Malaysia Airlines Flight 2133

Malaysia Airlines Flight 2133

A Malaysia Airlines Fokker 50 similar to the one which crashed.
Accident
Date	15 September 1995
Summary	Aircraft landed near runway end, pilot's insistence to land despite insufficient runway length
Site	Tawau Airport, Tawau, Sabah, Malaysia 4°18′0″N 118°6′0″E
Aircraft
Aircraft type	Fokker 50
Operator	Malaysia Airlines
Registration	9M-MGH
Flight origin	Kota Kinabalu International Airport, Kota Kinabalu, Sabah, Malaysia
Destination	Tawau Airport, Tawau, Sabah, Malaysia
Occupants	53
Passengers	49
Crew	4
Fatalities	34
Survivors	19
Ground casualties
Ground fatalities	0
Ground injuries	10

Malaysia Airlines Flight 2133 (MH2133/MAS2133) was a Malaysian scheduled domestic passenger flight from Kota Kinabalu to Tawau, operated by Malaysia's flag carrier Malaysia Airlines. On 15 September 1995, the Fokker 50 carrying 53 people flew onto a shanty town after the pilots failed to stop the aircraft while landing in Tawau, taking the lives of 32 of the 49 passengers and 2 of the 4 crew on board. This was the first hull loss of a Fokker 50.

The final report of the investigation, which was published in 1998, concluded that the crash was caused by the pilot's insistence to land in Tawau, which was influenced by the airlines' strict policy of fuel-saving and punctuality, despite the fact that the runway available after touchdown was not sufficient enough for the aircraft to stop. Investigators issued several recommendations to both Malaysia Airlines and Malaysian regulatory body, the latter was asked to make crew resource management training as a compulsory course for airliners in Malaysia.

Background

Aircraft

The aircraft was a 5-year-old Fokker 50 with a registration code of 9M-MGH and a manufacturer serial number of 20174. Delivered to Malaysia Airlines in March 1990, the aircraft was equipped with 2 Pratt & Whitney Canada and had accumulated a total of 17,483 flight cycles. The engines had been inspected just two days before the crash.

Flight crew

The Captain of the flight was Wong Khang Lock (40). He had accumulated a total of 4,892 hours, of which 427 hours were on the Fokker F27. He held valid flight certificates and medical certificate. The First Officer of the flight was Su Tiong Hee (28). He had accumulated a total of 1,162 hours, of which 962 were on the Fokker F27.

Accident

All times in this article are Malaysian Standard Time (MST) (UTC+8).

Flight 2133 was a domestic passenger flight from Kota Kinabalu, the capital of Sabah, to Tawau, a major city located at the Malaysia-Indonesia border in East Malaysia. There were 49 passengers, two pilots, and two cabin crew aboard the aircraft. The scheduled flight time was one hour.

Flight 2133 had been delayed for 30 minutes from its scheduled take-off time due to the aircraft's late arrival in Kota Kinabalu. The aircraft finally took off from Kota Kinabalu International Airport at 12:19 local time with instrument flight rules. Weather at Tawau was reported as "surface wind calm, visibility more than 10km, rain north to north east, scattered 1600ft and scattered 2700ft, broken at 14000ft, temperature 30 degrees C and QNH 1009mb, runway 17." At the time, Tawau's runway was only 5600ft long. The flight was uneventful until its approach.

Reaching the airport, the aircraft was passing 3,500ft. At this point, the aircraft was configured for landing. Despite this, the aircraft was still too fast and high on the approach, with the commander assuring the co-pilot "Runway is long so no problem Eh [sic]." The co-pilot continued to advise the commander of the excess speed, while the aircraft continued a descent of 3,000 ft/min at a pitch angle of -13 degrees. Such a flight attitude triggered the GPWS warnings, which were ignored.

At 13:05 (GMT+8), the aircraft touched down on the runway, approximately 3,400ft from the threshold, bouncing and touching down again 4500ft down the runway. A second bounce occurred, with a final touchdown 4,800ft down the runway, leaving only 800ft of runway to stop. It then overran the runway and crossed the airport's grassy area before it flew onto the Sri Menanti shanty town, slums mainly occupied by Filipinos and Indonesians migrant workers, approximately 500 meters from the end of the runway.

The aircraft broke into two parts and the wings had snapped due to the impact, causing fuels to leak. A fire had ignited due to the aircraft's collision with multiple houses in the area. As the fire intensified, passengers and crews on the aircraft tried to evacuate from the burning aircraft. However, a massive explosion suddenly engulfed the entire aircraft, burning the remaining passengers and crews inside the aircraft. Houses nearby got caught by the flames, causing it to spread to nearly the entire neighborhood. Residents in the area immediately fled for safety.

Tawau's fire fighting services immediately deployed 18 firefighters to the area. The rescue effort was hampered by the amount of onlookers at the crash site. Rescuers managed to douse the flames later at evening. A total of 34 dead bodies were found and 17 passengers, 2 crew members and 10 residents had to be treated for wounds. A total of 40 houses were damaged in the crash.

Investigation

Malaysian authorities set up a team of 6 investigators from Department of Civil Aviation to investigate the crash. Representatives from Malaysia Airlines, Netherlands (representing Fokker), Canada (representing Pratt and Whitney Canada) and United States (representing the Federal Aviation Administration) were also invited to assist in the investigation. The flight recorders were processed in United Kingdom's Air Accidents Investigation Branch (AAIB) facility in Farnborough.

Sequence of flight

During Flight 2133's descent into Tawau, the controller put the aircraft as number 2 to land at the airport, even though the aircraft's position was ahead of the number 1 aircraft (Transmile Flight 809), which was at a lower altitude. The number 3 aircraft was a Malaysia Airlines Boeing 737 located right behind Flight 2133 and the number 1 aircraft. This traffic situation would hold the key to the crash of Flight 2133 as the traffic caused Flight 2133's inability to obtain descent clearance to below 10,500ft.

The Captain and the First Officer discussed on the traffic and also attempted to obtain descent clearance from 17,000ft to 10,500ft. This request was denied and the Captain had to negotiate with the flight crew in Number 1 aircraft so that Flight 2133 could become the number 1 aircraft instead. Their request was later granted by the controller. As the pilots of Flight 2133 initiated the descent to 10,500ft way closer to Tawau than it normally was, the crew required a higher descent rate than normal. Flight 2133 then started its descent from 10,500ft to 7,000ft at 12:59 local time. The flight was cleared to descent to 7,000ft and later was cleared for a visual approach with an altitude below 7,000ft. The First Officer had warned the Captain on the high speed of the aircraft and the high descent rate. Later on, the Captain stated that, instead of slowing down, he would maintain the high speed. The aircraft at the time was still at a higher altitude than it normally was for an approach at that distance and the speed was also well above normal.

Noticing the high speed of the aircraft, the First Officer asked the Captain to slow down. The auto-pilot was disengaged and the flight crew performed the pre landing checklist. The Captain stated to the First Officer that "the approach would be okay as long as the speed of the aircraft was not more than 160 knots." A minute later, the Captain reassured the First Officer that there would be no problem for Flight 2133 to land in Tawau since the runway was long enough. The First Officer warned on the Captain to check the speed.

The Captain totally neglected his speed control. Even though the First Officer had warned the Captain on the high speed condition of the aircraft, he didn't take the appropriate actions to correct the situation. The Captain, instead of listening to the First Officer's suggestion to slow down, decided to reassure the First Officer that a landing was possible as long as the runway length was enough and that the speed of the aircraft was still below 160 knots.

Due to the high descent rate and a nose down attitude with a pitch angle of -3 degree, the GPWS warning then sounded. Malaysia Airlines' Operation Manual clearly stated that any activation of GPWS would necessitate the flight crew to make a go-around. However, the Captain chose to disregard it. The flight crew never mentioned the possibility for a go-around. The Captain had made up his mind to immediately land Flight 2133, despite the clear indications that the aircraft was in dangerous situation.

The Captain’s fixation to land later caused Flight 2133 to touchdown at three quarters of the runway's total length. The flight crew's attempts to slow down were rendered impossible due to the high speed of the aircraft and the insufficient remaining runway length.

Captain's frustration

The Captain's insistence to land in Tawau despite the dangerous condition of the aircraft could be explained by his prior stressful encounters with his managers and workers in Malaysia Airlines. The Captain claimed to his colleagues that someone in the company was "out to get him".

He had been involved in an incident on 19 May 1995 at Bintulu Airport. In response to the incident, the fleet manager of Malaysia Airlines' Fokker in Kuching accused the Captain of displaying poor airmanship and being uncooperative with air traffic controller despite the co-pilot’s supporting statements for the Captain in the 19 May event. The Captain expressed his disappointment due to the fact that, not only that the fleet manager did not support him in the incident, the said manager also agreed to carry out his next line check.

A few months after the incident, in September 1995, the Captain's flight logs were reviewed by his management. He felt that his management didn't try to give him a chance to explain and that the fleet manager was chasing after his back. He even expressed his fear of the fleet manager in Kuching as he opined that the manager's decision to give him the line check was a way to set the Captain to be fired from the company. Fortunately, he passed the flight check.

The last encounter was in 15 September 1995, the day of the accident. Exactly prior to the accident flight, the Captain had been counseled by the said fleet manager on the company's policy regarding cost cutting. The manager discussed on the avoidance to circle the airport and instead use straight in approaches, avoid instrument approaches and even delay top of descent wherever possible. The Captain was told to strictly adhere to the company's policies of cost cutting and fuel saving.

On the accident flight, Flight 2133 had passed 30 minutes from its scheduled time to take-off due to its late arrival in Kota Kinabalu. The traffic situation clearly didn't help with the flight crew's attempts to obtain descent clearance. The cockpit voice recorder managed to capture the Captain's concerns over the delay. At one time he was heard expressing his concern on the possibility of being called up again by his superior. His decision to land became firm as he was granted by the controller to become the number 1 aircraft to land in Tawau, where he could not afford to upset the traffic sequence.

Other contributing factors

The Captain had flown to multiple "very short airstrips" in the jungles of Malaysian Borneo and had operated short take off and land (STOL) aircraft. A significant portion of his flight hours had involved steep approaches. This might have caused the Captain to be overconfident as he was comfortable with steep airport approaches.

Another finding was that a visual illusion might have also played a role in the crash. A visual approach to Tawau would result in an illusion, which would cause the flight crew to feel that they were lower than the actual glideslope angle.

Conclusion

The report was published on 20 May 1998, nearly 3 years after the crash. Malaysian authorities cited the following:

The most probable cause of the accident was due to the commander's insistence to continue with an approach despite the fact that the runway available after touchdown was not sufficient enough for the aircraft to stop. The perception regarding economic consideration which put pressure on him to save fuel and adhere to schedules was a contributing factor.

In response to the negative image that Malaysia Airlines had received in light of the investigation, the company had tried to "clarify issues and narrow the gap between the management and the flight crew". Investigators issued a recommendation to Malaysia Airlines "to overcome flight crew hesitancy or resistance to change" when instilling flying discipline in order to meet corporate and business goals.

Even though the report blamed the Captain's action as the cause of the crash, it also highlighted the First Officer's lack of initiative to correct the situation. As such, investigators requested Malaysian regulatory body to mandate every airliners in Malaysia to include crew resource management as a compulsory training for flight crew. Malaysia Airlines was asked to implement this recommendation in immediate effect.

See also

• Garuda Indonesia Flight 200, similar incident which was caused by the Captain's insistence to land despite the high speed condition of the aircraft
• China Southern Airlines Flight 3456
• China Airlines Flight 676

External links

Aftermath of the crash from Associated Press