Crash of a Embraer ERJ-190-200LR in Kupang

Date & Time: Dec 21, 2015 at 1746 LT
Type of aircraft:
Operator:
Registration:
PK-KDC
Survivors:
Yes
Schedule:
Ende - Kupang
MSN:
190-00057
YOM:
2006
Flight number:
KD676
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
120
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9800
Captain / Total hours on type:
598.00
Copilot / Total flying hours:
2997
Copilot / Total hours on type:
557
Aircraft flight hours:
16862
Aircraft flight cycles:
14765
Circumstances:
On 21 December 2015, an ERJ 190-200 (Embraer 195) aircraft, registered PK-KDC, was being operated by Kalstar Aviation on a scheduled passenger flight. The crew was scheduled to fly three sectors from I Gusti Ngurah Rai International Airport (WADD) Bali – H. Hasan Aroeboesman Airport (WATE) Ende – El Tari International Airport (WATT) Kupang – Sultan Hasanuddin International Airport (WAAA), Makassar. The aircraft departed Bali at 0734 UTC which was delayed for 74 minutes from the normal schedule, due to late arrival of the aircraft from the previous flight. On the flight from Bali to Ende, the Pilot in Command (PIC) acted as pilot monitoring (PM) and the Second in command (SIC) acted as pilot flying (PF). The aircraft landed in Ende at 0839 UTC. During transit, the PIC received a short message from a flight operations officer of Kalstar Aviation in Kupang which informed him that the visibility at Kupang was 1 km. Considering the weather forecast in the Terminal Aerodrome Forecast (TAFOR) showed that the visibility at Kupang would improve at the time of arrival, the PIC decided to depart to Kupang. Another consideration was the operating hours of Ende which would be closed at 0900 UTC. The operating hours of Ende was extended and the aircraft departed Ende at 0916 UTC, with flight number KD676. On board this flight were two pilots, three flight attendants, and 125 passengers. The PIC acted as PM and the SIC acted as PF. There was no departure briefing performed by the PF. After takeoff, the pilot set the Flight Management System (FMS) to fly direct to KPG VOR and climbed to a cruising altitude of Flight Level (FL) 175 (17,500 feet). During climbing, the PIC instructed the SIC to reduce the aircraft speed by 20 knots with the intention to wait for the weather improvement at Kupang. During cruising, the pilots monitored communication between El Tari Tower controller with another pilot. El Tari Tower controller advised that the visibility at Kupang was 1 km while the minima for approach was 3.9 km. At 0927 UTC, the pilot established communication with El Tari Tower controller and requested for direct to initial approach point SEMAU. At 0932 UTC, the aircraft was at 62 Nm, the aircraft started to descend which was approved to 10,000 feet. When the aircraft passed FL 150, the pilot requested to turn left to fly direct to the inbound track of the VOR/DME approach for runway 07 in order to avoid cloud formation which was indicated by magenta color on the aircraft weather radar. At 0941 UTC, the El Tari Tower controller informed that the visibility on runway 07 was 4 km and issued clearance for RNAV approach to runway 07 and requested that the pilot report when the runway was in sight. Both pilots discussed the plan to make an RNAV approach to runway 07, with landing configuration with flap 5 and auto-brake set to position low. At 0943 UTC, the pilot reported that the runway was in sight when passing 2,500 feet and the El Tari Tower controller informed that the wind was calm and issued a landing clearance. During the approach, the PF noticed that all Precision Approach Path Indicator (PAPI) lights indicated a white color, which indicated that the aircraft was too high for the approach. Recognizing that the aircraft was too high, the crew performed a non-standard configuration setting by extending the landing gear down first with the intention to increase drag. The landing gear was extended at approximately 7 Nm from the runway 07 threshold and afterwards selected the flaps to 1 and 2. The published approach procedure stated that the sequence for establishing landing configuration is by selecting flap 1, flap 2, landing gear down, flap 3 and flap 5. On final approach, the crew noticed the aural warning “HIGH SPEED HIGH SPEED”. The SIC also noticed that the aircraft speed was about 200 knots. The pilots decided to continue the approach considering the runway was 2,500 meters long and would be sufficient for the aircraft to stop with the existing conditions. The pilots compared the runway condition at Kupang with the condition at Ende which had 1,650 meter length runway. On short final approach, the aircraft was on the correct glide path and the speed was approximately 205 knots. The PF noticed the Enhanced Ground Proximity Warning System (EGPWS) warning of “TOO LOW TERRAIN” activated. The aircraft then touched down at approximately the middle of the runway. After touchdown, the PF immediately applied thrust reverser. Realizing that the aircraft was about to overrun the end of the runway, and with the intention to avoid the approach lights on the end of the runway, the PIC turned the aircraft to the right. The aircraft stopped approximately 200 meters from the end of runway 07. At 0946 UTC, the El Tari Tower controller saw the aircraft overrun, then pushed the crash bell and informed the Airport Rescue and Fire Fighting (ARFF).
Probable cause:
Contributing Factors:
- The steep authority gradient resulted in lack of synergy that contributed to least of alternation to correct the improper condition.
- Improper flight management on approach resulted to the aircraft not fully configured for landing, prolong and high speed on touchdown combined with low brake pressure application resulted in insufficient runway for deceleration.
- The deviation of pilot performance was undetected by the management oversight system.
Final Report:

Crash of a Xian MA60 in Kupang

Date & Time: Jun 10, 2013 at 0954 LT
Type of aircraft:
Operator:
Registration:
PK-MZO
Survivors:
Yes
Schedule:
Bajawa - Kupang
MSN:
06 08
YOM:
2008
Flight number:
MZ6517
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
46
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12530
Captain / Total hours on type:
2050.00
Copilot / Total flying hours:
311
Copilot / Total hours on type:
141
Aircraft flight hours:
4486
Aircraft flight cycles:
4133
Circumstances:
On 10 June 2013, a Xi ‘An MA60 aircraft registered PK-MZO was being operated by PT. Merpati Nusantara Airlines on a scheduled passenger flight as MZ 6517. The aircraft departed from Bajawa Airport (WATB) Nusa Tenggara Timur, at 0102 UTC to El Tari (WATT) Kupang, Nusa Tenggara Timur. On board this aircraft were 2 pilots, 2 flight attendants with 46 passengers consisted of 45 adults and 1 infant. The flight was the second sectors for the aircraft and the crew on that day. The first flight was from Kupang to Bajawa Airport. During the flight the Second in Command (SIC) acted as the Pilot Flying (PF) and the Pilot in Command (PIC) as the Pilot Monitoring (PM). The flight from the departure until commencing for approach was un-eventful. At 0122 UTC, the pilot made first communication with El Tari Control Tower controller (El Tari Tower) and reported their position was on radial 298° 110 Nm from KPG VOR and maintaining 11,500 ft. The pilot received information that the runway in use was 07 and the weather information (wind 110° 11 kts, visibility 10 km, weather NIL, cloud few 2,000 ft, temperature 30° C, dew point 22° C, QNH 1010 mbs and QFE 998 mbs). At 0133 UTC, the aircraft was on radial 297° 68 Nm from KPG VOR and the pilot ready to descend and approved by El Tari Tower to descend to 5,000 ft. At 0138 UTC, the pilot reported the aircraft was passing 10,500 ft and stated that the flight was on Visual Meteorological Condition (VMC). At 0150 UTC, the aircraft position was on left base runway 07 at 5 Nm from KPG VOR. The El Tari Tower had visual contact with the aircraft and issued a landing clearance with additional information that the wind condition was 120° at 14 kts, QNH 1010 mbs. At 0151 UTC, the pilot reported that their position was on final and the El Tari Tower re-issued the landing clearance. The Flight Data Recorder (FDR) recorded that the left power lever was in the range of BETA MODE while the aircraft altitude was approximately 112 ft and followed by the right power lever at 90 ft until hit the ground. At 0154 UTC, the aircraft touched down at about 58 meters and halted on the runway at about 261 meters from the beginning of runway 07. The vertical deceleration recorded on FDR was 5.99 G and followed by - 2.78 G. After the aircraft stopped, the flight attendants assessed the situation and decided to evacuate the passengers through the rear main entrance door. One pilot and four passengers who seated on row number three, seven and eight suffered serious injury. On 11 June 2013, the aircraft was evacuated from the runway and moved to the Air Force hangar at 2100 UTC.
Probable cause:
The following contributing factors were identified:
- The procedure of selecting Power Lever Lock to “OPEN” during approach was made without comprehensive risk assessment.
- Both power levers entered BETA MODE at 90 feet due to the safety device namely Power Lever Lock has been opened during approach, which was in accordance to the operator procedure and lifting of Mechanical Power Lever Stop Slot which was not realized by the pilots.
- The movement of power levers to BETA MODE resulted the pitch angle changed to low pitch angle which produced significant drag and made the aircraft loss of significant lift.
Final Report:

Crash of a Fokker 100 in Kupang

Date & Time: Dec 2, 2009 at 2215 LT
Type of aircraft:
Operator:
Registration:
PK-MJD
Survivors:
Yes
Schedule:
Ujung Pandang - Kupang
MSN:
11474
YOM:
1993
Flight number:
MZ5840
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
88
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18776
Copilot / Total flying hours:
7074
Aircraft flight hours:
29637
Aircraft flight cycles:
29450
Circumstances:
PK-MJD was on passenger schedule flight from Sultan Hasanuddin Airport, Makassar with destination El Tari Airport, Kupang, East Nusa Tenggara. The flight number was Merpati 5840 and carried 94 person on board consist of 88 passengers including four children and four infants, two pilot and four flight attendant. A maintenance engineer was on-board in this flight. Acting as pilot flying was the Second in Command (SIC) while the Pilot in Command acted as Pilot Monitoring. On approach, the pilot selected landing gear to down position. The left main landing gear indicator light was showed red, its means that the left main landing gear was not in down position and unsafe for landing. The pilot reported to the Air Traffic Controller (ATC) for a go-around and requested an area for holding to solve the problem. The ATC gave a clearance to hold over Kupang bay. The pilot tried to solve the problem by conducting the procedure according to the emergency checklist, including selected the landing gear by alternate selector. The pilot then requested to the ATC to fly at low altitude over the airport and asked to the ATC to observe the landing gear condition. The pilot also asked through the company radio for an engineer on-ground to observe visually the landing gear condition. The pilot then returned to the holding area, repeated the procedure but unsuccessful. Both pilots and engineer had a discussion and decided to attempt un-procedural method to make the landing gear down. Prior making these efforts the pilot announced to the passengers about the problem and their attempts that might be unpleasant to the passengers. After all attempts to lower the landing gear had failed, the pilot decided to land with the left main landing gear in up position. The pilot also asked the flight attendant to prepare for an abnormal landing. The ATC were prepared the airport fire fighting and ambulance, and also contacted the local police, armed forces, and hospitals and asking for additional ambulances. The ATC then informed the pilot that the ground support was ready. On short final the pilot instructed ‘brace for impact’ and the FA repeated that instruction to all passengers. The aircraft touched down at the touch down zone on runway 07. The pilot flying held the left wing as long as possible and kept the aircraft on the centre line, and the pilot monitoring shut down both engines. The aircraft stopped at about 1,200 meters from the beginning of runway 07, on the left shoulder of the runway and the FA instructed to the passengers to keep calm and to evacuate the aircraft. The pilot continued the procedures for emergency. The evacuation was performed through all door and window exits. No one was injured on this serious incident.
Probable cause:
The debris trapped in the chamber between the orifice and the stopper of the restrictor check valve, it caused the orifice closed. This condition was resulted the hydraulic flow from the actuator blocked and caused the left main landing gear jammed at up position.
Final Report:

Crash of a Casa 212 Aviocar 200 in Kupang

Date & Time: Dec 13, 1996
Type of aircraft:
Operator:
Registration:
PK-NCO
Survivors:
Yes
MSN:
194/37N
YOM:
1981
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Kupang-El Tari Airport, the twin engine aircraft went out of control, veered off runway, lost its left wing and came to rest. All six occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Douglas C-47B-35-DK Dakota C.4 in Kupang

Date & Time: Jan 18, 1947
Operator:
Registration:
KP230
Flight Type:
Survivors:
Yes
MSN:
16701/33449
YOM:
1945
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On landing, the aircraft hit a pothole, went out of control, veered off runway and came to rest. There were no casualties but the aircraft was damaged beyond repair.

Crash of a Consolidated B-24J-135-CO Liberator into the Timor Sea: 10 killed

Date & Time: Oct 29, 1944 at 1200 LT
Operator:
Registration:
42-110120
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Fenton – Darwin – Kupang
MSN:
3916
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
En route, the four engine aircraft christened 'Sleepy Time Gal' went out of control and crashed into the Timor sea in unknown circumstances. No trace of the aircraft nor the crew was ever found.
Crew:
William C. Clarke 9.
Probable cause:
It is believed the accident was caused by an engine failure due to a problem on the fuel supply system.

Crash of a North American B-25 Mitchell in Tenau: 5 killed

Date & Time: Jan 4, 1944
Operator:
Registration:
N5-137
Flight Phase:
Flight Type:
Survivors:
No
MSN:
87-7900
YOM:
1941
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
Engaged in a bombing mission in the region of Kupang, the aircraft was shot down by enemy fire and crashed in Tenau, killing all five occupants.
Probable cause:
Shot down.

Crash of a Lockheed L-414 Hudson IIIA off Kupang: 4 killed

Date & Time: Oct 25, 1942
Type of aircraft:
Operator:
Registration:
A16-170
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Batchelor - Batchelor
MSN:
414-6424
YOM:
1942
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The crew left Batchelor Airport to attack the Penfoei Airport with two other similar aircraft. Upon arrival in Kupang, the twin engine aircraft disappeared without trace. SAR operations were suspended few days later.
Crew (2nd Squadron):
F/Sgt R. K. Dunning,
Sgt M. L. Kenihan,
Sgt L. H. Fraser,
Sgt D. W. Francis.

Crash of a Lockheed L-414 Hudson IIIA near Kupang: 5 killed

Date & Time: Oct 1, 1942
Type of aircraft:
Operator:
Registration:
A16-243
Flight Phase:
Survivors:
No
Schedule:
Darwin – Kupang
MSN:
414-6496
YOM:
1942
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
Disappeared in unknown circumstances in the region of Kupang, Indonesia, while performing a survey flight from Darwin to Kupang. SAR teams did not find any trace of the aircraft nor the crew.
Crew (13th Squadron):
P/O J. E. Alcock,
F/O G. V. Boynton,
F/O P. C. Gunson,
Sgt F. P. Kemp,
Sgt W. S. Powell.

Crash of a Lockheed L-414 Hudson IIIA into the Timor Sea: 4 killed

Date & Time: Apr 23, 1942
Type of aircraft:
Operator:
Registration:
A16-182
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Darwin – Kupang
MSN:
414-6354
YOM:
1941
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
Crashed into the sea of Timor while on a flight from Darwin to Kupang. No trace of the aircraft nor the crew was ever found.
Crew (2nd Squadron):
F/Lt Roger Joseph Blanchard, pilot,
Sgt Oberlin Benjamin Plester Gray, wireless operator and air gunner,
Sgt David Jacobs,
Sgt David Vynne Woods.