‘Human Error’ Main Cause Of Chopper Crash
Posted on September 2, 2012, Sunday
BANDAR SERI BEGAWAN: “Human Error” was found to be the main factor contributing to the tragic Bell 212 helicopter accident that claimed the lives of 12 military personnel at Ulu Rampayoh in Mukim Labi in the Belait District in July, according to the Supreme Board of Inquiry (BOI) report compiled by the Royal Brunei Armed Forces (RBAF) with support from international experts, Borneo Bulletin reported.
Investigations revealed that the pilot of the helicopter contradicted flying procedures with “unauthorised low-level flying”, causing a “Controlled Flight into Terrain (CFIT)” accident.
The report also suggested that the Air Traffic Control Unit of the Department of Civil Aviation (DCA) had failed to follow aviation control procedures to alert relevant parties when the Bell 212′s radio communication went off the ‘Brunei Radar’.
These findings were made public by the Supreme BOI upon conclusion of its five-week long investigation at a press conference held at the Ministry of Defence (MinDef) in Bolkiah Garrison yesterday.
The press conference was chaired by the Deputy Minister of Defence, Dato Paduka Awang Haji Mustappa bin Haji Sirat along with the Commander of the Royal Brunei Armed Forces (RBAF), Major General Dato Paduka Seri Haji Aminuddin Ihsan bin Pehin Orang Kaya Saiful Mulok Dato Seri Paduka Haji Abidin.
In his detailed report presentation, First Admiral Dato Seri Pahlawan Hj Abd Halim bin Hj Mohd Hanifah, Commander of the Royal Brunei Navy who is leading the BOI said illustrations obtained from the report of its findings suggested that that prior to the crash, the pilot of the helicopter made an “unauthorised low-level flying” at a speed of around 60-80 knots around the Wasai Wang Tebadak area (LP KB 195A) and subsequently made a “banking” of 45 degrees to trail the river’s route.
“The aircraft strayed and was reduced from its original altitude due to a G-force (a unit of force equal to the force exerted by gravity) factor,” he revealed.
He added that consequently, the aircraft hit the branches of a tree and did not follow the intended route after being in a straight and level position.
“At the very last minute, the aircraft attempted to raise its altitude but (it) was in vain and it subsequently crashed into two large trees,” he said.
The report added that the Bell 212 helicopter owned by the RBAF took off from the Royal Brunei Air Force Base in Kg Rimba at approximately 8.55am on the day of the incident, July 20, 2012. “The aircraft carried a total of 14 military personnel of whom three were aircraft crew, two trainers, one staff and eight Officer Cadets during an assignment of transporting back personnel who had just concluded military training from the landing base KB 404 to landing base KB 199. It was believed the aircraft crashed at around 10.15am”, said the report.
The report stated that the aircraft lost communication on the ‘Brunei Radar’ at 9.17am after taking off.
“According to the aviation control procedure of the Air Traffic Control Unit of the DCA, all aircraft operating in the country’s airspace are obliged to make bps normal call’ communication every 30 minutes. But no communication was made thereafter and the Air Traffic Control Unit, DCA failed to make an INCERFA (uncertainty phase) alert and inform the RBAF to implement a ‘distress procedure’. This dragged on until a few hours later, causing an ‘alerting service’ that was not implemented according to procedures,” the report added.
Search and rescue operations only started after the aircraft was confirmed missing by the Royal Brunei Air Force at about 1.53pm. The mangled remains of the aircraft were found at nearby Wasai Wang Tebadak at approximately 3.55pm, the report said.
Dato Halim said the BOI also assessed other facts such as ‘environment’ and ‘material’ factors.
“The weather at the time of incident was good and did not affect flight operations and the ‘airworthiness’ of the aircraft was at the proper level. No evidence was found that suggests the aircraft had any technical difficulties before it crashed. This has been verified by the three separate international investigation experts,” he said.
He revealed that the BOI was assisted by expert aircraft investigation teams from overseas, including Pratt & Whitney Canada, Bell Textron United States and United States Army Combat Readiness Center – Air Accident Investigation Team.
“MinDef and RBAF had established the Supreme BOI on July 25, 2012. The board had been tasked to conduct an inquiry into the helicopter crash and to find causes and facts related to it and forward recommendations that need to be taken to prevent such incident from happening again,” Dato Halim said.
“A number of firm recommendations were put forward in our initial report dated August 6, 2012 and a few measures have been taken especially in reinforcing processes and procedures as well as safety aspects,” he said.
He added that the full report from the BOI will be put forward on September 16, 2012, including recommendations to ensure such incident will not happen again.
The Borneo Bulletin was told that a meeting was held with family members of the helicopter crash victims prior to the press conference to inform them of BOI’s findings.