Incident Overview

Date: Wednesday 4 September 1991
Aircraft Type: Grumman American G-1159 Gulfstream II
Owner/operator: Conoco, lsf Du Pont de Numours and Co.
Registration Number: N204C
Location: ca 57 km S of Kota Kinabalu – ÿ Malaysia
Phase of Flight: En route
Status: Destroyed, written off
Casualties: Fatalities: 12 / Occupants: 12
Component Affected: Gulfstream II jet aircraftGulfstream II jet aircraft
Category: Accident
A Gulfstream II jet experienced a catastrophic accident due to a combination of factors. The flight was cleared to descend to 9500 feet, then reduced to 3000 feet, and ultimately impacted a significant hill. The controller’s inadequate descent clearance, coupled with crew confusion and reliance on ATC clearances, led to the accident. The navigational facility limitations in Kota Kinabalu, exacerbated by the rapid growth of air traffic, contributed to the situation.A Gulfstream II jet experienced a catastrophic accident due to a combination of factors. The flight was cleared to descend to 9500 feet, then reduced to 3000 feet, and ultimately impacted a significant hill. The controller’s inadequate descent clearance, coupled with crew confusion and reliance on ATC clearances, led to the accident. The navigational facility limitations in Kota Kinabalu, exacerbated by the rapid growth of air traffic, contributed to the situation.

Description

The Gulfstream II jet operated on a flight from Tokyo, Japan to Jakarta, Indonesia. A refueling stop was planned at Kota Kinabalu Airport, Malaysia. After passing the VJN VOR the crew were cleared to descend to 9500 feet. A further clearances was given to 6000 feet. After reporting 21 DME South of the airport, the flight was cleared down to 3000 feet. They were told to expect a clearance to turn finals for runway 02 after passing 4000 feet. At 06:10 UTC the crew reported at 4000 feet at 29 DME South of the airport. The controller then stated: “You are cleared to … join final for runway zero two, descend to two thousand five hundred.” This was the last contact with the flight. One of the flight crew members then remarked: “We’re getting pretty close to the hills here.” Shortly after deciding to initiate a climb, the aircraft impacted a 4100 feet high hill just below the top. Causal Factors The investigating team found the following causal factors to the accident: The Approach Controller’s inattentive descent clearance for the aircraft below the minimum sector altitude of 9,500 feet, his failure to recognize the safety hazard and to take corrective actions contributed to the cause of the accident. The air crew’s confusion with the air traffic system, failure to examine the sector altitude, and their high dependence on the ATC clearances contributed to the cause of the accident. The Navigational facilities in Kota Kinabalu aerodrome was sufficient to cope with the current traffic but will very soon require new and advanced technological facilities for the fast growing traffic. Some inconsistency with the interpretation of the Air Traffic Services and its standard operating procedures thus creating a gap between the Controller and the air crew.

Primary Cause

Controller’s inadequate descent clearance and failure to recognize a safety hazard.Controller’s inadequate descent clearance and failure to recognize a safety hazard.

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