Investigation Summary
The flight was a short domestic hop from Kota Kinabalu to Kudat. During the first approach to Runway 04, the crew encountered a significant tailwind (reported at 17 knots gusting to 31 knots from 270 degrees). Despite the tailwind exceeding the aircraft's 10-knot limit, the crew attempted the approach with only 10 degrees of flaps, which was also contrary to SOP. They eventually initiated a go-around at 500 feet and repositioned for Runway 22. On the second approach, the Captain (Pilot Flying) opted for a full flap setting of 37 degrees. As the aircraft reached the flare at approximately 20 feet, a sudden gust caused the right wing to drop and the nose to veer 45 degrees off the centerline. The Captain applied maximum power for a go-around but consciously decided not to retract the flaps to the standard 20-degree go-around setting because he felt the aircraft was too low. The resulting high-drag configuration, combined with a pitch attitude that induced a speed decay, prevented the aircraft from gaining altitude. The aircraft flew almost perpendicularly to the runway at a low height until it impacted trees and a house 165 meters from the runway centerline.
Final Conclusions
The investigation by AAIB Malaysia concluded that the accident was caused by the crew's failure to follow Standard Operating Procedures (SOP) regarding flap settings and go-around techniques in gusty conditions. Specifically, the use of full flaps for landing in gusty winds and the subsequent failure to retract those flaps during the go-around created a high-drag state that made a successful climb impossible. The report also noted a lack of synchronization between MASwings manuals and the DHC-6 Series 300 SOP regarding go-around procedures. The final report was released on July 8, 2015.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Pilot Flying
First Officer
Pilot Monitoring; fatally injured
Systems & Failure Modes
Flaps
The DHC-6 uses high-lift flaps; full extension (37 degrees) creates significant drag. SOP for go-around requires retraction to 20 degrees to allow for a positive rate of climb.
PT6A-27 Engines
Both engines were producing full power during the attempted go-around, but the aerodynamic drag from the full flaps exceeded the available thrust for climbing at the low airspeed.
Interesting Facts
- 01The aircraft was 30 years old at the time of the accident.
- 02The demonstrated crosswind limit for the DHC-6-310 is 25 knots and the tailwind limit is 10 knots.
- 03The first officer, who was the pilot monitoring, died from his injuries after the crash.
- 04A woman and her 11-year-old son inside the impacted house escaped without injury.
- 05The aircraft hit the house 165 meters to the right of the runway 22 centerline.
Safety Actions & Advisories
Fleet Grounding
MASwings temporarily grounded its Twin Otter fleet following the accident to conduct safety checks and review operating procedures at remote airfields.
SOP Synchronization
The investigation recommended synchronizing MASwings company manuals with the DHC-6 Series 300 SOP to ensure consistent go-around procedures.