Crash of a Boeing 737-524 off Jakarta: 62 killed

Date & Time: Jan 9, 2021 at 1440 LT
Type of aircraft:
Operator:
Registration:
PK-CLC
Flight Phase:
Survivors:
No
Schedule:
Jakarta - Pontianak
MSN:
27323/2616
YOM:
1994
Flight number:
SJY182
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
56
Pax fatalities:
Other fatalities:
Total fatalities:
62
Captain / Total flying hours:
17904
Captain / Total hours on type:
9023.00
Copilot / Total flying hours:
5107
Copilot / Total hours on type:
4957
Aircraft flight hours:
62983
Aircraft flight cycles:
40383
Circumstances:
On 9 January 2021, a Boeing 737-500 aircraft, registration PK-CLC, was being operated by PT. Sriwijaya Air on a scheduled passenger flight from Soekarno-Hatta International Airport (WIII), Jakarta to Supadio International Airport (WIOO), Pontianak . The flight number was SJY182. According to the flight plan filed, the fuel endurance was 3 hours 50 minutes. At 0736 UTC (1436 LT) in daylight conditions, Flight SJY182 departed from Runway 25R of Jakarta. There were two pilots, four flight attendants, and 56 passengers onboard the aircraft. At 14:36:46 LT, the SJY182 pilot contacted the Terminal East (TE) controller and was instructed “SJY182 identified on departure, via SID (Standard Instrument Departure) unrestricted climb level 290”. The instruction was read back by the pilot. At 14:36:51 LT, the Flight Data Recorder (FDR) data recorded that the Autopilot (AP) system engaged at altitude of 1,980 feet. At 14:38:42 LT, the FDR data recorded that as the aircraft climbed past 8,150 feet, the thrust lever of the left engine started reducing, while the thrust lever position of the right engine remained. The FDR data also recorded the left engine N1 was decreasing whereas the right engine N1 remained. At 14:38:51 LT, the SJY182 pilot requested to the TE controller for a heading change to 075° to avoid weather conditions and the TE controller approved the request. At 14:39:01 LT, the TE controller instructed SJY182 pilot to stop their climb at 11,000 feet to avoid conflict with another aircraft with the same destination that was departing from Runway 25L. The instruction was read back by the SJY182 pilot. At 14:39:47 LT, the FDR data recorded the aircraft’s altitude was about 10,600 feet with a heading of 046° and continuously decreasing (i.e., the aircraft was turning to the left). The thrust lever of the left engine continued decreasing. The thrust lever of the right engine remained. At 14:39:54 LT, the TE controller instructed SJY182 to climb to an altitude of 13,000 feet, and the instruction was read back by an SJY182 pilot at 14:39:59 LT. This was the last known recorded radio transmission by the flight. At 14:40:05 LT, the FDR data recorded the aircraft altitude was about 10,900 feet, which was the highest altitude recorded in the FDR before the aircraft started its descent. The AP system then disengaged at that point with a heading of 016°, the pitch angle was about 4.5° nose up, and the aircraft rolled to the left to more than 45°. The thrust lever position of the left engine continued decreasing while the right engine thrust lever remained. At 14:40:10 LT, the FDR data recorded the autothrottle (A/T) system disengaged and the pitch angle was more than 10° nose down. About 20 seconds later the FDR stopped recording. The last aircraft coordinate recorded was 5°57'56.21" S 106°34'24.86" E. At 14:40:37 LT, the TE controller called SJY182 to request for the aircraft heading but did not receive any response from the pilot. At 14:40:48 LT, the radar target of the aircraft disappeared from the TE controller radar screen. At 14:40:46 LT, the TE controller again called SJY182 but did not receive any response from the pilot. The TE controller then put a measurement vector on the last known position of SJY182 and advised the supervisor of the disappearance of SJY182. The supervisor then reported the occurrence to the operation manager. The TE controller repeatedly called SJY182 several times and also asked other aircraft that flew near the last known location of SJY182 to call the SJY182. The TE controller then activated the emergency frequency of 121.5 MHz and called SJY182 on that frequency. All efforts were unsuccessful to get any responses from the SJY182 pilot. About 1455 LT, the operation manager reported the occurrence to the Indonesian Search and Rescue Agency (Badan Nasional Pencarian dan Pertolongan/BNPP). At 1542 LT, the Air Traffic Services (ATS) provider declared the uncertainty phase (INCERFA) of the SJY182. The distress phase of SJY182 (DETRESFA) was subsequently declared at 1643 LT.
Probable cause:
The following contributing factors were identified:
• The corrective maintenance processes of the A/T problem were unable to identify the friction or binding within the mechanical system of the thrust lever and resulted in the prolonged and unresolved of the A/T problem.
• The right thrust lever did not reduce when required by the A/P to obtain selected rate of climb and aircraft speed due to the friction or binding within the mechanical system, as a result, the left thrust lever compensated by moving further backward which resulted in thrust asymmetry.
• The delayed CTSM activation to disengage the A/T system during the thrust asymmetry event due to the undervalued spoiler angle position input resulted in greater power asymmetry.
• The automation complacency and confirmation bias might have led to a decrease in active monitoring which resulted in the thrust lever asymmetry and deviation of the flight path were not being monitored.
• The aircraft rolled to the left instead of to the right as intended while the control wheel deflected to the right and inadequate monitoring of the EADI might have created assumption that the aircraft was rolling excessively to the right which resulted in an action that was contrary in restoring the aircraft to safe flight parameters.
• The absence of the guidance of the national standard for the UPRT, may have contributed to the training program not being adequately implemented to ensure that pilots have enough knowledge to prevent and recover of an upset condition effectively and timely.
Final Report:

Crash of a Boeing 737 MAX 8 off Jakarta: 189 killed

Date & Time: Oct 29, 2018 at 0631 LT
Type of aircraft:
Operator:
Registration:
PK-LQP
Flight Phase:
Survivors:
No
Schedule:
Jakarta - Pangkal Pinang
MSN:
43000
YOM:
2018
Flight number:
JT610
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
181
Pax fatalities:
Other fatalities:
Total fatalities:
189
Captain / Total flying hours:
6028
Captain / Total hours on type:
5176.00
Copilot / Total flying hours:
5174
Copilot / Total hours on type:
4286
Aircraft flight hours:
895
Aircraft flight cycles:
443
Circumstances:
The aircraft departed runway 25L at Jakarta-Soekarno-Hatta Airport at 0621LT bound for Pangkal Pinang, carrying 181 passengers and 8 crew members. The crew was cleared to climb but apparently encountered technical problems and was unable to reach a higher altitude than 5,375 feet. At this time, the flight shows erratic speed and altitude values. The pilot declared an emergency and elected to return to Jakarta when control was lost while at an altitude of 3,650 feet and at a speed of 345 knots. The airplane entered a dive and crashed 12 minutes after takeoff into the Kerawang Sea, about 63 km northeast from its departure point. The airplane disintegrated on impact and few debris were already recovered but unfortunately no survivors. It has been reported that the aircraft suffered various technical issues during the previous flight on Sunday night but was released for service on Monday morning. Brand new, the airplane was delivered to Lion Air last August 18. At the time of the accident, weather conditions were considered as good. The Cockpit Voice Recorder (CVR) was found on 14 January 2019. In the initial stages of the investigation, it was found that there is a potential for repeated automatic nose down trim commands of the horizontal stabilizer when the flight control system on a Boeing 737 MAX aircraft receives an erroneously high single AOA sensor input. Such a specific condition could among others potentially result in the stick shaker activating on the affected side and IAS, ALT and/or AOA DISAGREE alerts. The logic behind the automatic nose down trim lies in the aircraft's MCAS (Maneuvering Characteristics Augmentation System) that was introduced by Boeing on the MAX series aircraft. This feature was added to prevent the aircraft from entering a stall under specific conditions. On November 6, 2018, Boeing issued an Operations Manual Bulletin (OMB) directing operators to existing flight crew procedures to address circumstances where there is erroneous input from an AOA sensor. On November 7, the FAA issued an emergency Airworthiness Directive requiring "revising certificate limitations and operating procedures of the airplane flight manual (AFM) to provide the flight crew with runaway horizontal stabilizer trim procedures to follow under certain conditions.
Probable cause:
Contributing factors defines as actions, omissions, events, conditions, or a combination thereof, which, if eliminated, avoided or absent, would have reduced the probability of the accident or incident occurring, or mitigated the severity of the
consequences of the accident or incident. The presentation is based on chronological order and not to show the degree of contribution.
1. During the design and certification of the Boeing 737-8 (MAX), assumptions were made about flight crew response to malfunctions which, even though consistent with current industry guidelines, turned out to be incorrect.
2. Based on the incorrect assumptions about flight crew response and an incomplete review of associated multiple flight deck effects, MCAS’s reliance on a single sensor was deemed appropriate and met all certification requirements.
3. MCAS was designed to rely on a single AOA sensor, making it vulnerable to erroneous input from that sensor.
4. The absence of guidance on MCAS or more detailed use of trim in the flight manuals and in flight crew training, made it more difficult for flight crews to properly respond to uncommanded MCAS.
5. The AOA DISAGREE alert was not correctly enabled during Boeing 737-8 (MAX) development. As a result, it did not appear during flight with the mis-calibrated AOA sensor, could not be documented by the flight crew and was therefore not available to help maintenance identify the mis-calibrated AOA sensor.
6. The replacement AOA sensor that was installed on the accident aircraft had been mis-calibrated during an earlier repair. This mis-calibration was not detected during the repair.
7. The investigation could not determine that the installation test of the AOA sensor was performed properly. The mis-calibration was not detected.
8. Lack of documentation in the aircraft flight and maintenance log about the continuous stick shaker and use of the Runaway Stabilizer NNC meant that information was not available to the maintenance crew in Jakarta nor was it available to the accident crew, making it more difficult for each to take the appropriate actions.
9. The multiple alerts, repetitive MCAS activations, and distractions related to numerous ATC communications were not able to be effectively managed. This was caused by the difficulty of the situation and performance in manual handling, NNC execution, and flight crew communication, leading to ineffective CRM application and workload management. These performances had previously been identified during training and reappeared during the accident flight.
Final Report:

Crash of a Lockheed C-130 Hercules in Lhokseumawe

Date & Time: Dec 20, 2001 at 0935 LT
Type of aircraft:
Operator:
Registration:
A-1329
Flight Type:
Survivors:
Yes
Schedule:
Jakarta - Lhokseumawe
MSN:
4824
YOM:
1979
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
83
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Lhokseumawe-Malikussaleh Airport, the four engine aircraft went out of control, veered off runway and came to rest in a marshy area, bursting into flames. All 95 occupants were rescued, among them seven passengers were injured. The aircraft was destroyed by a post crash fire.

Crash of a Casa 212 Aviocar 100 on Mt Cemonyet: 13 killed

Date & Time: Jan 23, 1980
Type of aircraft:
Operator:
Registration:
PK-PCX
Flight Phase:
Survivors:
No
Site:
Schedule:
Bandung - Jakarta
MSN:
45/3N
YOM:
1975
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
13
Circumstances:
En route from Bandung to Jakarta, the crew was cleared to descend from 6,500 feet to 4,500 feet. Few minutes later, while flying at an altitude of 2,700 feet, the twin engine airplane struck the slope of Mt Cemonyet located about 64 km southeast of Jakarta. The aircraft was destroyed upon impact and all 13 occupants were killed.
Probable cause:
For unknown reasons, the crew started the descent prematurely, causing the aircraft to descend below the minimum safe altitude. The lack of visibility caused by poor weather conditions was considered as a contributing factor.

Crash of a Fokker F28 Fellowship 1000 in Palembang: 26 killed

Date & Time: Sep 24, 1975
Type of aircraft:
Operator:
Registration:
PK-GVC
Survivors:
Yes
Schedule:
Jakarta - Palembang
MSN:
11039
YOM:
1971
Flight number:
GA150
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
57
Pax fatalities:
Other fatalities:
Total fatalities:
26
Aircraft flight hours:
8516
Aircraft flight cycles:
7533
Circumstances:
While descending to Palembang-Sultan Mahmud Badaruddin II Airport, the crew encountered foggy conditions that reduced the visibility to 50 meters. On final approach, the airplane descended too low when it struck coconut trees and crashed about 4 km short of runway 28. All four crew members and 21 passengers were killed as well as one people on the ground. All 36 other occupants were injured. The aircraft was destroyed.
Probable cause:
The crew decided to continue the approach under VFR mode in a visibility that was below minimus. The crew led the airplane pass below the MDA until it impacted trees and crashed.

Crash of a Fokker F27 Friendship 600 in Bandar Lampung: 33 killed

Date & Time: Sep 7, 1974
Type of aircraft:
Operator:
Registration:
PK-GFJ
Survivors:
Yes
Schedule:
Palembang - Bandar Lampung - Jakarta
MSN:
10422
YOM:
1969
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
33
Aircraft flight hours:
8737
Aircraft flight cycles:
6976
Circumstances:
While descending to Bandar Lampung-Branti Airport, the crew encountered poor weather conditions. On final, the airplane passed below the glide when it struck a building and crashed in flames. Three passengers were rescued while 33 other occupants were killed, among them all four crew members.
Probable cause:
It was determined that the pilot descended below the glide in low visibility without any visual contact with the runway and/or the ground. The crew continued at an unsafe altitude and failed to initiate a go-around manoeuvre.

Crash of a Convair CV-990-30A-5 Coronado in Agana

Date & Time: Sep 10, 1973 at 1616 LT
Type of aircraft:
Registration:
N7876
Flight Type:
Survivors:
Yes
Schedule:
Jakarta - Agana - Moffett
MSN:
30-10-4
YOM:
1963
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13000
Captain / Total hours on type:
1621.00
Circumstances:
The crew was completing a ferry flight from Jakarta to Moffett AFB with an intermediate stop in Agana. On approach, the crew was informed by ATC about poor weather at destination with thunderstorm activity, strong crosswinds and heavy rain falls. The airplane landed 500 meters past the runway threshold then became uncontrollable. It veered off runway to the left then collided with various obstacles and came to rest. All four crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Improper in-flight decisions on part of the pilot-in-command. The following factors were reported:
- Turbulence associated with clouds and thunderstorms,
- Overload failure,
- No weather briefing received,
- Wind gusting up to 20 knots,
- Agana Tower advised the crew about large storm passing over the approach course.
Final Report:

Crash of a Douglas DC-6 in Tegal: 6 killed

Date & Time: Feb 1, 1972
Type of aircraft:
Operator:
Registration:
XW-PEH
Flight Phase:
Survivors:
Yes
Schedule:
Singapore - Jakarta
MSN:
43126/132
YOM:
1948
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
Approximately four hours after his departure from Singapore on a charter flight to Jakarta, the captain realized he was not on the correct route and was lost. As he was short of fuel, he reduced his altitude and attempted an emergency landing when the airplane crashed in a prairie located near Tegal, some 260 km southeast of the intended destination. A pilot and five passengers were killed while three other occupants were injured.
Probable cause:
It was determined that the crew lost his orientation in flight, probably due to a faulty compass reading on part of the crew or a possible technical problem with the compass. An emergency landing was necessary due to fuel exhaustion.

Crash of a Vickers 828 Viscount off Padang: 69 killed

Date & Time: Nov 10, 1971
Type of aircraft:
Operator:
Registration:
PK-MVS
Flight Phase:
Survivors:
No
Schedule:
Jakarta - Padang - Medan - Kuala Lumpur
MSN:
448
YOM:
1962
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
62
Pax fatalities:
Other fatalities:
Total fatalities:
69
Circumstances:
The crew just started the descent to Padang-Tabing Airport when the airport went out of control and crashed into the Mentawai Strait. Dew debris were found three days later about 120 km south of Padang. All 69 occupants were killed.
Probable cause:
The cause of the accident could not determined.

Crash of a Douglas C-47A-80-DL in Palembang: 17 killed

Date & Time: Jan 1, 1966
Operator:
Registration:
PK-GDE
Survivors:
No
Schedule:
Jakarta – Palembang
MSN:
19719
YOM:
1944
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
17
Circumstances:
While approaching Palembang-Sultan Badaruddin II Airport, the airplane collided with a second Garuda C-47 registered PK-GDU. Inbound from Medan, the second aircraft was also carrying 13 passengers and four crew members. Following the collision, both aircraft went out of control and crashed in a swampy area. All 34 occupants on both aircraft were killed.
Probable cause:
It is believed the collision was caused by the fact that both crew failed to pay sufficient attention to potential traffic while approaching the same airport at the same time. Poor ATC assistance may have been a contributing factor.