the Commander in trying to bring the helicopter under control resulted in "overfuelling'' and damage to both the engines.
(d) The extra working hours of the Commander had diminished his competency and ability in controlling the situation.
Taking into consideration the investigations and the evidence which was adduced in court, the court is satisified and of the opinion that:-
(1) Mechanical Aspect:
The court is satisfied, based on the evidence, that there were several faults with the Augusta A109E helicoper prior the crash. The 'List of Malfunctions" in Appendix M, P35 as well as documents tabled by Agusta itself (P50) dan engine manufacturers, Pratt & Whitney (P71), confirm this.
However, the court is satisfied based on the reports and evidence adduced that most of the components or equipment in the said helicopter were still functioning and normal at the time of the incident with the exception of the equipment or components which were damaged in the crash. In other words, there was no evidence to suggest any failure or fault in the equipment or component in the helicopter during the flight on that night.
As for a radio or emergency call, the court is satisfied that none was made by the pilot/passengers before the helicopter crashed.
The court agrees that there is no evidence which can determine the condition of the radio after the last call by the pilot to Sector 3 at 11.04pm. Investigations could not be undertaken as the radio was damaged in the crash.
ENGINE:
The court agrees that before the crash, the helicopter engine faced intermittent "Electronic Engine Control" (ECU/EEC) problems. And up until the air crash, the manufacturers, Pratt & Whimey were unable to determine the source of the problem.
However, based on the evidence as a whole, the helicopter did not face any engine failure, during the flight, until the pilot damaged the two engines using the "overide facilities''.
(2) FLIGHT PATH/VOR SIGNALS:
Based on the facts and evidence, the A109E helicopter had used the Whisky 526 flight path with a radial interception of 038 degrees from Batu Arang. The flight was a night flight using the SVFR and IFR regulations.
The court is satisfiad that there was no report or evidence that the flight path was not safe for a helicopter flying at night using flight instruments.
Also, there is no evidence that the VOR (VHF Omni Range) signals were weak and could not be received by any aircraft using the same flight path on the night of the incident.
The court was unable to enact the flight through IFR because the A109E helicopter is not available in Malaysia currently.
Based on the evidence adduced, the court cannot fully accept a theory that because of weak VOR signals or failure to receive the signals, the pilot to veer left suddenly from the original flight path resulting in spatial disorientation and the crash.
The condition of the additional navigational equipment such as the Global Positioning System or radio--which could have been of assistance to the pilot--at the material time could not be determined because they were damaged as a result of the crash.
(3) MAINTENANCE:
The maintenance and supervision of the A109E Helicopter was clearly the responsibility of its owner i.e Gadek Aviation Services Sdn Bhd. Based on the evidence, the court is satisfied that the maintenance of the helicopter was not properly done.
It is clear that the Chief Engineer (SI 10) and technician (SI 11) did not have the qualification/certificates issued by the DCA to supervise the AI09E helicopter. The owner, Gadek Aviation Services Sdn Bhd, also did not have any qualified engineer to maintain the helicopter and relied on Agusta's South East Asia representative Massimo Tosso, (SI 12) and Mofaz Air as a Service Centre. However, there was no agreement or maintenance contract between Gadek and Mofaz Air. The evidence showed that the helicopter was certified by SI 12 and the pilot, Mejar (R) Azlizan, himself.
The negligence of the Chief Engineer to document a proper and complete maintenance record including a copy of the helicopter's "Technical Log Book" resulted in investigations not being able to be carried out into helicopter's history and performance.
(4) PILOT/FLYING OF THE HELICOPTER:
PILOT
It cannot be denied that the pilot was responsible for ensuring the safety of each flight. Therefore, the court hhas tekn into consideration whether there was negligence or carelessness on the part of the pilot on the said flight.
From the evidence adduced, it cannot be determined whether it was Tan Sri Yahaya or Mej (R) Azlizan who flew the helicopter or was in full control of the helicopter on the night of the incident.
The evidence also failed to conclusively determine the position of the two at the material time.
Moreover, there are contradictions between SI7 and SI14, DSP Che Zaimani Che Awang, the investigating officer at the crash site, over the discovery of the "joystick'' on one of the bodies.
In this matter, the court, based on the evidence adduced, cannot arrive at a decision and delivers an open verdict.
SPATIAL DISORIENTATION
The court is satisfied that the evidence on the whole could not explain why the AI09E Helicopter had suddenly veered right 90 degrees off its path.
The court was presented with several possibilities, assumptions, theories and simulations for the pilot's action. However, none of the possibilities, assumptions, theories or simulations could satisfy the court in coming to an accurate finding and so I give an open verdict.
However, taking into consideration the the DCA's investigations and the evidence as a whole on the spatial disorientation experienced by the pilot, the court is satisfied that the spatial disorientation only occured after the right turn was made. The court also agrees that the spatial disorientation experienced by the pilot, second before the crash, is only a contributing factor to the crash.
On the issue of whether there were elements of FOUL-PLAY, SCHEMING OR SABOTAGE, the Court is satisfied, on the evidence adduced, that there is no evidence for the court to conclude that any of these took place in this air crash.
The Court agrees that the security level where the A109 helicopter was kept (Segambut Helipad) was unsatisfactory. Nevertheless, there is no proof, either from police investigations or the DCA, for the Court to conclude that there was trespass or sabotage by anyone.
Apart from that, the Court accepts the evidence of chemist Chee Ong Koh (SP 6) and his report (P22) which certified that there was no evidence of damage or foreign elements consistent with being caused by any explosives in the crash. The Court is satisfied that there is no sign that the helicopter exploded while in flight.
With regards to the pistol (P9) and magazine (P11) which were found, the Court accpets wholly the evidence adduced that there was no evidence of a shooting either before or during the crash.
With this, the Court concludes, on the evidence adduced, that the cause of death of the victims was not due to foul-play, a scheme or sabotage by any party.
IN CONCLUSION, the Court is satisfied, on the evidence adduced, that the 9MDRB A 109E Helicopter crash had no elements of foul-play, scheming or sabotage by any party which caused the deaths of the three victims.
However, based on the evidence, the Court cannot determine the actual cause of the crash.
It is the opinion of the court that air crashes are not common unlike the road accidents which occur daily. As such, the Court, based on the grounds given earlier, has no choice but to return an OPEN VERDICT in the cause of the 9M-DRB Agusta AI09E Power helicopter crash.
With this, the Court orders LMM 3, 4 & 5/97 along with any exhibits which were tendered to be returned to the Malaysian Public Prosecutor for further action.
Finally, I would like to record my sincere gratitude to all parties involved, including the Deputy Public Prosecutor Mohd. Shariff Abu Samah who was assisted by ASP Kamarudin Mohd Zakaria, Mubashir Mubashir Mansor and Treveor J.M. Padasian who held watching brief for Agusta s.p.a., Dato Ramiah Anpalagan and Moses Susayan for the family of the late Tan Sri Yahya Ahmad & Puan Sri Rohana Othman, Cik Looi Pek Hong for Pratt & Whitney and Sha****ala Sharma for Gadek Aviation Services Sdn Bhd., all of whom assisted the Court immensely in conducting this inquest.
Thank you.
http://thestar.com.my/news/story.asp?file=/2001/3/2/nation/sj1&sec=nation
Agusta A 109E 9M - DRB helicopter Crash Tragedy at Kampung Sungai Damak, Jerangsang, Benta, Kuala Lipis, Pahang Darul Makmur on March 3 1997
Magistrate's Court Kuala Lipis Inquest No: 88-2-99
Magistrate's Court Kuala Lipis Inquest No: 88-1-99
Magistrate's Court Kuala Lipis Inquest No: 88-3-99
(LMM 3/97: TAN SRI YAHYA ÜAHMAD{M=¤
LMM 4/97 : AZLIZAN ABDUL ÜMANAS{M=¤
LMM 5/97 : PUAN SRI ROHANA ÜOTHMAN){M=¤
The Court's Decision:
This inquest is the result of the crash of Agusta A 109E Power helicopter at Kampung Sungai Damak, Jerangsang, Benta, Kuala Lipis, Pahang at 11.15pm on 3/3/1997 where all three victims perished.
Based on the facts of the case, Helicopter 9M-DRB Agusta A 109E Power, owned by Gadek Aviation Services Sdn Bhd commenced its flight from the "Segambut Helipad'' at 10.45pm carrying three (3) passengers and was scheduled to land in Kuala Terengganu at 11.45pm. According to the Flight Plan, the helicopter was using the Whisky 526 route with minimum altitude of 9,000 feet and a radial interception of 038 degrees from VBA Batu Arang. Based on the radar, the helicopter looked like it had veered right from the route at 11.11pm and disappeared from the radar screen at 11.13pm. The helicopter was recorded as having crashed at 11.15pm, on 3/3/1997 at Kg. Atong, Sungai Damak, Jerangsang, Benta, Kuala Lipis.
The purpose of this inquest, based on Section 333 (1) and 339 (1) Criminal Procedure Code is to identify:
(a) The cause and reason for the crash;
(b) Reason and nature of the deaths of the victims involved: and
(c) Whether the deaths and the crash were caused by any act or ommission contrary to the law.
In the air crash tragedy of Helicopter A109E, the Court is satisfied, based on the overall evidence, that all the victims involved and who were killed were Tan Sri Yahya Abroad, Mejar (B) Azlizan Abdul Manas and Puan Sri Rohana Othman.
In determining the cause of the deaths, the testimonies of SI 7, Dato Dr. Abdul Karim Tajudin including the post-mortem reports for each victim (P23, P24 & P25), showed clearly that all the victims were killed as a result of multiple injuries resulting from the crash. The injuries were also consistent with injuries sustained in a helicopter crash. From the evidence, the Court is also satisfied that the fatal injuries occurred after the helicopter crashed and exploded.
To ascertain the cause and reason for the crash, court was supplied with evidence from concerning various aspects, including the mechanical (equipment, component and engine), flight safety, flight cistern and the victims' and pilot's positions.
In investigating the cause of the tragedy, an investigative team was set up by the Department of Civil Aviation (DCA) as specified under the Malaysian Civil Aviation Regulations 1996 which was headed by Kapt. Yahya Abdul Rahman (SI9) and aided by Suhaimi Abdul Ghani (SI8) as well as other officers. The results of this investigation has been presented in Court as P35.
According to DCA investigations, the crash could have been largely caused by a combination of the following factors:
(a) The Commander was disoriented after the helicopter veered suddenly to the right and he was then unable to control the helicopter by referring to the flight instruments.
(b) The Commander was unable to veer the helicoper back to its course from the extraordinary height using the flight instruments.
(c) The use of the "override facility'' by the Commander in trying to bring the helicopter under control resulted in "overfuelling'' and damage to both the engines.
(d) The extra working hours of the Commander had diminished his competency and ability in controlling the situation.
Taking into consideration the investigations and the evidence which was adduced in court, the court is satisified and of the opinion that:-
(1) Mechanical Aspect:
The court is satisfied, based on the evidence, that there were several faults with the Augusta A109E helicoper prior the crash. The 'List of Malfunctions" in Appendix M, P35 as well as documents tabled by Agusta itself (P50) dan engine manufacturers, Pratt & Whitney (P71), confirm this.
However, the court is satisfied based on the reports and evidence adduced that most of the components or equipment in the said helicopter were still functioning and normal at the time of the incident with the exception of the equipment or components which were damaged in the crash. In other words, there was no evidence to suggest any failure or fault in the equipment or component in the helicopter during the flight on that night.
As for a radio or emergency call, the court is satisfied that none was made by the pilot/passengers before the helicopter crashed.
The court agrees that there is no evidence which can determine the condition of the radio after the last call by the pilot to Sector 3 at 11.04pm. Investigations could not be undertaken as the radio was damaged in the crash.
ENGINE:
The court agrees that before the crash, the helicopter engine faced intermittent "Electronic Engine Control" (ECU/EEC) problems. And up until the air crash, the manufacturers, Pratt & Whimey were unable to determine the source of the problem.
However, based on the evidence as a whole, the helicopter did not face any engine failure, during the flight, until the pilot damaged the two engines using the "overide facilities''.
(2) FLIGHT PATH/VOR SIGNALS:
Based on the facts and evidence, the A109E helicopter had used the Whisky 526 flight path with a radial interception of 038 degrees from Batu Arang. The flight was a night flight using the SVFR and IFR regulations.
The court is satisfiad that there was no report or evidence that the flight path was not safe for a helicopter flying at night using flight instruments.
Also, there is no evidence that the VOR (VHF Omni Range) signals were weak and could not be received by any aircraft using the same flight path on the night of the incident.
The court was unable to enact the flight through IFR because the A109E helicopter is not available in Malaysia currently.
Based on the evidence adduced, the court cannot fully accept a theory that because of weak VOR signals or failure to receive the signals, the pilot to veer left suddenly from the original flight path resulting in spatial disorientation and the crash.
The condition of the additional navigational equipment such as the Global Positioning System or radio--which could have been of assistance to the pilot--at the material time could not be determined because they were damaged as a result of the crash.
(3) MAINTENANCE:
The maintenance and supervision of the A109E Helicopter was clearly the responsibility of its owner i.e Gadek Aviation Services Sdn Bhd. Based on the evidence, the court is satisfied that the maintenance of the helicopter was not properly done.
It is clear that the Chief Engineer (SI 10) and technician (SI 11) did not have the qualification/certificates issued by the DCA to supervise the AI09E helicopter. The owner, Gadek Aviation Services Sdn Bhd, also did not have any qualified engineer to maintain the helicopter and relied on Agusta's South East Asia representative Massimo Tosso, (SI 12) and Mofaz Air as a Service Centre. However, there was no agreement or maintenance contract between Gadek and Mofaz Air. The evidence showed that the helicopter was certified by SI 12 and the pilot, Mejar (R) Azlizan, himself.
The negligence of the Chief Engineer to document a proper and complete maintenance record including a copy of the helicopter's "Technical Log Book" resulted in investigations not being able to be carried out into helicopter's history and performance.
(4) PILOT/FLYING OF THE HELICOPTER:
PILOT
It cannot be denied that the pilot was responsible for ensuring the safety of each flight. Therefore, the court hhas tekn into consideration whether there was negligence or carelessness on the part of the pilot on the said flight.
From the evidence adduced, it cannot be determined whether it was Tan Sri Yahaya or Mej (R) Azlizan who flew the helicopter or was in full control of the helicopter on the night of the incident.
The evidence also failed to conclusively determine the position of the two at the material time.
Moreover, there are contradictions between SI7 and SI14, DSP Che Zaimani Che Awang, the investigating officer at the crash site, over the discovery of the "joystick'' on one of the bodies.
In this matter, the court, based on the evidence adduced, cannot arrive at a decision and delivers an open verdict.
SPATIAL DISORIENTATION
The court is satisfied that the evidence on the whole could not explain why the AI09E Helicopter had suddenly veered right 90 degrees off its path.
The court was presented with several possibilities, assumptions, theories and simulations for the pilot's action. However, none of the possibilities, assumptions, theories or simulations could satisfy the court in coming to an accurate finding and so I give an open verdict.
However, taking into consideration the the DCA's investigations and the evidence as a whole on the spatial disorientation experienced by the pilot, the court is satisfied that the spatial disorientation only occured after the right turn was made. The court also agrees that the spatial disorientation experienced by the pilot, second before the crash, is only a contributing factor to the crash.
On the issue of whether there were elements of FOUL-PLAY, SCHEMING OR SABOTAGE, the Court is satisfied, on the evidence adduced, that there is no evidence for the court to conclude that any of these took place in this air crash.
The Court agrees that the security level where the A109 helicopter was kept (Segambut Helipad) was unsatisfactory. Nevertheless, there is no proof, either from police investigations or the DCA, for the Court to conclude that there was trespass or sabotage by anyone.
Apart from that, the Court accepts the evidence of chemist Chee Ong Koh (SP 6) and his report (P22) which certified that there was no evidence of damage or foreign elements consistent with being caused by any explosives in the crash. The Court is satisfied that there is no sign that the helicopter exploded while in flight.
With regards to the pistol (P9) and magazine (P11) which were found, the Court accpets wholly the evidence adduced that there was no evidence of a shooting either before or during the crash.
With this, the Court concludes, on the evidence adduced, that the cause of death of the victims was not due to foul-play, a scheme or sabotage by any party.
IN CONCLUSION, the Court is satisfied, on the evidence adduced, that the 9MDRB A 109E Helicopter crash had no elements of foul-play, scheming or sabotage by any party which caused the deaths of the three victims.
However, based on the evidence, the Court cannot determine the actual cause of the crash.
It is the opinion of the court that air crashes are not common unlike the road accidents which occur daily. As such, the Court, based on the grounds given earlier, has no choice but to return an OPEN VERDICT in the cause of the 9M-DRB Agusta AI09E Power helicopter crash.
With this, the Court orders LMM 3, 4 & 5/97 along with any exhibits which were tendered to be returned to the Malaysian Public Prosecutor for further action.
Finally, I would like to record my sincere gratitude to all parties involved, including the Deputy Public Prosecutor Mohd. Shariff Abu Samah who was assisted by ASP Kamarudin Mohd Zakaria, Mubashir Mubashir Mansor and Treveor J.M. Padasian who held watching brief for Agusta s.p.a., Dato Ramiah Anpalagan and Moses Susayan for the family of the late Tan Sri Yahya Ahmad & Puan Sri Rohana Othman, Cik Looi Pek Hong for Pratt & Whitney and Sha****ala Sharma for Gadek Aviation Services Sdn Bhd., all of whom assisted the Court immensely in conducting this inquest.
Thank you.
http://thestar.com.my/news/story.asp?file=/2001/3/2/nation/sj1&sec=nation