A preliminary report by a special task force within the transport ministry has identified multiple factors which contributed to the bus crash in Gerik that claimed 15 lives.
The report highlighted that the incident was not solely due to technical failure or driver error, as it also pointed to weaknesses in the operational structure, the selection of an unsuitable driver, inadequate safety measures, and a lack of monitoring and enforcement systems.
The discovery of numerous traffic summonses involving the bus drivers, and the operator’s failure to conduct safety checks indicated a management failure within the organisation, the report continued.
Based on visual analysis of the incident, the preliminary report states that the estimated speed sustained by the bus in the incident was 117.6 km/h. It added that the margin of error due to video resolution limitations is 16.8 km/h, thus the true speed range of the bus was estimated to be between 111.3 km/h and 134.4 km/h, the report stated.
The estimated speed of the bus exceeded the critical speed for overturning, found to be in the range of 111.3 km/h to 114.5 km/h from prior technical analysis. The speed limit on the stretch of road where the incident had occurred is 60 km/h, and so the bus was found to be travelling at nearly twice the speed limit.
Preliminary reporting found that all six tyres fitted to the bus were in good condition, and complied with safety standards, and the tyres used were not retreaded, nor for snow. The drum brakes on the bus were also found to be using brake lining that was in good condition, exceeding the minimum 5 mm thickness requirement.
Initial inspection of the brake system on the bus revealed several physical marks the brake shoe and brake drum components, indicating the possibility of excessive heat which could lead to brake fade. Initial findings were blue marks on the front left brake drums, scoring of the rear brake pads, and minor cracks on the rear left brake drum.
To determine whether or not brake fade has occurred in this incident, a material test and analysis will be carried out on the brake components; this is to determine if the materials have been affected by excessive heat.
Meanwhile, further technical inspections on the braking system of the bus will be carried out, for components which could be tested visually, such as the brakes’ pneumatic system. This inspection process will be carried out with the technical assistance of the bus chassis manufacturer, Hino Motors Malaysia.
While static physical inspections upon the main components of the bus such as tyres, brakes and suspension have found no apparent failure prior to the incident, dynamic testing for its brake and steering systems can not be carried out due to damage sustained in the crash, and this limits the full evaluation of brake performance during the incident, the preliminary report wrote.
Of the two designated drivers of the bus, the preliminary report found the first driver to be in possession of a valid driver’s and PSV license, while the second bus driver was found to have licenses which expired in 1998. The first bus driver was found to have no JPJ summonses, 18 PDRM summonses (five settled, 13 outstanding); the second bus driver was found to have nine active JPJ summonses, and 13 outstanding PDRM summonses.
In terms of road conditions, observations of the location found that all road markings, including double lines and edge lines were not visible or have faded, likely due to deterioration and lack of road maintenance, the preliminary report wrote.
Observation of the incident site found that the visual range on the twisty stretch of road is limited, and the report states that based on road design standards of this category, the stopping sight distance required is around 490 m. However, checks found that the contour of the road is not clearly visible, even from a distance of 300 m.
The deteriorated road markings have diminished the visual guidance offered to drivers, particularly when driving at night or in poor weather. The lack of visual guidance could make it difficult for drivers to maintain the correct position on the road, thus increasing the risk of vehicles crashing or leaving the road, the report wrote.
“All these factors showcase a systemic failure which needs a complete overhaul involving all parties in the public transport ecosystem,” the report said. Investigations are ongoing and there are potentially updates to be added to the final report, however the task force emphasised that the findings aim to prevent future accidents, rather than to assign blame or liability.
“The findings and recommendations in this report are primarily to prevent such accidents from happening again and to strengthen the road transport system to protect the lives of road users,” the report said, urging stakeholders to focus on safety improvements and necessary rectifications.
The incident occurred in early June, when a bus chartered by UPSI students for the Hari Raya Aidiladha holidays was travelling from Jertih, Terengganu to Tanjung Malim where UPSI is, overturned at a bend after colliding with a Perodua Alza on the East-West Highway near Tasik Banding, Gerik.
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