The report, released on Jan 16, said active and latent condition failures had breached the various defence layers which had been systematically put in place to ensure a safe flight training environment.
“The main unsafe act for this accident is the inadvertent selection of the ignition switch to the wrong position after engine ground check.
“Skill-based error caused the pilot who had lost currency in night flying to inadvertently select the ignition switch to the ‘L’ instead of ‘BOTH’ position on completion of the right magneto check,” said the report sighted by FMT.
In the accident on Aug 1 last year, flight instructor Fajim Juffa Mustafa Kamal, 52, was killed while another flight instructor Din Fikri Zainal Abidin, 62, was injured when the light aircraft crashed on a road near an overhead bridge in Ipoh.
AAIB commended Fajim Juffa for his quick thinking and landing the aircraft on the best option available, which was along Jalan Dr Nazrin Shah in Sungai Rokam, Medan Gopeng, after his instructor Din Fikri had passed out during the emergency.
The report said the wrong selection of the switch had resulted in the engine running on less power, which subsequently caused the pilots to inaccurately identify the nature of emergency during the take-off.
“The error was not noticed by both pilots which resulted in the aircraft taking-off with less engine power and subsequently causing a power loss during the climbing phase. “
AAIB said contributing factors to this judgement and decision-making error included procedures not adequately covered during the night flying brief which resulted in both pilots not being ready to handle the emergency when it happened at low altitude, at night and the knowledge that there were limited safe landing areas within the aerodrome vicinity.
“The decision to carry out an intersection take-off instead of using the full runway length further complicated the judgement and decision-making error,” it added.
The investigators said despite the pilot making two Mayday calls three minutes after taking off, the crash alarm was not activated by the air traffic controller (ATC), with the information transmitted by tower to the airport fire and rescue service via direct line.
Another factor was the rushed night flying programme brought about by the aerodrome operator approving only two days as compared with four days originally with a limited time slot of two hours per day.
“A self-initiative to perform engine ground run check and the rush to carry out night flying currency check in a shorter night flying training duration are rush actions that had contributed to the unsafe act.
“The main precondition for unsafe acts is the lack of cross monitoring when performing duties as a check pilot on another pilot who had lost currency in night flying,” it said.
The probe also found that there were no personnel manning the aircraft operator’s flight operations control centre during the night flying training, adding that there was only one personnel on duty to marshal two training flights taking-off at about the same time.
According to AAIB there were nine air accidents last year with two final crash reports completed while the others have had their preliminary reports done, pending the final reports.