Rescue personnel surrounding the wreckage of the GAF Nomad aircraft that went down on June 6, 1976 at Kota Kinabalu, Malaysia.
PETALING JAYA: "Double Six" pilot Gandhi J. Nathan was likely under pressure, exhausted and was experiencing stomach discomfort at the time of the aircraft's crash, according to the declassified report on the tragedy.
"Pathological tests on the pilot proved that he was reasonably fit at the time and not suffering from the effects of alcohol or drugs; though there was other evidence to suggest that he was tired and had a mild stomach disorder," the report read.
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The report also said Gandhi had been flying for 11 hours and seven minutes, which was over the 10-hour regulated limit then.
Prior to the accident at 3.42pm, Gandhi had flown successfully from Labuan to Kota Kinabalu twice, starting at 6.35am.
The second flight from Labuan to Kota Kinabalu was at 1.10pm.
"Therefore, as he took off at 6.35am and suffered the fatal accident at 3.42pm, he had already been on duty for an official time of 11 hours and seven minutes – this was in excess of the company duty period of 10 hours.
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"Thus, at the time of the accident, he had already exceeded duty by 67 minutes," added the report.
The report said there were suggestions by a witness that Gandhi was tired, but it was inconclusive as it could not be determined how much sleep he had the night before.
"It is possible that he was suffering the effects of his previous evening's meal because he specifically complained of feeling unwell before leaving on the last flight to Labuan at 1.10pm and again before departing from Labuan at 3.09pm on the final flight," the report said.
Investigations on the 'Double Six' plane crash have also shown that operating procedures on the flight company's pilots was "casual" and it was not up to professional standards.
For instance, the report said that there was a legal requirement to prepare load sheets before each flight.
"This was not carried out on this occasion and indeed it is not clear that any pilot of the company ever raised this," said the report.
A load sheet is a document that allows pilots to determine the aircraft's load and its distribution throughout the plane so that the mass and balance limits of the plane are not exceeded.
The report also said the pilot had a habit of not completing standard requirements and procedures before flying.
"Technical log entries were of such a poor standard as to make the document meaningless," the report read.
According to the report, the distribution of passengers in the flight was incorrect, affecting the plane's centre of gravity.
"Thus the scene appears to have set where the pilot, not in the habit of completing many of the requirements or procedures, called for by the company, did no more than a casual walk around the aircraft in Labuan and sat in the cockpit when the final loading was completed, oblivious to the incorrect distribution of the load," said the report.
The report also said there was a possibility that Gandhi was not in control of the passenger seat distribution due to the presence of VIP passengers in the plane.
"It is of course not known what pressures were on the pilot with such important passengers, to get on with the flight," it said.
The report also said the plane was not overweight, contrary to claims.
But it said Gandhi could have been under pressure to be on the flight despite feeling ill and tired.
The report also said that Gandhi failed to comply with the request of the Kota Kinabalu air traffic control (ATC) to report passing an altitude of 2,000 feet.
"He also did not respond to the ATC landing clearance twice," said the report.
The report also said Gandhi's failure to respond to the ATC could be due to Gandhi noticing that the tailplane trim of the plane was in a "full down" position.
"It should have been apparent to the pilot that this trim position was not normal and could only be due to a loading problem," said the report.
The report also said investigations on the pilot's history show that Gandhi had poor flying performance.
"Investigations indicated that Gandhi had some difficulty in passing both ground and air tests and only succeeded in gaining a Nomad endorsement in his licence in Feb 1976 following a series of poor write-ups from the company check pilots," the report read.
In its conclusion, the report said that the planes were maintained in accordance with approved maintenance schedules and there was no malfunction detected.
The report also said there was no evidence of sabotage.
The 'Double Six' crash report that killed 11 people including the then Sabah chief minister was released by the Transport Ministry on its website on Wednesday (April 12).
