In a report released today, the task force said the bus’s braking system was compromised because of deformation and wear on the left rear brake drum, grease and oil contamination on the linings, and inconsistencies in the brake lining material.
These factors reduced braking efficiency, compounded by the bus being driven at speeds exceeding the safe limit along the Gerik-Jeli East-West Highway.
The combination of brake issues and excessive speed caused the bus to lose stability, skid, and overturn, the report said. The vehicle struck a W-beam guardrail, which penetrated the cabin, resulting in multiple injuries and fatalities.
“Failure of the contaminated and inconsistent braking system, combined with driving at unsafe speeds, led to loss of vehicle control,” it said.
“Overall, the investigation found that the accident resulted from a complex combination of mechanical, human, environmental, and organisational factors.”
The report identified several interrelated contributing factors, including weaknesses in road design, vehicle specifications, poor operator governance, insufficient industry compliance, and gaps in regulatory oversight.
The preliminary report, released last July, estimated that the bus was travelling at 117.6 km/h, nearly double the 60 km/h limit, and above the critical rollover threshold of 111.3 to 114.5 km/h.
While the driver claimed that the brakes suddenly failed two to three kilometres from the crash site, technical analysis showed the failure was progressive, linked to brake deterioration.
“Under these conditions, the driver admitted his focus shifted entirely to steering, continuing at high speed until full loss of control,” the task force said.
“Although he intended to stop the bus in an open area, no early action was taken to reduce risk. This indicates that driver’s actions were influenced not only by technical failure but also by prior operational decisions, including speed selection and braking patterns, which placed continuous stress on the brakes.”
The bus, operated by Kenari Utara Travel & Tours Sdn Bhd, had illegally transferred its permit to a third party. It lacked basic safety systems, including seat belts, an active speed limiter, and GPS tracking. Both drivers had accumulated more than 30 traffic summonses, many unpaid.
The task force recommended upgrading barriers on hilly and dangerous routes, improving signage and road markings, and introducing additional safety controls such as dividers, reduced speed limits, slow zones, and automated enforcement cameras.
On the operational front, it called for mandatory seat belts for all passengers, tighter controls on licence leasing, surprise audits to curb illegal operations, and stricter driver screening and periodic training in defensive driving, emergency management, and brake handling.
The report also emphasised the use of GPS tracking, speed-limiting devices, dashcams, certified spare parts for critical systems, and pilot programmes using artificial intelligence to detect risky driving patterns and predict failures.
It suggested establishing an independent transport accident investigation body to issue unbiased safety recommendations.
The task force stressed that its findings are not intended to assign blame or determine liability, in line with its terms of reference and international best practices.
“Rather, the findings and recommendations aim to prevent similar incidents, strengthen Malaysia’s road transport safety system, and safeguard the lives and wellbeing of road users,” it said.