AIRCRAFT SERIOUS INCIDENT FINAL REPORT SI 05/24

At 0826 LT, shortly after take-off, the pilot heard a warning sound and observed the No. 2 engine coolant temperature indicating a high reading (in the Red zone). The engine also exhibited rough operation. In response, the pilot shut down the No. 2 engine and requested clearance to return to base. The aircraft was redirected to runway 33, and the pilot declared a Mayday to the Subang Tower. During the approach and landing, the pilot failed to lower the landing gear, resulting in a belly landing on the runway. A Mandatory Occurrence Report (MOR) was subsequently submitted by the Aircraft Handler to the Civil Aviation Authority of Malaysia (CAAM) and the Air Accident Investigation Bureau, Malaysia (AAIB) to formally notify them of the incident. FINAL REPORT SI 05/24 2 1.0 FACTUAL INFORMATION 1.1 History of the Flight The N566CB aircraft was scheduled for a flight test on 26 April 2024 at 0830 LT at Sultan Abdul Aziz Shah Airport (WMSA), following the pilot's report of high temperature and low oil pressure on the No. 2 engine during a previous flight. Engine trend data was downloaded, and the service centre was consulted for further investigation. The service centre recommended servicing the cooling system as part of the rectification process. This rectification work was carried out in accordance with the service centre's recommendations, and the aircraft was returned to service on 25 April 2024. The pilot, who is also the owner and operator, scheduled the aircraft for a test flight on 26 April 2024. After receiving clearance, the aircraft took off at 0826 LT. Unfortunately, shortly after take-off, a coolant overheat warning occurred. The No. 2 engine coolant temperature indicated high, and the engine began operating roughly. The pilot responded by shutting down the No. 2 engine and requesting to return to base. The aircraft was redirected to Runway 33, and the pilot declared a Mayday to Subang Tower. During the landing, the pilot failed to lower the landing gear, resulting in a belly landing on the runway. 1.2 Injuries to Persons Injuries Crew Passengers Others Total Fatal NIL NIL NIL NIL Serious NIL NIL NIL NIL Minor/None 1 1 NIL NIL FINAL REPORT SI 05/24 3 1.3 Damage to Aircraft Preliminary analysis indicates significant damage to the left-hand (LH) and right-hand (RH) propellers, as shown in Figures 1 and 2. The damage to the LH propeller is notably more severe than that to the RH propeller. Additionally, noticeable scratch marks and damage were observed on both the bottom engine cowling and the tail boom area, as shown in Figure 3. Initial assessment revealed that the aircraft skidded approximately 220 metres before coming to a stop, leaving visible scratch marks on the runway, as shown in Figure 4. The detailed damage assessment report is provided in Appendix B. Figure 1: LH Propeller Damage FINAL REPORT SI 05/24 4 Figure 2: RH Propeller Damage. Figure 3: Tail Section Area FINAL REPORT SI 05/24 5 Figure 4: Initial Impact Point and Scratch Marks on Runway 1.4 Other Damage Nil. 1.5 Personnel Information 1.5.1 Pilot Status Pilot in Command (PIC) Nationality Australia Age 58 years old Gender Male License Type PPL (3632007) Date of Issue 21 January 2020 Aircraft Rating Airplane Single and Multi-Engine Land No 1 Engine Impact Point No 2 Engine Impact Point FINAL REPORT SI 05/24 6 Total Hours on Type 332 hrs Total Flying Hours 680hrs Rest Period Since Last Flight More than 24hrs Medical Expiry Date 10 February 2025 The pilot was licensed, qualified, and approved to perform the flight in accordance with existing regulations. The pilot was medically fit and adequately rested to operate the flight. 1.5.2 Passenger A 28-year-old CAMO engineer from Aerohandlers Sdn Bhd. 1.6 Aircraft Information Aircraft Type Diamond DA42 NG Twin Star Manufacturer Diamond Aircraft Industries Inc Year of Manufacturer 2012 Owner Techstrait Ltd /Pilot Registration No. N566CB Aircraft Serial No. 42.N111 C of A Issued Date 01 August 2018 C of R Expiry Date 30 June 2024 The aircraft has a valid registration and Certificate of Airworthiness (C of A) and has been maintained in compliance with applicable regulations. Maintenance records indicate that the aircraft is properly equipped and maintained in accordance with existing regulations and approved procedures. The pilot is the owner of the company Techstrait Ltd. The aircraft general specifications are detailed in Appendix A. FINAL REPORT SI 05/24 7 1.7 Meteorological Information The occurrence took place during daylight. The weather conditions on that day did not contribute to the occurrence of the event. 1.8 Aids to Navigation All navigation aids were operating normally. 1.9 Communications All ATC communication frequencies were operating normally. 1.10 Aerodrome Information Sultan Abdul Aziz Shah Airport, Subang (WMSA), as shown in Figure 5, is located at latitude 03°07'52"N and longitude 101°32'53"E, with an elevation of 89 feet. Runways 15 and 33 were used for the landing, with no abnormalities observed in the surface condition. A landing distance available (LDA) of 3,780 feet was available for the landing. Figure 5: Sultan Abdul Aziz Shah Airport (WMSA) FINAL REPORT SI 05/24 8 1.11 Flight Recorders The aircraft was not equipped with a FDR or a CVR; neither was required by regulations. 1.12 Wreckage and Impact Information Figure 6: General description map of the incident The red line in Figure 6 illustrates the flight path of the aircraft, which made a turn back after taking off from runway 15. Figure 7 highlights the impact point and visible scratch marks on the runway. The damage assessment is detailed in Appendix B. Impact point as shown in Figure 7 FINAL REPORT SI 05/24 9 Figure 7: Initial impact point and Scratch Marks on Runway 1.13 Medical and Pathological Information The pilot underwent a urine drug panel screening on 30 April 2024, four days after the accident, and the results were negative for substance abuse. 1.14 Fire There were no reports of fire either before or after the impact. 1.15 Survival Aspects Not applicable. 1.16 Tests and Research The aircraft is not equipped with a FDR. The investigation relied on witness statements and system investigations of the engine, ignition, fuel injection, and fuel systems. Additionally, the investigation examined adherence to aircraft operating and maintenance procedures. No 1 Engine impact point No 2 Engine impact point FINAL REPORT SI 05/24 10 1.17 Organisational and Management Information 1.17.1 Owner/Operator The pilot owns the Diamond DA42NG Twin Star aircraft, registration N566CB, and is also the owner of Techstrait Ltd. The pilot is the sole operator of the aircraft. 1.17.2 Aircraft Ground Handler Sapura Aero offers a range of private aviation services, including hangarage, aircraft handling, and aircraft management. Aerohandlers Sdn Bhd, a subsidiary of Sapura Aero, conducted all required maintenance and repairs for the Diamond DA42NG Twin Star aircraft (N566CB). Aerohandlers Sdn Bhd is located at Subang Airport and is a qualified Continuing Airworthiness Management Organisation (CAMO) under the FAA for necessary servicing. 1.18 Additional Information Nil. 1.19 Useful or Effective Investigation Techniques N/A. 2.0 ANALYSIS 2.1 Human Factor Analysis Human factor issues related to this accident were examined, focusing on the pilot’s actions, decision-making, and potential errors. The analysis also considered environmental and operational factors that may have influenced performance. FINAL REPORT SI 05/24 11 2.1.1 Crew Resource Management (CRM) 2.1.1.1 Although the aircraft is designed for single-pilot operation, the availability of dual controls allows for the presence of a second pilot. While CRM is not a formal requirement for single-pilot aircraft, its incorporation can significantly enhance safety, particularly during functional check flights. Flying with a second pilot, rather than a regular passenger, enables better workload distribution, which is crucial in emergency situations. 2.1.1.2 In this incident, the reliance on a single pilot created challenges, especially as critical checklists were only accessible via an iPad. This setup proved cumbersome, requiring the pilot to manage flying, troubleshooting, and referencing emergency procedures simultaneously. Effective CRM strategies, such as the presence of a second pilot and more accessible resources, are vital for managing tasks, making informed decisions, and ensuring safety during critical flight phases. 2.1.2. Compliance with Standard Operating Procedures (SOPs) Figure 8: Cockpit Picture After the Incident FINAL REPORT SI 05/24 12 The pilot did not complete the pre-landing and landing checklist actions according to SOPs, as confirmed by both the pilot and passenger in interviews. Post-incident analysis revealed that the landing gear selector and flaps were in the up position at the time of impact (see Figure 8). This incident highlights the need to improve checklist accessibility, potentially by displaying it directly within the cockpit rather than relying solely on an iPad. SOPs are designed to safeguard operations by providing clear guidelines and consistent expectations. Non-compliance with SOPs undermines this safety framework, increasing the likelihood of errors, especially under high-stress or emergency conditions. 2.1.3 Training and Competency The pilot's experience on this aircraft is limited, as reflected in relatively low flying hours due to the underutilisation of the aircraft. Since this is a private aircraft, the responsibility for planning and maintaining training and competency lies with the pilot. According to the pilot’s logbook and interview, the pilot has accumulated 332 hours on this aircraft type since its purchase in 2017. Adequate training and familiarity with an aircraft type are critical for safe and effective operation, particularly in managing in- flight challenges and emergencies. Limited training and infrequent practice on the aircraft may have impacted the pilot’s ability to execute necessary tasks and respond to unexpected situations. 2.1.4 Decision-Making and Judgment The pilot made a rushed decision to shut down the No. 2 engine based solely on the coolant temperature reaching the red line (see Appendix C) during take-off, which was not in accordance with the checklist (see Appendix D). Furthermore, the immediate decision to turn back after the engine shutdown compounded the situation, leaving the pilot with limited time to assess and respond. This incident raises concerns about the pilot’s judgement and risk assessment. These decisions may reflect overconfidence in personal capability or an underestimation of the risks associated with deviating from established procedures. Effective decision-making, particularly in high-stakes situations, requires a thorough understanding of potential outcomes and strict adherence to safety protocols. FINAL REPORT SI 05/24 13 2.1.5 Workload Management After shutting down the engine and initiating an immediate turn-back, the pilot likely faced an increased workload and heightened stress, making it more challenging to prioritise tasks effectively. This rapid escalation in demands may have impaired the pilot’s ability to maintain situational awareness and execute the required actions accurately. Effective workload management is essential to maintain focus, ensuring all necessary tasks are performed correctly, and sustaining situational awareness, particularly during critical phases of flight. 2.1.6. Situational Awareness Situational awareness involves understanding the current environment, anticipating future developments, and recognising changes that could impact safety. Due to limited emergency-handling training, the pilot focused on shutting down the engine and made a rushed decision to turn back without completing all necessary landing checklists. This led to a loss of situational awareness, as the pilot concentrated solely on landing rather than balancing the broader demands of the emergency. Maintaining situational awareness is vital, especially in emergencies, to ensure all aspects of the situation are managed effectively, reducing risks and ensuring a safe outcome. 2.1.7 Conclusion – Human Factors Analysis The human factors analysis identifies key areas where deviations from standard procedures, insufficient training, and ineffective decision-making likely played significant roles in the incident. To prevent similar occurrences, it is crucial to emphasise compliance with established protocols, provide comprehensive and recurrent training, and foster a safety culture that prioritises adherence to SOPs and robust risk management principles. FINAL REPORT SI 05/24 14 3.0 CONCLUSION 3.1 Findings 3.1.1 Pilot 3.1.1.1 The pilot was qualified and licensed to operate the DA 42NG Twin Star aircraft in accordance with existing regulations. 3.1.1.2 The pilot’s medical certificate was valid, and the pilot was adequately rested to operate the flight. 3.1.1.3 There was no evidence of physical incapacitation or physiological factors that affected the pilot's performance. 3.1.1.4 The pilot transmitted a "MAYDAY" call, which was responded to appropriately by the ATC Tower in accordance with SOPs. 3.1.1.5 The pilot did not complete the before-landing checklist due to fixation on landing. 3.1.1.6 The pilot shut down the engine after the coolant temperature reached a high level, without referring to the emergency checklist. 3.1.1.7 The pilot did not deploy the landing gear due to fixation and loss of situational awareness. 3.1.2 Environmental Conditions 3.1.2.1 The incident occurred at 0828 LT, with clear visibility and favourable meteorological conditions reported. FINAL REPORT SI 05/24 15 3.1.3 Aircraft – Diamond DA42NG Twin Star, Registration N566CB 3.1.3.1 The aircraft was airworthy, with a valid Certificate of Airworthiness (C of A) and Certificate of Registration (C of R). 3.1.3.2 The maintenance records indicated that the aircraft was equipped and maintained in accordance with existing regulations and approved procedures. 3.1.3.3 The aircraft was not equipped with a Flight Data Recorder (FDR) or Cockpit Voice Recorder (CVR), limiting the available data for the investigation. 3.1.3.4 Notably, the aircraft had been operated in Malaysia since 2018 under its current ownership. However, there was no intention to register the aircraft under domestic registration, as required by CAR 147. 3.1.3.5 The aircraft's engine coolant temperature was indicating high. 3.2 Cause/Contributing Factors 3.2.1 The cause of the incident was the pilot’s failure to carry out the checklist for landing with one engine inoperative, leading to the aircraft belly-landing. This serious incident is categorised as an Abnormal Runway Contact (ARC). 3.2.2 Contributing factors included deviations from standard procedures, insufficient training, and ineffective decision-making. 4.0 SAFETY RECOMMENDATION 4.1 Aircraft Owner/Operator The aircraft owner/operator is recommended to enhance pilot training programmes to ensure strict adherence to Standard Operating Procedures (SOPs), particularly in FINAL REPORT SI 05/24 16 emergency situations. This should focus on preparing the pilot to manage emergencies effectively and follow critical checklists, even under stress. 4.2 Civil Aviation Authority of Malaysia (CAAM) CAAM is recommended to strengthen oversight of foreign-registered aircraft operating in Malaysia, especially those operated by foreign-licensed aircrew. This should include enforcing Civil Aviation Regulation (CAR) 147 for foreign aircraft operating in Malaysia for more than six months, and reviewing licensing, training, and operational protocols to ensure compliance with international safety standards and reduce operational risks. 5.0 COMMENTS TO DRAFT FINAL REPORT In accordance with ICAO Annex 13, paragraph 6.3, the Draft Final Report was sent to the State of Registry (NTSB), State of Design and Manufacturer (Austrian Safety Investigation Authority), Civil Aviation Authority of Malaysia (CAAM), as well as the aircraft operator inviting their significant and substantiated comments on the report. The following (Table 7) is the status of the comments received: Organisations Status of Significant and Substantiated Comments NTSB, United States of America No comments received Austrian Safety Investigation Authority No comments received CAAM, Malaysia No comments received Operator No comments received Table 7: Status of significant and substantiated comments. FINAL REPORT SI 05/24 17 CONCLUDING STATEMENT This investigation has revealed instances of non-compliance and operational errors. It is essential to emphasise that these findings are not intended to assign blame or liability, but rather to prevent future accidents and improve aviation safety as a whole. Addressing these findings and implementing the recommended safety measures will strengthen aviation safety and reduce risks associated with operational lapses and regulatory gaps. It is imperative that all stakeholders prioritise safety and commit to implementing the necessary measures to prevent recurrence. INVESTIGATOR IN-CHARGE Air Accident Investigation Bureau Ministry of Transport Malaysia FINAL REPORT SI 05/24 A-1 APPENDIX A Diamond DA42NG Twin Star Dimension FINAL REPORT SI 05/24 B-1 APPENDIX B N566CB DAMAGE ASSESSMENT REPORT AIRCRAFT INFORMATION TCDS NO.: EASA.A.005 AIRWORTHINESS CATEGORY: JAR-23 NORMAL CATEGORY AIRFRAME MAKE: DIAMOND AIRCRAFT INDUSTRIES MODEL: DA-42NG SERIAL NO.: 42.N111 REGISTRATION: N566CB STATE OF MFG: AUSTRIA STATE OF REGISTRY: USA AFHRS: 686.7 CYC: 493 ENGINE NO.1 MAKE: AUSTRO ENGINE MODEL: E4-C SERIAL NO.: E4-C-00023 TSN/TSO: 686.7 CSN/CS0: 493 ENGINE NO.2 MAKE: AUSTRO ENGINE MODEL: E4-C SERIAL NO: E4-C-00024 TSN/TSO: 686.7 CSN/CSO: 493 FINAL REPORT SI 05/24 B-2 Damage to Antenna Damage to LH Engine Lower Cowling LH Engine Exhaust Nozzle LH Step FINAL REPORT SI 05/24 B-3 Damage to Tail Structure and Rudder Trim FINAL REPORT SI 05/24 B-4 Damage on RH Step Damage / chip on RH Engine Propeller FINAL REPORT SI 05/24 B-5 Damage to RH Engine Bottom Damage to LH Engine Propeller Damage on RH Engine Exhaust Nozzle FINAL REPORT SI 05/24 B-6 All Aircraft Exterior Structure, other than mentioned are in good and satisfactory condition. Other possible damage MAY include: • Landing Gear Uplock Mechanism Damage • LH Engine Gearbox integrity due to Prop strike • RH Engine Gearbox integrity due to Prop strike • RH and LH Engine Coolant Cooler Damage Reported damages are preliminary damage assessment report. Further assessment shall only be carried out once accident/incident investigation is completed. END OF REPORT FINAL REPORT SI 05/24 C-1 APPENDIX C Engine Datalog report One file (the EvtrRec-file) was indeed corrupted; however, they successfully recovered the necessary information from its content. Below is a copy of the email sent by the software expert. For your reference, please find the approved temperature limits for the E4 engine type, as specified in the EASA Type Certificate Data Sheet (TCDS), provided below: FINAL REPORT SI 05/24 C-2 The data shows the limit violations of coolant temperature (105°C) and also oil temperature (135°C): FINAL REPORT SI 05/24 C-3 The engine log shows the serial number E4-C-00024 and a total engine runtime of 874 hours. There are no faults or warnings stored in the fault code memory. The data log shows problems with the coolant temperature on 25th and 26th of April: FINAL REPORT SI 05/24 D-1 APPENDIX D Extract of DA42 NG Checklists FINAL REPORT SI 05/24 D-2 FINAL REPORT SI 05/24 D-3 FINAL REPORT SI 05/24 D-4 FINAL REPORT SI 05/24 D-5 FINAL REPORT SI 05/24 D-6