The Transport Ministry's final report on a helicopter crash in Semenyih, Selangor on April 4 last year, which claimed the lives of six people has indicated pilot error.

The report points to the failure of Captain Clifford Fournier to conduct a detailed damage assessment of Helicopter Dauphin 9M-IGB, after an earlier unplanned landing at an open field.

The report released by the ministry's Air Accident Investigation Bureau (AAIB) revealed the rough landing at the open field at Sekolah Kebangsaan Ladang Kota Bahagia had caused the helicopter's left main landing gear to sink into loose soil.

"The pilot had failed to conduct detailed damage assessment of the left main landing gear, knowing the presence of excessive oil leak and damages to other parts of the helicopter.

"The vertical fin attached to the LH horizontal stabiliser contacted the soil and subsequently, fractured the inboard root of the LH horizontal stabiliser.

"The pilot was seen by a witness to have exited the helicopter and accompanied the disembarked passengers, clear of the main rotor area. However, he did not carry out any inspection of the helicopter," it said.

The final report was uploaded onto the Transport Ministry website (www.mot.gov.my) on Sept 9.

The crash which occurred at Kampung Sungai Pening-Pening in Semenyih took the lives of Rompin MP Tan Sri Dr Jamaluddin Jarjis; Principal Private Secretary to the Prime Minister, Datuk Azlin Alias; businessman Datuk Tan Huat Seang; Jamaluddin's bodyguard, Corporal Razkan Seran; Fournier; and, the pilot's acquaintance, Aidana Baizieva.

They were on their way home after attending the wedding reception in Pekan of the daughter of Prime Minister Datuk Seri Najib Tun Razak and Datin Seri Rosmah Mansor, Nooryana Najwa, and Daniyar Kessibayev.

According to the report, other factors which contributed to the accident were the descending high cruising speed, compounded with landing gears down had aerodynamically put excessive loads on the fractured left horizontal stabiliser.

"Passenger intervention to pilot to return home on several occassions could create peer pressure on the pilot to rush for flying home," it said.

The Solid State Combination Cockpit Voice and Flight Data Recorder (SSCVFDR) information and inspection of the last landing area before the acccident revealed that the left landing gear had sunk to approximately 20 inches deep into the soft ground, causing the helicopter to tilt more than 13 degrees to the left.

"The LH horizontal stabiliser vertical fin and the tail section below the tail rotor fenestron had impacted the ground, causing some damage to the inboard root of the LH horizontal stabiliser," it explained.

The report further found that there was also evidence of excessive fluid leakage in the sink hole made by the left landing gear, as well as on the grass about 10 metres forward of the landing point.

"The fluid could have originated from the LH landing gear oleo strut and hydraulic brake system. However, no hydraulic warning was triggered during the check performed by the pilot before taking off," it said.

"At the end of the recording, as the helicopter was flying under auto pilot at 148 kts., the pitch of the helicopter unexpectedly and significantly decreased. The helicopter rapidly went beyond the flight envelop limits without any pilot input.

The report further mentioned that the crew was properly licensed and proficient to fly the helicopter.
"The helicopter maintenance contract with Airbus Helicopter was properly carried out as per the maintenance programme and there was no anomaly in the maintenance documents," it said.

A preliminary report on the cause of the aircraft was released on May 14 last year, revealing the damage to a stabiliser as the cause of the crash.