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 Learjet 31A in Jakarta

Date & Time: Sep 25, 2016 at 1946 LT
Type of aircraft:
Operator:
Registration:
PK-JKI
Flight Type:
Survivors:
Yes
Schedule:
Yogyakarta – Jakarta
MSN:
31-213
YOM:
2001
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing an ambulance flight from Yogyakarta-Adisujipto Airport to Jakarta-Halim Perdanakusuma on behalf of the Indonesian Red Cross (Palang Merah Indonesia). The approach was completed by night and marginal weather conditions. After touchdown on runway 24, the aircraft skidded on the wet runway and after a run of 1,300 meters, it veered to the right and left the pavement. While contacting soft ground, the right main gear was sheared off while the left main gear was partially torn off. The aircraft then hit the ground several times, causing the left wing to be bent. Eventually, the right engine dislodged from his mount. All eight occupants were evacuated safely and there was no fire.

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:
Crew (one instructor and six pilot under supervision) was engaged in a training flight and left Jakarta-Halim Perdana Kusuma Airport around 1310LT for a circular flight consisting of touch and go manoeuvre. While performing a last left turn to the left to join the runway 18 glide, aircraft stalled and crashed in flames onto houses located less than one km from runway threshold. Aircraft was destroyed by impact forces and post impact fire and nine houses were destroyed by fire as well. Six occupants of the aircraft and four people on the ground were killed as the copilot survived. Unfortunately, he did not survive to his severe injuries and died few hours later at hospital. It appears that the approach speed was to low during the last turn, causing the aircraft to stall.

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. Aircraft landed on wet runway 15 and skidded. It eventually veered off runway to the left and went through a muddy field. Nose gear was sheared off while both main gears sunk, leaving both engines on the ground. While all 153 occupants were evacuated unhurt, aircraft was later declared as damaged beyond repair. At the time of the accident, weather conditions were as follow: wind from 230 at 22 knots, visibility 600 meters, few clouds at 900 feet, broken at 700 feet, CB's above the terrain and turbulence.

Crash of a Sukhoï Superjet 100-95 in Mt Salak: 45 killed

Date & Time: May 9, 2012 at 1431 LT
Type of aircraft:
Operator:
Registration:
RA-97004
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Jakarta - Jakarta
MSN:
95004
YOM:
2009
Flight number:
RA36801
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
41
Pax fatalities:
Other fatalities:
Total fatalities:
45
Captain / Total flying hours:
10347
Captain / Total hours on type:
1348.00
Copilot / Total flying hours:
3318
Copilot / Total hours on type:
625
Aircraft flight hours:
843
Aircraft flight cycles:
500
Circumstances:
Aircraft was performing a demo flight and left Jakarta-Halim Perdanakasuma Airport at 1400LT with 41 passengers (potential buyers) on board and a crew of four. About thirty minutes later, while turning around Mount Salak, pilots received the authorization to descend from 10,000 feet to 6,000 feet in low visibility. Aircraft hit the edge of a cliff and crashed few yards further and was totally destroyed by impact and post impact fire. SAR teams arrived on scene 18 hours later and all 45 occupants were killed. At the time of the accident, weather conditions were marginal with clouds shrouding both Mount Salak and Mount Gede. First accident involving a Sukhoi Superjet 100. Present model was manufactured 09AUG2009 and totalized 843 flying hours for 500 cycles. Captain had 10,347 flying hours and was a test pilot by Sukhoi Civil Aircraft Company.
Probable cause:
- The flight crew was not aware of the mountainous area in the vicinity of the flight path due to various factors such as available charts, insufficient briefing and statements of the potential customer that resulted in inappropriate response to the TAWS warning. The impact could have been avoided by appropriate action of the pilot up to 24 seconds after the first TAWS warning.
- The Jakarta Radar service had not established the minimum vectoring altitudes and the Jakarta Radar system was not equipped with functioning MSAW for the particular area around Mount Salak.
- Distraction of the flight crew from prolonged conversation not related to the progress of the flight, resulted in the pilot flying not constantly changing the aircraft heading while in orbit. Consequently, the aircraft unintentionally exited the orbit.
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 PZL-Mielec AN-28 in Wami: 5 killed

Date & Time: Oct 27, 2010 at 1630 LT
Type of aircraft:
Operator:
Registration:
P-4204
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Nabire-Amboine-Makassar-Djakarta
MSN:
AJE003-07
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
Three Police Officer and two pilots were on board this aircraft and were returning to Jakarta after they delivered aid to the victims of Wasior floods in Irian Jaya Province. Aircraft left Nabire Airport at 1555LT to Ambone but crashed near Wami, most probably due to bad weather conditions. Rescue teams found the debris a day later and all five occupants were killed.

Crash of a Lockheed C-130 Hercules in Madiun: 100 killed

Date & Time: May 20, 2009 at 0630 LT
Type of aircraft:
Operator:
Registration:
A-1325
Flight Type:
Survivors:
Yes
Schedule:
Djakarta-Madiun
MSN:
4917
YOM:
1982
Country:
Region:
Crew on board:
14
Crew fatalities:
Pax on board:
98
Pax fatalities:
Other fatalities:
Total fatalities:
100
Circumstances:
On approach, the aircraft hit four houses and crashed in a rice field. At least 98 occupants were killed and 2 people on the ground. All occupants were Indonesian soldiers and members of their families.

Crash of a McDonnell Douglas MD-90 in Jakarta

Date & Time: Mar 9, 2009 at 1535 LT
Type of aircraft:
Operator:
Registration:
PK-LIL
Survivors:
Yes
Schedule:
Ujung Pandang - Jakarta
MSN:
53573/2182
YOM:
1997
Flight number:
LNI793
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
166
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25000
Captain / Total hours on type:
5000.00
Copilot / Total flying hours:
5000
Copilot / Total hours on type:
800
Aircraft flight hours:
18695
Aircraft flight cycles:
14507
Circumstances:
Lion Mentari Airline (Lion Air) as flight number LNI-793, departed from Sultan Hasanuddin Airport (WAAA), Makassar, Ujung Pandang, Sulawesi at 0636 UTC for Soekarno-Hatta International Airport (WIII), Jakarta. The estimated flight hour from Makassar to Jakarta was 2 hours. The crew consisted of two pilots and four flight attendants. There were 166 adult passengers. The copilot was the pilot flying for the sector, and the pilot in command (PIC) was the support/monitoring pilot. During the approach to runway 25L at Jakarta, the weather at the airport was reported as wind direction 200 degrees, wind speed 20 knots, visibility 1,000 meters, and rain. The PIC reported that he decided to take over control from the copilot. The PIC later reported that he had the runway in sight passing through 1,000 feet on descent, and he disengaged the autopilot at 400 feet. At about 50 feet the aircraft drifted to the right and the PIC initiated corrective action to regain the centreline. The aircraft touched down to the left of the runway 25L centerline and then commenced to drift to the right. The PIC reported that he immediately commenced corrective action by using thrust reverser, but the aircraft increasingly crabbed along the runway with the tail to the right of runway heading. The investigation subsequently found that the right thrust reverser was deployed, but left thrust reverser was not deployed. The aircraft stopped at 0835 on the right side of the runway 25L, 1,095 meters from the departure end of the runway on a heading of 152 degrees; 90 degrees to the runway 25L track. The main landing gear wheels collapsed, and still attached to the aircraft, were on the shoulder of the runway and the nose wheel was on the runway. The passengers and crew disembarked via the front right escape slide and right emergency exit windows. None of the occupants were injured
Probable cause:
The aircraft was not stabilized approach at 100 feet above the runway.
Final Report:

Crash of a Boeing 737-200 in Jambi

Date & Time: Aug 27, 2008 at 1634 LT
Type of aircraft:
Operator:
Registration:
PK-CJG
Survivors:
Yes
Schedule:
Jakarta - Jambi
MSN:
23320/1120
YOM:
1985
Flight number:
SJY062
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
123
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 13/31 (2,400 meters long) at Jambi-Sultan Taha Syarifudn Airport, Boeing 737-2H6 could not be stopped in time. It overrun, went down a five meters high embankment, lost its undercarriage and came to rest in a rice field. All 129 occupants escaped uninjured while two people on the ground were injured. Aircraft was damaged beyond repair as a result.