Investigating The Hospital Sultanah Aminah Tragedy

The ICU Ward on the 2nd floor of the HSA on fire. Six people lost their lives in the tragedy
The ICU Ward on the 2nd floor of the HSA on fire. Six people lost their lives in the tragedy
A fire broke out at the Intensive Care Unit on the Second Floor of the Sultanah Aminah Hospital in Johor Bahru on the morning of the 25th October 2016 that killed six patients and injured one hospital staff.  It was said that the hospital staff was one of the nurses who refused to leave the doomed patients undergoing intensive care inside the ward.  They had to be pulled away to safety.  One of the dead was a man who had had a brain surgery two days earlier.  Taking the patients off their life-support system to safety was definitely a Catch-22 situation for the hospital staff and this would be a tragedy they would carry with them for the rest of their lives.  The Fire Forensics team of the Fire and Rescue Services Department will now have to secure the fire scene, protect the trace and transient evidences, identify fire patterns and try determine the cause of the fire.

A Board of Inquiry will be held and with all the evidences and statements from witnesses to be made available to them once the investigation has been completed, they would have to determine the root causes of the incident, what went wrong, why they went wrong, what barriers or control measures that have failed, and what barriers or control measures that were not adhered to.

This was not the first fire incident that has occured at the Hospital Sultanah Aminah (HSA). There had been at least five other incidents, three of which occured in the Intensive Care Unit ward itself. On the 30th July 2008, a fire broke out at the ICU ward where the latest tragedy had occured destroying properties inside the store room. Then on the 20th October 2009, a fire broke out at the Ground Floor of the Main Block at the Phase IV Development Site Office.  In early January 2010 a fire broke out at the Southern ICU Ward. This was caused by a damaged electrical fuse. On the 17th April 2010, an overloaded power supply switch caused a fire inside the Main Block’s Air Handling Unit’s room.  And finally I was told that about three weeks ago, sparks were spotted coming out from the panel inside the ICU ward where the latest incident took place.

Given that fire is not uncommon at the HSA, I am sure that the hospital does have a Fire Response Plan as prepared according to the Arahan Perkhidmatan 1986, Bab Lapan Peraturan Am. This Arahan Perkhidmatan would require the HSA to hold fire drills and fire-fighting training as well as the inspection by the Fire and Rescue Services Department of fire-fighting equipments AT LEAST ONCE A YEAR. I used to hold one each week for the Drilling Rigs under my charge, fortnightly on board the offshore support vessels and once a quarter for each of the Mass Rapid Transit project package.

The Fire Safety Policy of the HSA would also require for a Fire Safety Team (PAKKHSA) to be formed and a Fire Security Officer to be appointed.  The Fire Security Officer would be tasked among others would be to conduct scheduled fire-fighting equipment inspections together with the entity that is responsible for the maintenance of these equipment – Pantai Medivest Sdn Bhd.  Pantai Medivest I am sure would in turn appoint local contractors to sub-contract the inspection and maintenance works out.

My questions would be:

  1. When was the last time a fire drill held?
  2. When was the last time an evacuation drill held?
  3. When was the last time the PAKKHSA underwent a fire-fighting training?
  4. When was the last time hospital staff trained on how to handle portable fire-fighting equipment?
  5. When was the last time that fire and fire fighting equipment inspections were conducted?
  6. What were the findings made during the post-mortem of each of the drills and whether they had been addressed?
  7. What measures were taken to ensure that the electrical sparks that appeared in the ICU ward three weeks ago do not recur?
  8. Did Pantai Medivest physically verify the corrective actions taken to prevent the recurrence of the sparks?
  9. When was the last time Pantai Medivest audited its contractors as part of its contractors anagement plan?
  10. When was the last time that the State Health Department audited Pantai Medivest’s performance as well as its adherence to the HSA’s and MOHs fire safety policies?

The above would be the basic question that I would be asking but of course my questions would not limited to just those. The more we find out during the investigation the more questions that would be raised.  My only hope is that a truly thorough investigation would be conducted especially that Pantai Medivest is the common denominator at all Government Hospitals in the country, and any weakness not identified would be another costly tragedy waiting to happen, and by learning nothing from this tragedy the six would have died in vain.

Hail The Playstation Pilots

Franklin slams on the brakes of his Truffade Adder, exits his car and gets into a lift (or elevator, depending on the part of the world you are from) all the way to the rooftop of a building in Los Santos where he boards a helicopter on the rooftop helipad. A simple press of the R2 button and he’s off into the air.  He flies above the serene Mount Gordo without any problem, then lands the helicopter at the airfield in Sandy Shores before hijacking a Canis Mesa listening to East Los FM. That is how simple flying a helicopter is to some…especially on their Grand Theft Auto V game.

Franklin runs to a chopper - picture courtesy of Gametipcenter
Franklin runs to a chopper – picture courtesy of Gametipcenter

If only life is as simple as according to the whiners out there.  Unfortunately, it is not.

Many whine and complain about the late response by the military, Fire and Rescue Services Department, police etc., to rescue stranded climbers on top of Mount Kinabalu after a M5.9 earthquake killed 19 climbers, trapped more than a hundred others, and damaged or destroyed buildings in Ranau, southeast of the mountain.  An Australian climber even lambasted the Malaysian authorities to the world’s press.  On Facebook, keyboard pilots echo the psychotic behaviour of the Australian climber, criticizing the so-called delay in response by the authorities.

So why can’t a Franklin just fly the helicopter to the peak of Mount Kinabalu?  The only Franklin I knew who flew close to Mount Kinabalu was my squadmate, Lieutenant Gabriel Buja Joel RMAF, who rescued British SAS who got lost near the mountain in 1995.  For that he was awarded the Air Force medal (Pingat Tentera Udara) and a medal from Her Majesty Queen Elizabeth II.  In 2003, Gabriel was unfortunately killed near Lawas, by another mountain.

What am I getting at?

Mountain Waves Turbulence!  It is the unseen nightmare that has brought down a number of airliners and helicopters, including late Gabriel’s, and damaged a whole bunch more worldwide.  It is so violent and unforgiving that the Federal Aviation Authority (FAA) of the US had issued a specific instruction just for mountain flying. To safely fly above a mountain pass, a clearance of at least 2,000 feet above the highest pass an aircraft is to cross.  On top of that, mountain flying is not recommended if the winds aloft are greater than 25 knots as potentially dangerous turbulence as well as strong up and down drafts are likely to occur. I will go deeper into this later.

On 10th January, 1964, a Boeing B-52H Stratofortress strategic bomber (tail number 61-023) had its vertical stabilizer (or tail if you want to) sheared off by mountain waves after flying above the Rocky Mountains at 14,000 feet.

B-52H Nr 61-023 without its vertical stabilizer on 10th January 1964 - courtesy of Talkingproud
B-52H Nr 61-023 without its vertical stabilizer on 10th January 1964 – courtesy of Talkingproud

On 9th December 1992, a DC-8 aircraft of the American International Airways had its Engine No.1 sheared off by mountain wave turbulence.

The DC-8 of the American International Airways that lost an engine - courtesy of University Corporation for Atmospheric Research
The DC-8 of the American International Airways that lost an engine – courtesy of University Corporation for Atmospheric Research

Both aircraft and crew above were lucky to make it back alive.  Others like Gabriel weren’t so lucky.

The late Gabriel )3rd row, right most) and the writer (3rd row, second from right) during a jungle warfare exercise in January 1988
The late Gabriel )3rd row, right most) and the writer (3rd row, second from right) during a jungle warfare exercise in January 1988

Most of the time, those who frequently look at Mount Kinabalu from far could see streams of clouds occasionally envelope the mountain.  Let me show you a photo taken from one of the rescue helicopters that attempted to land at Laban Rata:

Visibility from a rescue chopper headed towards Mount Kinabalu - courtesy of @ayaqjagung on Twitter
Visibility from a rescue chopper headed towards Mount Kinabalu – courtesy of @ayaqjagung on Twitter

The visibility can change drastically and in Alaska, many pilots and passengers have perished thinking the visibility would remain clear all the time.

But the weather was clear and the stranded climbers could see all the way down!

Did they watch what was above?  Clear visibility also means high winds have pushed away the clouds.  What you need to look above are those thin, long clouds that we who have our feet firmly planted on the ground and head that stays on our neck unlike those who suffer from psychosis call Lenticular clouds.

Lenticular clouds formation caused by mountain wave turbulence - courtesy of the City University of New York
Lenticular clouds formation caused by mountain wave turbulence – courtesy of the City University of New York

As you can see, beneath the lenticular clouds are what meteorologists call rotor – a turbulent horizontal vortex generated around the “troughs” of mountain wave activity.  Rotors could either push an aircraft upwards, or slam it down to the ground as shown in the diagram below:

The effects of rotor turbulence on aircraft - courtesy of Flight Safety Australia
The effects of rotor turbulence on aircraft – courtesy of Flight Safety Australia

In the end, the helicopters did manage to get to Laban Rata to bring down bodies and some of the injured victims.  Of course not to the instance wanted by the climbers.

Yes, the Kinabalu Park guides are the heroes in this most unfortunate tragedy.  Why them and not the soldiers or pilots or firemen or the police?  They are the ones with the best knowledge of the area.  Even of some trails have been cut off, they would still be able to find their way up and down the mountain because they are most familiar with the area.  I salute them, as I salute the other rescuers who have and still are risking their lives trying to bring down the stranded climbers as well as bodies of the victims.

So, stop whining and forget what you have watched on TV or in the movies.  Life does not work like how the directors want you to believe.  And helicopter flying is nothing like how Franklin does it in GTA V.

Let the professionals do their job!

LIMA 2015 Begins With A Bang

Two days before the opening ceremony of the Langkawi International Maritime and Aerospace 2015 (LIMA 2015), two KT-1B Wongbee aicraft belonging to the Indonesian Air Force’s Jupiter Aerobatic Team clipped wings in what seemed to be an “opposing solo” maneuver and crashed off site, with one aircraft hitting the ground causing two houses to catch fire. All four pilots ejected safely.

The Yogyakarta-based team are here in Langkawi to perform at LIMA 2015 and were practising when the incident occured. All pilots are safe while no injury has been reported on the ground.  The pilots were evacuated by a RMaF EC-725 and the Fire and Rescue Services Department’s Mi-172 helicopters.

This is the second incident involving aerobatic teams during practice for a LIMA series. In 1991, a RMAF Pilatus PC-7 from the Tamingsari aerobatics team crashed into the back of a house in Kepala Batas, Alor Setar, Kedah while performing a twinkle at the end of a “bomb burst” formation for the inaugural LIMA exhibition. The pilot died on the spot.

The aerial displays will carry on in spite of the incident.









Sources of photos: Twitter, Agendadaily and Berita Harian.

In a related development, the Defence Minister of Malaysia, Hishammuddin Hussein, and the Defence Minister of Indonesia, Gen (Rtd) Ryamizard Ryacudu, visited the pilots who are being treated at the Langkawi Hospital.  Both Malaysia and Indonesia will conduct a joint investigation into the incident.





Source of photo: Malaysian Ministry of Defence

SAREX LIMA 2015 – The RMAF EC725

The survivor floats on the surface of the sea, having escaped a plane crash less than an hour ago.  The current here is strong and he drifts farther away from the main group of survivors.  Then he saw a speck of grey flying towards him.  It was a Airbus Helicopter EC725 dubbed the Super Cougar, the new workhorse of the Royal Malaysian Air Force.

Inside the cockpit, the pilot could spot the lone survivor and a few others, drifting towards the open sea.  Thanks to the AHCAS (Advanced Helicopter Cockpit and Avionics System), pilots of the EC725 could do what its predecessor, the Sikorsky S-61A4 Nuri, could not.  The EC725 features a full glass cockpit and the Active Matrix Liquid Crystal Displays ensure the pilots better monitoring of the displays under the glaring late morning sun.

The pilot hovers over the drifting survivor. He is assisted by a digital search and rescue system that provides automatic search patterns, transition and hover. Unlike the Nuri, the EC725 could “drift” along with the survivor as the winch strop is lowered by the air quartermaster.  Although the hover altitude is higher (more than double the Nuri’s), the EC725 managed to pick up the drifting survivor and other drifting survivors in no time, thanks to the powerful twin Turbomeca Makila 1A4 turboshaft engines that features a dual-channel Full Authority Digital Engine Control (FADEC) , something the Nuri was not capable of.  The Nuri would have to fly away after a couple of pick ups to cool its engines off.

The above was the Water Search And Rescue portion of the Search and Rescue exercise (SAREX LIMA 15) in preparation for next week’s Langkawi International Maritime and Aerospace Exhibition 2015 (LIMA 2015).  The exercise was divided into two segments, Water SAR and Land SAR.  SAREX LIMA 15 was to test the Search and Rescue plan and inter-agencies coordination and logistical cooperation.  The aim was to test, assess and improve the Airport Emergency Plan before the commencement of LIMA 2015. The Exercise was held from the 4th to 6th March 2015 and involved among others the Royal Malaysian Air Force, Royal Malaysian Police, Royal Malaysian Navy, the Malaysian Maritime Enforcement Agency, Malaysia Airports Holdings Berhad, the Fire and Rescue Services Department, the Malaysian Marine Department, Ministry of Health, the Malaysian Meteorological Department, the Malaysian Army’s Royal Medical Corps, Malaysia Airlines, Air Asia and last but not least, the Department of Civil Aviation of Malaysia.  Assets that were involved included two helicopters, 11 surface vessels and four jet-skis.

The EC725 takes off carrying critically-injured survivors during SAREX LIMA 15
The EC725 takes off carrying critically-injured survivors during SAREX LIMA 15

When met, RMAF’s Chief of Staff (Air Operations) Major General Dato Haji Abdul Mutalib bin Abdul Wahab TUDM said that he was awed by the superb performance of the EC725.  He opined that the EC725 is by far the best search-and-rescue asset he has ever seen, given the capabilities it displayed during SAREX LIMA 15.  This is of course of utmost importance as there are quarters bent on ridiculing military purchases.  Seeing with my own eyes how the EC725 was able to hover effortlessly throughout the exercise brought much satisfaction to me knowing that this was the correct choice made by the RMAF and there should not be any politically-motivated condemnation towards the organisation for purchasing what it should have had for the longest time.

The Fire and Rescue Services Department should also be applauded for a superb medical evacuation exercise task performed at SAREX LIMA 15 using its Mi-171 helicopter.

The FRSD's Mi-171 takes off carrying three critically-injured survivors during SAREX LIMA 15
The FRSD’s Mi-171 takes off carrying three critically-injured survivors during SAREX LIMA 15

It is hoped that the inter-agencies coordination that was put to test during SAREX LIMA 15 will better prepare the emergency services for any eventuality not just for LIMA 2015, but for all search-and-rescue incidents.