Crash of a Piper PA-31-350 Navajo Chieftain near Bontang: 4 killed

Date & Time: Aug 24, 2012 at 0810 LT
Operator:
Registration:
PK-IWH
Flight Phase:
Survivors:
No
Schedule:
Samarinda - Bontang
MSN:
31-7852065
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
17547
Captain / Total hours on type:
4250.00
Aircraft flight hours:
16743
Aircraft flight cycles:
14830
Circumstances:
On 24 August 2012, a Piper Chieftain PA-31-350 aircraft, registered PK-IWH, was being operated by PT. Intan Angkasa Airservice to conduct an aerial survey (aero magnetic) flight at a survey area located north of Bontang, East Kalimantan. There were 4 persons on board; one pilot, one security officer and two surveyors. Based on the flight plan submitted by the Pilot in Command (PIC) to the Briefing Office, the flight was planned with an altitude of 3,000 feet AMSL en-route and 500 feet AGL while surveying the area. The fuel endurance was for 6 hours flight time and the aircraft equipped with an Emergency Locator Transmitter (ELT). The aircraft departed from Temindung Airport (WALS), Samarinda at 0751 local time (LT - 2351 UTC). At 0004 UTC, the pilot informed to the Temindung Control Tower controller (Temindung Tower) that the aircraft was abeam Tanjung Santan descending from 3,000 feet and established contact with Bontang Info officer (Bontang Info). At 0005 UTC, the pilot informed the Bontang Info that the aircraft altitude was 300 feet and estimated over Bontang at 0011 UTC. Bontang info acknowledged this transmission and advised the pilot to report when the flight left the Bontang Area. At 0010 UTC, the SureTrack (flight following system) stopped receiving data from the aircraft. The last recorded information was an aircraft speed of 138 knots, heading 352°, latitude 0°8’33” N and longitude 117°12’54” E. At 0600 UTC, the engineer of the PK-IWH aircraft asked the Temindung Tower about the flight as the fuel endurance had been exceeded. The Temindung Tower contacted Bontang Info to get information about the aircraft. After receiving the request, Bontang Info tried to contact the pilot twice and there was no reply. Bontang Info also contacted the Tanjung Bara Airstrip to request information about the aircraft but there was no information. The Temindung Tower reported that:
• at 0610 UTC declared INCERFA (Uncertainty phase);
• at 0630 UTC declared ALERFA (Alert phase);
• at 0700 UTC declared DETRESFA (Distress phase).
At 0730 UTC, the search and rescue team was assembled; the team consisted of the Temindung Airport Authority, National Search and Rescue, Indonesian Police, Army and Airforce. The search operation was conducted via ground and air using three helicopters. On 26 August 2012 at 0850 UTC, the aircraft wreckage was located by a ground search team on a ridge of Mayang Hill, Bontang at approximately 1,200 feet AMSL at coordinates 00°12’34.3”N, 117°16’57.3”E, 12 NM from Bontang Aerodrome on bearing of 294°. The accident site was within the planned aircraft survey area. All occupants were fatally injured and the aircraft was destroyed by impact force and post impact fire.
Probable cause:
The accident was typical of a Controlled Flight into Terrain (CFIT). Low altitude VFR flying in a low visibility environment limited the pilot’s visibility and increased the probability of impact with terrain.
Final Report:

Crash of a Fokker F27 Friendship 400M in Jakarta: 11 killed

Date & Time: Jun 21, 2012 at 1450 LT
Type of aircraft:
Operator:
Registration:
A-2708
Flight Type:
Survivors:
No
Schedule:
Jakarta - Jakarta
MSN:
10546
YOM:
1976
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The crew (one instructor and six pilot under training) were engaged in a training flight and departed Jakarta-Halim Perdanakusuma Airport at 1310LT for a local flight consisting of touch-and-go manoeuvres. After a circuit, the pilot-in-command completed a last turn to the left to join the glide for runway 18 when the aircraft stalled and crashed onto several houses located less than one km from the runway threshold. The aircraft was destroyed as well as several houses. Six occupants in the aircraft and four people on the ground were killed while the copilot was critically injured. Unfortunately, he did not survive to his severe injuries and died few hours later at hospital.
Probable cause:
It was reported that the approach speed was too low during the last turn, causing the aircraft to stall. The distance between the aircraft and the ground was insufficient to expect recovery.

Crash of a Boeing 737-4Y0 in Pontianak

Date & Time: Jun 1, 2012 at 1235 LT
Type of aircraft:
Operator:
Registration:
PK-CJV
Survivors:
Yes
Schedule:
Jakarta - Pontianak
MSN:
24689/1883
YOM:
1990
Flight number:
SJY188
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
155
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25000
Circumstances:
The approach to Pontianak was unstable and really difficult due to turbulence and poor weather conditions (heavy rain falls). The aircraft landed on wet runway 15 and skidded. It eventually veered off runway to the left and went through a muddy field. The nose gear was torn off while both main gears sank, leaving both engines on the ground. While all 163 occupants were evacuated safely, the aircraft was damaged beyond repair. At the time of the accident, weather conditions were as follow: wind from 230 at 22 knots, visibility 600 metres, few clouds at 900 feet, broken at 700 feet, CB's above the terrain and turbulences.

Crash of a Pilatus PC-6/B2-H4 Turbo Porter in Muaritan: 2 killed

Date & Time: Apr 25, 2012 at 1730 LT
Operator:
Registration:
PK-VVQ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Balikpapan - Balikpapan
MSN:
965
YOM:
2009
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1912
Captain / Total hours on type:
81.00
Aircraft flight hours:
2397
Aircraft flight cycles:
3466
Circumstances:
The Pilatus Porter PC-6 aircraft operated by PT. Puji Astuti Aviation (Susi Air) registered PK-VVQ on Areal Survey Flight, departed from Sepinggan-Balikpapan to Melak Area on 25 April 2012 at 0440 UTC (Universal Time Coordinate) or 1240 LT. There were one pilot and one pasenger on board, the estimate flight endurance was seven hours. At 0505 the aircraft reported leaving Balikpapan Approach. At 0910 the aircraft was reported to Melak Radio on radial 060 at the altitude of 3,500 feet, and that it would be leaving Survey after a further twenty minutes. Melak Radio reported that the aircraft lost contact at 0930. At 0922 a text message was sent by the passenger to his employer stating “Run out of fuel, landing on road”. The Search and Rescue Bureau informed that a distress signal was tetected on 1025 at the position of 00 25’.02” N 116.02’.48”E. On 26 April 2012 at 1730 UTC the aircraft was found in Muaritan – Kecamatan Tabang, Kutai Karta Negara at the position 00 25’.03” N 116.01’.55”E. The aircraft was substantially damaged, the pilot and the passenger were fatally injured.
Probable cause:
The engine flamed out caused by lack of fuel supply from main fuel tank to the engine. The pilot likely fixated on the survey flight execution and lost awareness of his fuel situation. The transferring of fuel from the auxiliary tank was not performed during the flight as required. The combination of inexperience of the pilot related to survey flying, fatigue and the highly demanding survey operator contributed to this sequence of events.
Final Report:

Crash of a Boeing 737-36M in Yogyakarta

Date & Time: Dec 20, 2011 at 1713 LT
Type of aircraft:
Operator:
Registration:
PK-CKM
Survivors:
Yes
Schedule:
Jakarta - Yogyakarta
MSN:
28333/2810
YOM:
1996
Flight number:
SJY230
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
131
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
29801
Copilot / Total flying hours:
562
Aircraft flight hours:
31281
Aircraft flight cycles:
21591
Circumstances:
On 20 December 2011, a Boeing 737-300 aircraft, registered PK-CKM, was being operated by PT. Sriwijaya Air on a schedule passenger flight SJ230 from Soekarno Hatta International Airport (WIII) Jakarta to Adisutjipto International Airport (WARJ), Yogyakarta. There were 141 persons on board; two pilots, four cabin crews and 135 passengers consisted124 adult, 7 children and 4 infant. The aircraft departed from Jakarta at 14.00 LT (07.00 UTC), the pilot in command was the pilot flying and the co-pilot was the pilot monitoring. At 08.10 UTC the aircraft made holding at 8 NM from JOG VOR due to bad weather. After the second holding and the weather was deteriorated, the airport authority closed the airport for takeoff and landing. The pilot requested divert to Juanda Airport (WARR), Surabaya and landed at 08.40 UTC. After refuelling and received the information about weather improvement in Yogyakarta then the aircraft departed, at 09.20 UTC, in this sequence of flight the PIC acted as PF, with 137 persons on board consisted of two pilots, four cabin crews and 131 passengers consisted 120 adult, 7 children and 4 infant. The aircraft was on the fifth sequence from seven aircraft approaching Adisucipto airport Yogyakarta. Passing JOG VOR it was seen on radar screen that the aircraft speed was read 203 Kts at 2700 ft. Approach Controller instructed to reduce the speed. At about 1200 ft, the pilot had the runway insight and disengaged the autopilot and auto throttle. The pilot made correction to the approach profile by roll up to 25 degrees and rate of descend up to 2040 ft per minute. The GPWS warning of ‘pull up’ and sink ‘rate were’ activated. Aircraft touched down at speed 156 Kts of 138 Kts target landing speed. During landing roll, the auto-brake and spoiler activated automatically. The thrust reverse were deployed and the N1 were recorded on the FDR increase and decrease to idle before increased to 80% prior to aircraft stop. The PIC noticed that the aircraft would not be able to stop in the runway and decided to turn the aircraft to the left. The aircraft stopped at 75 meter from the end of runway 09 and 54 meter on the left side of the centre line. Most of the passenger evacuated through left and right forward escape slides. All passengers were evacuated safely. The passenger on the stretcher case was evacuated by the airport rescue. 6 passengers reported minor injured while all crew and the remaining passengers were not injured. The aircraft suffered major damage on the right main and nose wheel.
Probable cause:
Findings:
1. The aircraft was airworthy prior the accident. There was no evidence that the aircraft had malfunction during the flight.
2. The crew had valid license and medical certificate. There was no evidence of crew incapacitation.
3. In this flight Pilot in Command acted as Pilot Flying and Second In command acted as Pilot Monitoring.
4. The flight crew did not conduct approach crew briefing.
5. There was no checklist reading.
6. The PIC as Pilot Flying did not have the instrument approach procedure immediately available to review during approach.
7. During the approach, the PIC course indicator was set at 091 and the SIC was at 084.
8. The rate of descend recorded vary and up to 1920 ft per minute and below 500 ft AGL the rate of descend recorded up to 2040 ft per minute.
9. The approach did not meet the stabilize approach criteria as stated in the FCOM.
10. There were several GPWS warning of ‘sink rate’ and ‘pull up’ activated during approach.
11. The aircraft touched down at speed 156 Kt before bounced, instead of 138 Kt target landing speed.
12. The flap extended to 40 after the aircraft touch down.
13. The FDR recorded reduction in N1 during thrust reverser activation after landing.
14. The CRM was not well implemented.
Factors:
Unsuccessful to recognize the two critical elements, namely fixation and complacency affected pilot decision to land the aircraft while the approach was not meet the criteria of stabilized approach.
Final Report:

Crash of a PAC 750XL in Abmisibil: 2 killed

Date & Time: Dec 17, 2011 at 0740 LT
Operator:
Registration:
PK-RCD
Survivors:
Yes
Schedule:
Jayapura - Abmisibil
MSN:
149
YOM:
2009
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
After landing on a wet runway at Abmisibil Airport, the single engine aircraft went out of control, veered off runway and came to rest in a ravine, bursting into flames. The pilot was killed and a passenger died few hours later. All three other occupants were seriously injured and the aircraft was destroyed by impact forces and a post crash fire.

Crash of a Casa 212 Aviocar 200 in Larat

Date & Time: Dec 3, 2011 at 1308 LT
Type of aircraft:
Operator:
Registration:
PK-NCZ
Survivors:
Yes
Schedule:
Langur - Larat
MSN:
274/79N
YOM:
1986
Flight number:
MNA9933
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7500
Captain / Total hours on type:
5500.00
Copilot / Total flying hours:
343
Copilot / Total hours on type:
72
Aircraft flight hours:
26935
Aircraft flight cycles:
30064
Circumstances:
The Casa 212-200 aircraft registered PK-NCZ operated by PT. Merpati Nusantara Airlines on a scheduled flight from Langur to Larat, touched down at 224 meters from runway 09, was bouncing twice to the left of runway centre line, out of the runway and stopped at 607 meters from runway 09 touch down area as final position, and 15 meters to the left of runway edge. The Pilot Flying was First Officer, and after second bouncing, PIC took over, and he tried to bring the aircraft to the centre line of the runway without success. The aircraft continued rolled to the shoulder away from the runway and stopped at the final position. This is the second landing at Larat runway on the same day. There were 15 passengers, 3 children, one baby, Pilot In Command, two First Officers, one First Officer was Pilot Flying from Langur to Larat, one engineer on board. One passenger was serious injured, another one passenger minor injured.
Final Report:

Crash of a Cessna 208B Grand Caravan in Bilogai-Sugapa: 1 killed

Date & Time: Nov 23, 2011 at 0942 LT
Type of aircraft:
Operator:
Registration:
PK-VVG
Flight Type:
Survivors:
Yes
Schedule:
Nabire - Bilogai-Sugapa
MSN:
208B-1308
YOM:
2007
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1859
Captain / Total hours on type:
1550.00
Copilot / Total flying hours:
690
Copilot / Total hours on type:
231
Aircraft flight hours:
4331
Aircraft flight cycles:
5375
Circumstances:
The flight route was Nabire to Bilogai as an unscheduled cargo flight. There were two pilots on board and the freight load was a mixture of food, palm oil, and cement. The aircraft departed from Nabire at 2355 UTC (0855 LT), the estimate time of arrival of Bilogai was 0045 UTC. At 0042 UTC the aircraft was reported above touchdown zone and the altitude recorded of 6,960 feet, direction 277 degrees and air speed 94 knots. The aircraft executed a go around due to an unauthorized person entering the shoulder of the runway 27, the aircraft then continued to climb and headed left. It was reported while the aircraft initially was climbing with the nose up but following lost altitude. During go around manoeuvre the aircraft attitude was in high nose up position, caused the angle of attack was too high and beyond a stall margins caused the aircraft stall. The aircraft bank to the right and crashed on a corn farm at coordinate S 03 44.58 E 137 0.96 and altitude about 6,550 feet with heading about 260 degrees. The aircraft was destroyed on impact with the ground. The captain seriously injured and still on seat in the aircraft wearing the shoulder harness. The second in command was fatally injured outside of the aircraft at the crashed site.
Probable cause:
FINDINGS :
• The aircraft was airworthy prior the accident and there was no evidence of system malfunction during the flight.
• The crew had valid license and medical certificate.
• There were no fences at the airport perimeter.
• There was a local plantation area nearby the runway.
• Unauthorized person entering the shoulder of the runway 27.
• There was no warning signal to alert if unauthorized persons entering the runway, especially during any aircraft Takeoff and Landing.
• The valley (gap) on the south side of the runway was too narrow for successful go around manoeuvre by a caravan aircraft.
• The aircraft most probably stalled due to very high angle of attack, when the aircraft was manoeuvre to avoid the surrounding terrain and bank to the right.
• The communication of incoming and outgoing Susi Air aircraft from and to Bilogai was only to Susi Air ground handling Agent at Sugapa.
CAUSES :
The aircraft was executed a Go Around due to a unauthorized person entering the shoulder of the runway 27, after go around, crew tried to avoid terrain impact, increasing the aircraft attitude more pitching up caused the angle of attack was higher and beyond a stall margins , finally stall just before impact.
Final Report:

Crash of a Casa 212 Aviocar 200 near Bohorok: 18 killed

Date & Time: Sep 29, 2011 at 0750 LT
Type of aircraft:
Operator:
Registration:
PK-TLF
Flight Phase:
Survivors:
No
Site:
Schedule:
Medan - Kuta Cane
MSN:
88N/283
YOM:
1989
Flight number:
NBA823
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
18
Captain / Total flying hours:
5935
Captain / Total hours on type:
3730.00
Copilot / Total flying hours:
2500
Copilot / Total hours on type:
1100
Aircraft flight hours:
11329
Aircraft flight cycles:
13626
Circumstances:
On 29 September 2011, a CASA 212-200 aircraft registered PK-TLF was being operated by Nusantara Buana Air as a non-scheduled passenger flight from Polonia International Airport (MES/WIMM), Medan - North Sumatera1 to Alas Leuser Airstrip Kuta Cane, South East Aceh. The flight was conducted under Visual Flight Rules (VFR) The aircraft departed from Medan at 0728 LT (0028 UTC) and scheduled to be arrived at Kuta Cane at 0058 UTC. There were 18 person on board consisted of two pilots and 16 passengers including two children and two infants. The aircraft radar target was last observed on the radar screen at about 0050 UTC, while at position on radial 262˚ and 35 NM from MDN VOR. The aircraft was found impacted to a of 70º slope terrain at 5,055 feet altitude in the Leuser Mountain National Park, direction of 109 and 16 Nm from Kuta Cane on coordinate N 030 24’ 00” E 0980 01’ 00”. All 18 occupants were fatally injured and the aircraft was severely damage.
Probable cause:
Factors:
1. The flight was in VFR however both pilots agreed to fly into the cloud, consequently, the flight crew had lack of situation awareness due to lost of visual references to the ground and no or late recovery action prior to impact due to low visibility.
2. There was lack of good crew coordination due to steep cockpit transition gradient.
3. There was no checklist reading and crew briefing.
Final Report:

Crash of a Pilatus PC-6/B2-H4 Turbo Porter near Yahatma: 3 killed

Date & Time: Sep 22, 2011 at 1313 LT
Operator:
Registration:
PK-UCE
Flight Phase:
Survivors:
No
Site:
Schedule:
Pagai - Wamena
MSN:
943
YOM:
2004
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11312
Captain / Total hours on type:
2647.00
Aircraft flight hours:
5774
Aircraft flight cycles:
6662
Circumstances:
On 22 September 2011, a PC 6 Pilatus Porter aircraft, registration PK-UCE was being operated by Yayasan Jasa Aviasi Indonesia (YAJASI) departed from Pagai to Wamena. The aircraft departed at 0403 UTC1 (1303 LT) and estimated to arrive at Wamena was at 0436 UTC. Aircraft cruise at altitude of 10,000 feet and conducted under Visual Flight Rules (VFR) and followed the visual route via North Gap corridor, which one of visual route to Wamena. Prior to enter the North Gap corridor at time 0413 UTC, the pilot sent a message via a system they called AFFIS to the company Flight Following Officer at Sentani Airport, which was the operation base. The pilot also sent a blind transmission message through Wamena Tower radio frequency. This was local procedure, to submit the message consists of position, altitude and destination to make the other aircraft pilots aware each other. As in the intern YAJASI flight following procedure, pilot should send message when the flying passes the North Gap corridor. In this flight, until the normal elapsed time, the pilot did not send any message to their Flight Following Officer at Sentani that the flight has passed the North Gap corridor. Since there was no message nor radio contact from the pilot until the ETA in Wamena, the Flight Following Officer at Sentani informed to the other personnel at the operation base, and alarmed to the other YAJASI aircraft which were flying in that area to start search the PK-UCE. Some other aircrafts which were flying in the vicinity also contacted to search the PKUCE. PK-UCE was found in mountain location adjacent to Pass Valley airstrip. The accident site was at coordinate S 030 54’ 54.4’’, E 1390 02’ 24.3”, the aircraft was hit the trees and the ground where the elevation was about 7500 feet , the propeller blades was not on feather and bent rearward, the left wing was broken and the aircraft stopped on heading about 85°.
Probable cause:
The pilot decided to descend from the cruise altitude 10000 feet to penetrate the area of marginal weather was most likely not as what his perceive. The pilot avoided the cloud to the left of the VFR route guidance and most likely that the space available was less than the requirement stated for the Weather Minimum class F.
Final Report: