MASWings DHC6 at Kudat on Oct 10th 2013, impacted house

Last Update: July 30, 2015 / 14:33:50 GMT/Zulu time

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Incident Facts

Date of incident
Oct 10, 2013

Classification
Accident

Airline
MASWings

Flight number
MH-3002

Departure
Kota Kinabalu, Malaysia

Destination
Kudat, Malaysia

Aircraft Registration
9M-MDM

Aircraft Type
De Havilland DHC-6 Twin Otter

ICAO Type Designator
DHC6

A MASWings de Havilland Dash 6-300 Twin Otter, registration 9M-MDM performing flight MH-3002 from Kota Kinabalu to Kudat (Malaysia) with 14 passengers and 2 crew, was on its second approach about to land on Kudat's runway 22 in strong gusting winds at about 14:50L (06:50Z) but impacted a private property's house, contacted ground outside the airport perimeter and went through the property's wall. The first officer and a passenger died in the accident, 8 occupants received injuries.

In their first statement the airline reported the aircraft "landed short of the runway in Kudat".

In their third statement the airline confirmed 9M-MDM was involved in an accident near Kudat at about 14:50L but reports no further details anymore. The airline confirmed one fatality and 5 injuries as result of the accident.

Following the airline's third statement confirming one fatality it became known the first officer had also passed away in hospital.

There were conflicting reports whether the aircraft suffered the accident while landing arriving from Kota Kinabalu scheduled arrival at 14:45L or departing for its onward leg to Sandakan scheduled to depart at 15:00L.

Kudat police reported a male passenger (90) died in the accident, the first officer succumbed to his critical injuries in hospital care. One more person received critical injuries. Three others received serious but not life threatening injuries.

On Oct 12th 2013 Malaysia's Accident Investigators confirmed a passenger (69) and the first officer (22) died in hospital a few hours after the accident. All occupants, 14 passengers and 2 crew, were taken to hospitals. The aircraft was on its second approach to Kudat when it veered off its approach path. The investigation is hampered by the total destruction of the cockpit, parts of the aircraft are strewn all around the house the aircraft impacted. Several theories are currently being developed and investigated as to how the aircraft got into the position it ended up in. The investigation will take time.

The regional health department reported 6 occuptants were already discharged after observation, 8 occupants remain in hospital care and are in stable condition.

The airline reported the captain had 4,700 total flying hours of experience, the aircraft had been well maintained. The airline is already in talks with all affected including the owner of the house, that was damaged by the accident.

In Jul 2015 Malaysia's Ministry of Transport released their final report concluding the probable causes of the accident were:

Based on the information from the recorded statements of witnesses and Captain of the aircraft, it clearly indicates that the aircraft was attempting to land on Runway 04 with a tail-wind blowing at 270° 15kts gusting up to 25kts on the first approach, contrary to what was reported by the Captain to the investigators. The demonstrated cross wind landing on the DHC6-310 is 25kts and tailwind landing is 10kts. The aircraft was unsettled and unstable until it passed abeam the terminal building which was not the normal touch down point under normal landing condition.

The flap setting on the first approach with the tail-wind condition was at 10°, which is not in accordance with company’s procedures. A tail wind landing condition that will satisfy the criteria for the DHC6-310 is not more than 10kts tail-wind and a flap setting of not more than 20°. One of the stabilized approach criterias for visual conditions (VMC) into Kudat is landing configuration must be completed by 500ft Above Ground Level (AGL) for the DHC6-310 where else if the above conditions could not be met, a go-around should be initiated.

Hence, the Crew should have initiated a go-around earlier before the aircraft reached 500ft AGL on the first approach. The aircraft should be in the correct landing configuration at or below the stabilized approach altitude of 500ft AGL, since the aircraft was not stable due to the tail wind and gusting weather. The procedure carried out on the approach for Runway 04 was not consistent with MASwings’ Standard Operating Procedure (SOP) for a tail-wind condition. Nonetheless, the first approach for Runway 04 though was uneventful.

On the second approach from Runway 22, the wind condition was still not favorable for landing, and gusting. The aircraft was believed to be slightly low on the initial approach and was still unstable. The flap setting for the second approach for Runway 22 was at full flap (37°). As the wind was gusting, a flap setting to full-down should be avoided for the landing as stated in company’s DHC6-310 SOP. With the full-flap configuration, the aircraft had difficulty to settle down on the runway thus dragging the aircraft until abeam the tower which is way beyond the normal touch down zone.

At the point where the aircraft was approaching to land it was reported that the aircraft was hit by a sudden gust, several factors, including the following, have been looked into:

a) Why was the aircraft unable to climb after initiating the go-around?

The full flap setting would require a zero degree pitch attitude to ensure the aircraft speed is maintained. With go-around power set, the zero degree pitch would ensure a climb without speed loss. A pitch above zero degree can cause the aircraft speed to decrease and induce a stall condition resulting in the aircraft being unable to climb.

b) Was the go-around technique executed correctly, taking into consideration that the wind was blowing from 270° and gusting?

The Captain had said that “I applied maximum power and expected the aircraft to climb. At this point, the aircraft was still in left-wing high situation. I noticed the aircraft did make a climb but it was a shallow climb. I did not retract the flaps to 20°, as at that time, in my mind, the aircraft was still low.”

c) Under normal conditions, the rule of thumb for initiating a go-around procedure is to apply maximum power, set attitude to climb, confirm airspeed increasing and reduce the flap setting. This procedure was found not to be properly synchronized between MASwings Manuals and DHC6-310 Series 300 SOP.

d) Were the pilots in control of the aircraft?

Based on the Captain’s statement and other associated factors, the pilots were not in total control of the aircraft.

Malaysia's Air Accident Investigation Board (MAAIB) reported the captain (56, ATPL, 4,740 hours total, 807 hours on type) was pilot flying, the first officer (22, CPL, 651 hours total, 400 hours on type) was pilot monitoring. When the aircraft approached Kudat tower reported winds from 270 degrees gusting up to 31 knots, the captain performed an approach to runway 04 and set flaps to 10 degrees. When levelling off at 500 feet AGL the crew noticed they had a strong tail wind prompting the crew to go around, climb to 1000 feet AGL and perform a tear drop procedure to land on runway 22. While on approach to runway 22 the captain indicated that if they couldn't make the landing they would return to Kota Kinabalu.

Flaps were set to 20 degrees this time, the aircraft descended to 300 feet AGL, the winds appeared to be calm at that point and the captain announced he was committed to land. Descending through 200 feet AGL the flaps were fully extended (37 degrees).

When the aircraft commenced the flare, about 20 feet above the runway based on the automated GPWS call, the aircraft was hit by a sudden gust causing it to yaw right and roll to the right. The captain applied maximum power, however, did not retract/reduce the flaps and did not roll the aircraft wings level. The aircraft therefore climbed only at a shallow rate of climb, could not clear the trees ahead in its flight trajectory, contacted the trees causing the airspeed to reduce and without further climb continued almost perpendicular to the runway center line at low height. The aircraft impacted another tree at the airport perimeter, began to descend, impacted another tree at the house, impacted the roof of the house ploughing through roof top, kitchen, toilet and dining area, hit a solid pillar of concrete at the house's garage, impacted a lamp post just outside the house's perimeter fence, swung back and came to a stop now facing towards the runway, the left engine was still running, right wing separated from the aircraft, right main and nose gear separated from the aircraft.

The captain regained consciousness and found the left engine was still running but could not find the levers for throttle and fuel cutoff because the top portion of the cockpit with those levers had been torn off and were missing. The engine continued to run in excess of one hour until emergency services, having obtained clearance from the MAAIB, pulled the fire handle.

In the cabin one passenger seat had separated from the cabin floor together with the passenger, the passenger was fatally injured. The other passengers escaped through the rear exit door. The flight crew was rescued by emergency services and rushed to hospital. The first officer succumbed to polytrauma injuries on Oct 10th 2013 as result of the impact forces.

5 passengers and the captain received serious injuries, 8 passengers received minor injuries.

The aircraft was destroyed. The building, the garage as well as two vehicles in the garage were substantially damaged.

Metars:
WBKT 100900Z 26010KT 230V300 9999 FEW014 BKN280 28/24 Q1008
WBKT 100800Z 27013G23KT 210V300 9999 SCT014 BKN280 29/24 Q1008
WBKT 100700Z 27017G31KT 210V300 9999 SCT014 BKN280 30/24 Q1008
WBKT 100600Z 27015G25KT 230V320 9999 FEW015 BKN280 31/24 Q1008
WBKT 100500Z 26012G22KT 210V300 9999 FEW015 SCT140 BKN280 31/24 Q1009
WBKT 100400Z 25014G28KT 190V300 9999 FEW015 SCT140 BKN280 31/23 Q1010
WBKT 100300Z 26012G22KT 210V340 9999 FEW015 SCT140 BKN280 31/24 Q1010
WBKT 100200Z 26011G21KT 210V340 9999 FEW015 SCT140 BKN270 30/23 Q1011
Incident Facts

Date of incident
Oct 10, 2013

Classification
Accident

Airline
MASWings

Flight number
MH-3002

Departure
Kota Kinabalu, Malaysia

Destination
Kudat, Malaysia

Aircraft Registration
9M-MDM

Aircraft Type
De Havilland DHC-6 Twin Otter

ICAO Type Designator
DHC6

This article is published under license from Avherald.com. © of text by Avherald.com.
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