Investigation Summary
The investigation revealed a significant human factors element involving the captain's psychological state. Prior to the flight, the captain had been counseled by a fleet manager on strict fuel-saving and cost-cutting measures, which included avoiding circling and instrument approaches. Feeling pressured by management and fearing for his job security following a previous incident in Bintulu on 19 May 1995, the captain attempted a visual approach that was poorly stabilized. Despite warnings from the first officer and the Ground Proximity Warning System (GPWS), the captain continued the descent at a rate exceeding 3,000 feet per minute. The aircraft bounced twice before finally settling on the runway nearly 4,800 feet past the threshold, leaving insufficient distance to stop.
Final Conclusions
The most probable cause was the commander's insistence on continuing an approach when the available runway after touchdown was insufficient for the aircraft to stop. Contributing factors included the pilot's perception of economic pressure to save fuel and adhere to schedules, as well as the first officer's failure to intervene and correct the situation.
Video Analysis
Malaysia Airlines Flight 2133 Tragedy: They Should Have... — A detailed look at the 1995 Fokker 50 crash in Tawau, examining how pilot pressure and a rushed approach led to a fatal runway overrun.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Hours on type refers to the Fokker F27.
First Officer
Hours on type refers to the Fokker F27.
Systems & Failure Modes
GPWS
The Ground Proximity Warning System issued 'sink rate' and 'pull up' alerts due to the excessive 3,000 ft/min descent rate, which were ignored by the captain.
Flaps
The crew selected flaps to 25 degrees during the approach, but the aircraft's speed remained too high for a safe landing.
Interesting Facts
- 01This was the first hull loss of a Fokker 50 aircraft.
- 02The runway at Tawau was only 5,600 feet long at the time of the accident.
- 03The aircraft crashed approximately 500 meters from the end of the runway.
- 04The crash destroyed or damaged 40 houses in the shanty town.
- 05The captain had been counseled on fuel-saving policies just hours before the flight.
- 06The 34 fatalities consisted of 32 passengers and 2 crew members; additionally, 10 residents on the ground were treated for injuries.
- 07The aircraft accumulated 17,483 flight cycles at the time of the accident.
Safety Actions & Advisories
CRM Mandate
Investigators recommended that the Malaysian regulatory body make Crew Resource Management (CRM) training compulsory for all airliners in Malaysia.
Management-Crew Relations
Malaysia Airlines was advised to improve communication between management and flight crews to overcome hesitancy or resistance to change when meeting corporate goals.