When I read the report published in the Borneo Bulletin Sunday, September 2, 2012 which says "Human Error" was found to be the main factor contributing to the tragic Bell 212 helicopter accident that claimed the lives of 12 military personnel, I am compelled to write this letter to express my opinion on this subject, especially when I heard the pilot was to be blamed and that an officer from Air Traffic Control Unit of the DCA was sacked from his job.
First allow me to introduce my aviation background, or else many readers might think I am just talking rubbish on this subject.
As I was once in charge of a section in an aviation organisation, I was nominated as a "Form 4 Holder" under European Aviation Safety Agency authority.
I wasn't nominated by the organisation I was working with, it was from an independent foreign authority.
The nomination meant that I was tasked with the responsibility of ensuring the organisation I was working with was always in compliance with the aviation regulation requirements.
To make it simple for people to understand of my responsibilities, let me explain further.
In case of any aircraft crash that causes death, I could be charged in court for negligence and manslaughter, even though I was only working in the office as a manager, and the crash was caused by some careless engineers.
So clearly there is no room for pointing finger or to make some poor guy as a "scapegoat" here, or to start using the 'Bangau' blame culture.
It must be understood by the relevant authorities that we should find the fault in the working system, not fault in the person, as the same incident may happen again, and the person who gets blamed next time will be the unfortunate guy who happens to be working on that particular day, doing that particular job, just like what had happened to the person from the Air Traffic Control Unit of the DCA who just lost his job.
According to the report, it was believed that the helicopter crashed at around 10.15am and that the helicopter lost communication with the 'Brunei radar' at 9.17am after taking off.
The report also stated, "According to the aviation control procedure of the Air Traffic Control Unit of the DCA, all aircraft operating in the country's airspace are obliged to make 'ops normal call' communication every 30 minutes. But no communication was made thereafter and the Air Traffic Control Unit, DCA failed to make an 'INCERFA' (uncertainty phase) alert and inform the RBAF to implement a 'distress procedure'.
"This dragged on until a few hours later, causing an 'alerting service' that was not implemented according to procedure."
Search and rescue operations only started after the aircraft was confirmed missing by the Royal Brunei Air Force at about 1.53pm.
The mangled remains of the aircraft were found at nearby Wasai Wang Tebadak at approximately 3.55pm.
Now, what puzzles me most is why there was nothing mentioned in the report about the failure of RBAF base to have communication with the missing Bell 212 helicopter or with any of its military personnel from 9.17am to 1.53pm?
For exactly 4 hours and 10 minutes RBAF wasn't in contact with the group and had no idea at all about their status. In case of a war, this is totally unacceptable.
I am not siding with anyone, but there are still some areas I feel that need to be looked at.
It was also stated that the weather at the time of incident was good and did not affect flight operations and the 'airworthiness' of the aircraft was at the proper level. No evidence was found that suggests the aircraft had any technical difficulties before it crashed. This has been verified by the three separate international investigation experts.
If that is so, then my next question is, if according to the report, the investigations revealed that the pilot of the helicopter contradicted flying procedures with "unauthorised low-level flying", causing a "Controlled Flight into Terrain (CRT)" accident, and that the Air Traffic Control Unit of the Department of Civil Aviation (DCA) had failed to follow aviation control procedures to alert relevant parties when the Bell 212's radio communication went off the 'Brunei radar', is there a possibility that this "unauthorised low-level flying" is a normal bad practice performed by RBAF pilots which to them is not such a big issue?
If a commercial aircraft went off the Brunei radar, red button will surely be pressed immediately. But for helicopters, there is no way a radar can detect them if they fly low.
Obviously the red button wasn't pressed because flying low is common in military helicopters and to have communication every 30 minutes with a civilian in the DCA is illogical in any military operation. By right, any military transport and its operation should be handled by the military themselves.
How many times have such incidents happened in the past where pilots contradicted flying procedures? Only this time?
If it isn't, then that explains why RBAF didn't check what happened to them for the first 4 hours and 10 minutes as it has become a precedent to carry out unauthorised low-level flying, with no communication with the main military base for more than 4 hours, and for DCA not to follow the actual aviation control procedures.
I would be very surprised to hear if this is the first time in history a pilot had contradicted flying procedures.
How about the RBAF helicopter Bell 212 that was involved in an accident while landing in the vicinity of Bukit Belalong, Temburong District back in February?
Was it a human error as well? How come DCA has excellent record when comes to dealing with commercial aircraft?
It's unfair to blame the pilot or the DCA personnel as their family will suffer the humiliation for the rest of their lives as well from an unfair or a possible false judgement.
Have the investigators done a thorough investigation with no stone left unturned?
Did they try to find out if the pilot had enough rest or he wasn't under any pressure from his superiors?
We have to understand, physical and mental stress can contribute to human performance and the cause of this is mainly due to poor system which higher officials fail to address.
I don't like to point fingers, but if anyone deserved to be blamed, it is those people who failed to monitor the people under them, and to ensure that they have a perfect system of working or procedures in place, and that they are strictly being followed.
This is the reason why European Aviation Safety Agency had tasked people like me in the past with the total responsibility of ensuring that the organisation was always in compliance with the aviation regulation requirements, and to put the blame on me if there was a fault in the system or failing in the compliance of the regulation requirements.