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| The Double Six Tragedy. Pic source: The Star |
https://www.mot.gov.my/en/aviation/reports/n22b-nomad
I received the link above from my La Sallian classmate on 12 April 2023.
47 years ago on 6 June 1976, my classmate's father perished in what is now known as the Double Six Tragedy, in the waters of Sembulan, where now stands a monument to this mishap.
I am not writing this to add to the furore of netizens dissing the declassified report on the air accident as "full of holes", although I used the very same words myself upon reading it. I am also fully cognisant of how this is a sacred matter, one where many are bereft. This tragedy be trebled then, that something of personal pain is also of such enduring public interest, to say naught of stale political expedience.
I am simply recording my thoughts, as an aviator, on a report which seems incongruent to anyone who knows the discipline and has even the most basic understanding of the science known as the principles of flight.
Let me vent here. And I will vent beginning with how dead men can't talk.
I find such statements insufferable. First of all, it is summarily judged that the pilot was of "poor performance". While there is a slew of questions over such a blanket judgement, I will home in on a singular item: the pilot was licensed. That's the bit of paper or laminate you need to drive, to practise law, medicine or any professional trade in exchange for a salary. The same applies to the flying discipline for the purpose of commercial air transport. A regulatory body, then called the Department Of Civil Aviation, now the Civil Aviation Authority of Malaysia, governs the issuance and periodic endorsement of a pilot's license after his skills are tested in the air and on the ground on a host of subjects and medical fitness every year for the rest of his employed life.
During the examniations, the pilot either performs (and thereby his license is issued-noob- or renewed-recurrent) or doesn't (and his license is supended). Neither the Ministry nor the Department (now called the Authority) will allow any "pilot of poor or marginal performance" to carry a license bearing its logo and signature of its Director-General what more if your'e making your money off it. Therefore that opening statement in the report is fundamentally flawed.
Interesting, isn't it? Done with the Captain, on to the Second Pilot. If the copilot loaded (or as the report alleges, overloaded) the aft baggage hold, could he if still living, verify this veiled accusation? He wasn't on board the ill-fated aircraft. Should he not want to clear his name of being part of the weak links in the overall failures leading to such a number of fatalities? Did he subsequently progress in his career in the same company or another airline and have his part in this quietly fade into his past?
Let's allow the conspiracy theories and urban legends of the 70s run wild here: the way it looks now, he joins the list of rather suspect surviving and demised ex ministers as those who were by divine or nefarious intervention, having dodged the bullet by not boarding the aircraft at the final few moments before departure. If they were suspected of foul play, he could too. Although it was his captain's decision to fly solo instead of dual pilot, being struck off the operating crew pairing cannot be so casual an acquital. Indeed, the response of Datuk Donald Mojuntin towards this report in that it raises more questions than it doth answer, is pertinent.
The third item put forth here is the aircraft configuration. This has to do with how an aircraft is configured (set up) for a particular phase of flight eg take off, cruise, descent and in this case finals approach to land.
The allegation here was that the aircraft configuration favoured nose-up (positive pitch) moments on its approach to land which as the flight progressed towards threshold runway 20, were compunded with the aft baggage hold overload, conditions favouring stall.
Yes, almost every aircraft whether fixed wing or rotary wing, as a function of passenger and freight loading and position affect where the centre of gravity sits during the course of flight. During this time, the centre of gravity can move forward or aft with fuel consumption, repositioning of passengers in their seating arrangement or refuelling during a stop on ground, for most uneventful flights. The next time you're listening to the safety and emergency briefing on board MYAirlines, pay attention and you will find this bit relevant.
This is usually limited to a range, often measured in milimetres, called the CG margin. Almost every aircraft is a fun fact: I have been made to understand that the Boeing Vertol Chinook has a negligible CG margin because of its dual main rotor design. The CG can be anywhere between those two and the aircraft will preserve its balance.
If the CG moves too far forward or conversely too far aft, the aircraft will, respectively, have predominately nose down or nose up moments respectively as it interacts with the Centre of Pressure (CP) located coarsely for this narrative, where the wings are since CG and GP now form a "couple", creating "moments". Yes, this is still aerodynamics and not dating tactics.
To put it rather unscientifically, the CP is the string from whence the weighing scale is Lift-ed, and the CG is where the weight sits in the tray, and the counterweight can be.....configuration? So in this pedestrian visual, the closer CP and CG are, the more stable the loading and the more latitude with config. Just don't quote me on this, it is tough staying away from aerodynamic jargon! Or maybe it isn't a bad simile, since as the report shows, with the CG so far aft from CP, config did make things worse.
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| A bad comparison, but it will serve. |
Loading is important therefore to keep the CG margin as close as possible to the wings where lift is made, so that lift acting mostly upwards does not form too strong a "couple" with weight which mostly works towards the earth. The couple is further managed via configuration peculiar to phase of flight.
In this argument, the CG being too far aft, would mean that for certain low airspeeds, such as an approach to land, the aircraft's wing surfaces will be tilted upwards close to the angles at which stall will occur. Combined with a malfunctioned stall warning horn, and a "steering yoke" which had physical contact against its forward travel limit, the captain would neither have recognised an impending stall due to the absence of aural warning, nor would he have been able to recover the aircraft because the steering yoke could no longer be pushed forward to "unstall" the wings. In short: a perfect shitstorm.
The description of eyewitness accounts and the configuration as described in the report point towards a low-altitude stall on approach to land, and with tale telling of a wing dip, stall can rapidly develop into an incipient spin. A few details of the report are rather telling.
The "threshold" to Runway 20 at that time is located adjacent to the today's location of thr Bulatan Bed-and Breakfast hotel as compared to today where it is a hundred metres or so opposite Sunny Supermarket or on the other side of the runway, through the corner window of Ma Pitz, it csn be viewed panoramically. 5676 feet before the threshold as the crash point places it almost a mile away from Bulatan along the same axis. Not quite where the monument is today at Grace Point, but well, close enough, yes? However, with the wreckage ponting away from Runway 20, on a heading of 20 degrees does indeed indicate it had spun to face the north.
Evidently the report reads the way any standard accident report would. There will be the chronology of events, scrutiny of the aircrew, documents, aircraft, engineering practices and deviations from procedures.
I have no issue with that.
However, with reference to the above, I am doubtful that any captain would neglect the basic duty of drafting out a proper trim sheet (c of g margin chart) before flight. That is simply a bread and butter issue of any captain worth his salt. Suggesting that he also deliberately violated the aircraft limitations by overloading the baggage hold is another departure from the norm which I cannot rest well with. Limitations are life!
I say this in comparison to how reading through the report shows that the company and its pilots had become lackadaisal in adherance to their own company operating manuals. This is because there are post-holders in any company, also licensed pilots, who are there to ensure compliance to both Civil Aviation Regulations and company Operating Manuals. They become extra temperamental whenever the Authority comes around annually to audit the company before its operating certificate is renewed.
To allege that a cavalier attitude had overtaken an entire company seems a stretch to me. No aviation service provider should have been allowed to survive a shitstorm like this if such deep-set systemic failures and negligence found its way into paper, let alone a crash killing half the state cabinet ministers and its Chief Minister.
The bit about having to fly Instrument Flight Rules for VIP flights does puzzle me. The meteorological conditions of the time of flight were pretty damned good. A 30 kilometre visibility range would not "require" IFR when his reported cruise and rejoin for landing altitudes were 5000 and 3000 feet respectively. With but 2/8 or "few" clouds at 1500 feet and 3/8 or "broken" clouds at 2000 feet conditions to fly visually with the abundance of ground references for navigation rather than by IFR were satisfactory indeed. Anyway, submitting a flight plan under IFR does not mean a pilot is stuck with IFR as he can still fly visually all the way to landing. It was merely in the company's operating manuals that VIP flights require an IFR flight plan. I believe that this was emphasised to indicate deviations from procedures and the absence of a monitoring system to ensure compliance, underscoring the systemic failures aready discussed.
In all probability maybe all that was alleged in the report was actually true, in that litmus, irrefutable and throroughly forensic principle known as "whaaaaat if"!
What-ifs are obviated in commercial airlines, beginning in 1967, when Flight Data Recorders and Cockpit Voice Recorders were made mandatory equipment for flight. These "black boxes" which are actually painted day-glo to aid crash site retrieval, provide all the data necessary to piece together the aircraft configuration and performance parameters up to the point of mishap. The cockpit voice recorder of course will tell us what the pilots were dealing with along the same time frame. These have aided aircraft accident investigations immensely. It is both tragic and convenient that mandatory eqiupment is reported as not quite so in the case of the Nomad. Why was this not pointed out as a non compliance in the report, is also curious. The omission of the device should have been reported as gross negligence instead of the slap on the wrist (hardly) it appears to be as reflected in the report.
I can only speculate that this regulation was bypassed because Penerbangan Sabah was not really an "airline" per se. It was a state-affiliated charter aviation service, so I am not certain of what waivers it may have been granted.
Those of us in the industry are well aware of the fact that even with the digital aids of the FDR/CVR, the complete picture of the line up to an air accident is not complete. It may come close and yet something crucial can be missed. But to not have one at all, is to fire rockets blindfolded.
And in that spirit, I'll be the devil's advocate in pondering the possibility that this may not even have been a political conspiracy and perhaps was simply a commercial one.
An aircraft plagued with incidents and mishap can easily see its removal from the aviation scene. For instance, the Eurocpter (now Airbus Helicopters) EC225 was a very viable offshore helicopter but in 2016 and onward, a series of mishaps led to the aircraft being removed from the North Sea Oil aviation scene. It led to the Malaysian Helicopter Services closing shop in Kerteh as worldwide, offshore boys made it clear via their workers' unions that they never wanted to set foot in a 225 ever again.
Therefore the report would serve the business continuity of the companies operating the Nomad, whether local or at the manufacturer's home country. The OEM would also find it in their interest if the blame could be laid squarely on the shoulders of the hapless captain. The last flight I know of involving a long-range sortie for the Nomad was the BODEVAC for the late Captain Sahaimi of Sabah Air after his Bell206B crashed in Sibu during the state elections of 2011, my account in the link below. Even if we count from 1976 till 2011, that's a healthy 35 years for all parties staying afloat. Hence when there are many interested parties and possibilities, a smoking gun is easier to conceal.
I didn't ever expect that the declassifying of the report would reveal a smoking gun. How genuine it is that the baggage recovered from a mangled wreck would correctly have been in place and intact just as it was before flight at the forward and aft cargo holds and thereby point directly to bad loading, calls for quite a bit of faith in the printed word. I find it hashed up and rather speculative.
The problem is this: for decades we have been fed with the idea that this report is the Grail which will prove some convoluted Federal Government-led conspiracy against the state. Vote-fishing can get ugly when parochial politicians keep hankering for the release of classified materiel, dragging their electorate with them as if the release thereof will lead to a momentuous grand revelation of how the state has been a victim of a colonising Federal Government. It's the shortest path to an equally short lived statesmanship.
But having seen what I have, declaring either one side as being the good guys cannot be further from my intent. For the same reason, I see no reason to exonerate the insidious players of that day. Besides, colonisation requires collaborators. It is rare for an entire government to be inherently evil save perhaps, for juntas. But common it is for individuals in a governent however benevolently said government may posture itself, to infest the halls of power with venom. I'm not saying there was no conspiracy. Just saying that proof of it isn't in the pages of this report.
If those clamouring statesmen play-actors sincerely want to pursue the truth, they could, instead of politicising the report, call for a forum comprising existing Nomad pilots to review the report. There is a Nomad aircraft languishing on the tarmac of Layang Layang Aviation right now. Where are her pilots? Either the aircrew open up a can of worms requiring further clarification of the report, and points us in the direction of the actual Grail, or they concur with it and all of us, poltician and concerned citizen alike will have to forever hold our peace.
For it doesn't take an air accident investigator to conclude, that if anything over the Double Six Tragedy is being hidden, concealment was secured well before that ill fated Nomad hit the waters of Sembulan.
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