KUALA LUMPUR, Jan 23 — The fatal express bus crash that claimed the lives of 15 students from Universiti Pendidikan Sultan Idris (UPSI) along the Gerik-Jeli East-West Highway (JRTB) in June last year has been confirmed to have resulted from a combination of brake failure and the driver’s actions while descending.
The conclusion was disclosed in the Transport Ministry’s final report, which was released after receiving Cabinet approval.
In the 188-page report, it was stated that the bus’s braking system was compromised due to deformation and wear on the rear left brake drum, contamination by grease on the brake lining, and inconsistencies in the lining material composition.
“These factors reduced braking friction and accelerated the onset of ‘brake fade’.
Brake fade is a temporary loss of braking power caused by excessive heat, causing brakes to become less responsive, feel spongy or require more pedal force.
“At the same time, the bus was being driven at a speed exceeding the safe limit for the route.
“Aggressive braking at high speed caused a rapid rise in brake component temperatures, further worsening the brake failure.
“The combination of brake failure and excessive speed caused the bus to lose stability, skid and overturn,” the investigation found.
The report said the bus then struck a W-beam guardrail, which penetrated the passenger cabin, resulting in severe injuries and fatalities among passengers.
“The damage pattern was consistent with a high-speed lateral impact and direct interaction with a W-beam guardrail,” it said.
A total of 15 UPSI students died when the chartered bus carrying them from Jertih, Terengganu, to the main campus in Tanjong Malim, Perak, was involved in an accident on the JRTB near Tasik Banding, Gerik.
Of the 15, 13 were pronounced dead at the scene while two others died while receiving treatment at the hospital.
The accident also resulted in injuries to 33 others, including the bus driver and conductor, as well as the driver and three passengers of a multi-purpose vehicle (MPV).
An analysis revealed that 11 of the deceased were seated on the left side of the bus.
“The rear left section of the overturned bus crushed a W-beam guardrail installed along the road shoulder, with the impact causing several W-beam rails to penetrate the bus body structure, resulting in severe damage to the bus pillars and roof and significantly increasing the severity of passengers’ injuries.
“The force of the collision also caused part of the bus roof structure to detach, throwing several passengers out of the vehicle,” it said, adding that the bus had rotated anticlockwise as it skidded before coming to a stop on the road shoulder.
The report also said the bus tyres were found to be in compliance with safety standards, further indicating that tyre failure was not a direct contributing factor to the incident.
Nevertheless, the report also found that seat belts were only installed on the driver’s seat, and all passenger seats and the secondary driver’s seat were not equipped with seat belts.
“The absence of seat belts at passenger seats constituted a significant passive safety limitation,” the report added.
Brakes already compromised
The report said the overall results of field and laboratory tests indicated inconsistent performance of the tour bus’s braking system, particularly the rear left brake, which failed to generate effective braking force due to wear and deformation of the brake drum beyond the minimum specifications.
“Laboratory analysis of the brake lining revealed the presence of hydrocarbon contamination as well as evidence of thermal degradation and oxidation, consistent with exposure to high operating temperatures.
“Although the pneumatic system, secondary braking system (spring brake) and exhaust brake were found to be functioning as designed, the combined mechanical and material findings indicate that the braking system’s performance had been compromised prior to the incident,” it said.
This is despite the fact that a review of maintenance records found that the bus’s braking system had undergone maintenance work on February 9, approximately four months before the incident.
In addition, the report said the vehicle underwent a Puspakom inspection on April 13 and passed the brake efficiency test with an overall score of 59 per cent, meeting the minimum requirements under existing regulations.
“The combination of these factors led to a critical case of brake fade, consistent with physical evidence on the brake components, reports of a burnt smell by passengers and eyewitness accounts of the bus’s speed prior to the accident.
“This brake system failure was a major contributing factor to the loss of vehicle control and the subsequent fatal crash,” it said.
Human factor exacerbated by organisational failure
The report said human factors should not be viewed in isolation but understood as part of a broader system failure.
It said the overall analysis indicated that human factors played a significant role in the incident, including a combination of high-speed driving, poor driving discipline, unstructured fatigue management and limited response to the deterioration of brake performance.
“The driver’s history of significant traffic violations, particularly those related to speeding, indicates a consistent pattern of risky behaviour.
“In the context of this incident, this pattern increased reliance on the braking system while descending the slope, accelerated brake failure, and limited the driver’s response options once the situation became critical,” it said.
Exacerbating the human factor were identified violations including the leasing of licences without authorisation, misuse of the tourist driver exemption system and failures in safety audits, which indicated that the current system was insufficient to ensure the safe and ethical operation of tour vehicle.
“Overall, organisational factors were a major contributor to this accident.
This included violations of licence conditions, unauthorised leasing practices, misuse of the Tourism, Arts and Culture Ministry exemption system, and failures to comply with regulators’ safety training highlighted serious weaknesses in operator governance and institutional oversight by the relevant agencies.
“The operator’s failure to review the driver’s record, which included dozens of offences such as speeding violations, demonstrated significant gaps in human resource selection and monitoring.
“This scenario reflects a pattern of systemic failure, resulting in unqualified, undisciplined, and high-risk drivers being assigned to operate public vehicles,” it said.
