Crash of a Boeing 737-4Y0 in Jakarta

Date & Time: Mar 20, 2021 at 1126 LT
Type of aircraft:
Operator:
Registration:
PK-YSF
Flight Type:
Survivors:
Yes
Schedule:
Jakarta - Makassar
MSN:
23869/1639
YOM:
1988
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6228
Captain / Total hours on type:
5208.00
Copilot / Total flying hours:
1255
Copilot / Total hours on type:
1084
Aircraft flight hours:
55982
Aircraft flight cycles:
65005
Circumstances:
On 20 March 2021, a Boeing 737-400F, registered PK-YSF, was being operated by Trigana Air Service on a non-schedule cargo flight from Halim Perdanakusuma International Airport (WIHH), Jakarta, Indonesia with intended destination of Sultan Hasanuddin International Airport (WAAA), South Sulawesi, Indonesia. On board in this flight was two pilots, one engineer and one Flight Operation Officer (FOO). According to the weight and balance sheet, the flight carried 16,672 kgs of general cargo, takeoff fuel of 11,100 kg and the takeoff weight was 60,695 kg (133,835 lbs). The Pilot in Command (PIC) acted as Pilot Flying (PF) and the Second in Command (SIC) acted as Pilot Monitoring (PM). At 0328 UTC (1028 LT), the PM requested clearance to Halim Tower controller (the controller) to pushback and start the engines. At 1031 LT, the PM requested to the controller for taxi clearance. There was no report of aircraft system abnormality prior to the aircraft departure. At 1047 LT, the controller issued clearance to the PK-YSF pilot to enter and to backtrack Runway 24. At 1051 LT, the PM reported ready for departure to the controller. The controller issued takeoff clearance with additional departure clearance that after takeoff, turn left to heading 180° and initially climb to altitude of 3,000 feet. The PM acknowledged the clearance. The takeoff was conducted with reduced takeoff thrust by assumed temperature of 40°C and the aircraft became airborne at 10:52:57 LT. At 1055 LT, the controller advised the pilot to report when established on heading 180°. The PM reported that they were experiencing right engine failure and requested to fly to AL NDB . The controller advised the PM to turn left heading 060° and to climb to 2,500 feet. Furthermore, the controller asked the pilot intention whether to hold over AL NDB or direct for landing approach. The PM replied that they would hold over AL NDB and added the information that no fire was detected. The controller issued clearance to fly to AL NDB at altitude of 2,500 feet. The controller assumed that PK-YSF would return to Halim and advised the Airport Rescue and Fire-Fighting (ARFF) personnel that PK-YSF experienced right engine failure and would return to Halim. At 1058 LT, the controller requested the information of time required for holding over AL NDB and was replied by the PM that holding would require about 15 minutes. Furthermore, the controller requested whether the pilot able to hold at a point about 15 to 20 Nm from AL NDB and was replied by the PM that they did not objection to the proposal. The controller instructed the pilot to maintain outbound heading up to 15 Nm, at altitude of 2,500 feet. This was intended by the controller to manage the departure and arrival aircraft to and from Halim. At 1116 LT, the PM reported that they were ready to turn left for approach. The controller advised the pilot to turn left and to intercept localizer of the Instrument Landing System (ILS) Runway 24. At 1125 LT, the PM reported to the controller that the Runway was in sight. The controller advised that the wind was from 060° at velocity of 6 knots, QNH 1,007 mbs and issued landing clearance. The aircraft touched down on the touchdown zone and shortly after, both wheels of the right main landing gear detached. The controller noticed spark appeared from the aircraft and pressed the crash bell. At 1127 LT, the controller informed pilots of the other aircraft that the runway blocked by the landing aircraft and identified fire on one of the engines. Few seconds later, the PM called the controller whether any fire and was replied by the controller that fire was visible on the left side of the aircraft.

Crash of a De Havilland DHC-6 Twin Otter 300 on Mt Bajaja: 10 killed

Date & Time: Oct 2, 2015 at 1451 LT
Operator:
Registration:
PK-BRM
Flight Phase:
Survivors:
No
Site:
Schedule:
Masamba – Makassar
MSN:
741
YOM:
1981
Flight number:
VIT7503
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
2911
Captain / Total hours on type:
2911.00
Copilot / Total flying hours:
4035
Copilot / Total hours on type:
4035
Aircraft flight hours:
45242
Aircraft flight cycles:
75241
Circumstances:
On 2 October 2015, a DHC-6 Twin Otter, registered PK-BRM, was being operated by PT. Aviastar Mandiri as a scheduled passenger flight with flight number MV 7503. The aircraft departed from Andi Jemma Airport, Masamba (WAFM)1 with the intended destination of Sultan Hasanuddin International Airport, Makassar (WAAA) South Sulawesi, Indonesia. On board the flight were 10 persons consisting of two pilots and eight passengers, including one company engineer. The previous flights were from Makassar – Tana Toraja – Makassar – Masamba – Seko - Masamba and the accident flight was from Masamba to Makassar which was the 6th sector of the day. The aircraft departed from Masamba at 1425 LT (0625 UTC2 ) with an estimated time of arrival at Makassar of 0739 UTC. The Pilot in Command (PIC) acted as Pilot Flying (PF) while the Second in Command (SIC) acted as Pilot Monitoring (PM). The flight was conducted under the Visual Flight Rules (VFR) and cruised at an altitude of 8,000 feet. At 0630 UTC, the pilot reported to Ujung Pandang Information officer that the aircraft passed an altitude of 4,500 feet and was climbing to 8,000 feet. The Ujung Pandang Information officer requested the pilot of the estimate time of aircraft position at 60 Nm out from MKS VOR/DME. At 0632 UTC, the pilot discussed about the calculation of estimate time to reach 60 Nm out from MKS and afterward the pilot informed Ujung Pandang Information officer that the estimate at 60 Nm was at 0715 UTC. At 0633 UTC, the Ujung Pandang Information officer informed the pilot to call when reaching 8,000 feet and was acknowledged by the pilot. At 0636 UTC, the pilot informed the Ujung Pandang Information officer that the aircraft had reached 8,000 feet and requested the squawk number (ATC transponder code). The Ujung Pandang Information officer acknowledged and gave the squawk number of A5616, which was acknowledged by the pilot. At 0637 UTC, the pilots discussed to fly direct to BARRU. BARRU is a town located at about 45 Nm north of Makassar. Both pilots agreed to fly direct and the SIC explained the experience of flying direct on the flight before. At 0651 UTC, the PIC told the SIC that he wanted to climb and one second later the CVR recorded the sound of impact.
Probable cause:
The following findings were identified:
1. The aircraft had valid Certificate of Airworthiness prior to the accident and was operated within the weight and balance envelope.
2. Both pilots had valid licenses and medical certificates.
3. The accident flight from Masamba (WAFM) to Makassar (WAAA) was the 6th sector for the aircraft and the crew that day. The PIC acted as Pilot Flying and the
SIC acted as Pilot Monitoring.
4. The satellite image published by BMKG at 0700 UTC showed that there were cloud formations at the accident area. The local villagers stated that the weather
on the accident area was cloudy at the time of the accident.
5. The aircraft departed Masamba at 0625 UTC (1425 LT), conducted under VFR with cruising altitude of 8,000 feet and estimated time of arrival Makassar at 0739 UTC.
6. After reached cruising altitude, at about 22 Nm from Masamba, the flight deviated from the operator visual route and directed to BARRU on heading 200° toward the area with high terrain and cloud formation based on the BMKG satellite image
7. The pilots decision making process did not show any evidence that they were concerned to the environment conditions ahead which had more risks and required correct flight judgment.
8. The CVR did not record EGPWS aural caution and warning prior to the impact. The investigation could not determine the reason of the absence of the EGPWS.
9. The CVR data and cut on the trees indicated that the aircraft was on straight and level flight and there was no indication of avoid action by climb or turn.
10. The SAR Agency did not receive any crashed signal from the aircraft ELT most likely due to the ELT antenna detached during the impact.
11. Regarding to the operation of the EGPWS for the flight crew, a special briefing was performed however there was no special training.
12. The operational test of TAWS system was not included in the pilot checklist.
13. The investigation could not determine the installation and the last revision of TAWS terrain database.
14. The investigation could not find the functional test result document after the installation of the TAWS.
15. Some of the DHC-6 pilots have not been briefed for the operation of the TAWS and EGPWS.

Contributing Factors:
Deviation from the company visual route without properly considering the elevated risks of cruising altitude lower than the highest terrain and instrument meteorological condition in addition with the absence of the EGPWS warning resulted in the omission of avoidance actions.
Final Report:

Crash of a PZL-Mielec M28-05PI Skytruck near Wami: 5 killed

Date & Time: Oct 27, 2010 at 1630 LT
Type of aircraft:
Operator:
Registration:
P-4204
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Nabire – Ambon – Ujung Pandang – Jakarta
MSN:
AJE003-07
YOM:
2004
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The twin engine aircraft departed Nabire Airport at 1555LT and was carrying three police officers and two pilots who were returning to Jakarta after they delivered aid to the victims of Wasior floods in West Papua. Two intermediate stops were scheduled in Ambon and Ujung Pandang (Makassar). En route, the aircraft crashed in unknown circumstances near Wami, most probably due to poor weather conditions. The wreckage was found a day later and all five occupants were killed.

Crash of a Boeing 737-301 in Ujung Pandang

Date & Time: Dec 21, 2009 at 0151 LT
Type of aircraft:
Operator:
Registration:
PK-MDH
Survivors:
Yes
Schedule:
Surabaya – Ujung Pandang
MSN:
23932/1554
YOM:
1988
Flight number:
MZ766
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
102
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Surabaya-Juanda Airport, the crew started a night approach to Ujung Pandang-Sultan Hasanuddin Airport (Makassar). On short final, at a height of 50 feet, the aircraft descended fast and landed nose first. A tyre burst on impact and the aircraft was stopped following a normal landing course. All 108 occupants evacuated safely and the aircraft was damaged beyond repair due to fuselage damages.

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 McDonnell Douglas MD-90-30 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 737-4Q8 off Ujung Pandang: 102 killed

Date & Time: Jan 1, 2007 at 1459 LT
Type of aircraft:
Operator:
Registration:
PK-KKW
Flight Phase:
Survivors:
No
Schedule:
Jakarta – Surabaya – Manado
MSN:
24070
YOM:
1989
Flight number:
DHI574
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
96
Pax fatalities:
Other fatalities:
Total fatalities:
102
Captain / Total flying hours:
13356
Captain / Total hours on type:
3856.00
Copilot / Total flying hours:
4200
Copilot / Total hours on type:
998
Aircraft flight hours:
45371
Aircraft flight cycles:
26725
Circumstances:
On 1 January 2007, a Boeing Company 737-4Q8 aircraft, registered PK-KKW, operated by Adam SkyConnection Airlines (AdamAir) as flight number DHI574, was on a scheduled passenger flight from Surabaya (SUB), East Java to Manado (MDC), Sulawesi, at FL350 (35,000 feet) when it disappeared from radar. The aircraft departed from Djuanda Airport, Surabaya at 05:59 Coordinated Universal Time (UTC) under the instrument flight rules (IFR), with an estimated time of arrival (ETA) at Sam Ratulangi Airport, Manado of 08:14. The fuel endurance on departure from Surabaya was hours 30 minutes, and the crew had flight planned for an alternate of Gorontalo (GTO). The pilot in command (PIC) was the pilot flying for the sector to Manado and the copilot was the monitoring/support pilot. There were 102 people on board; two pilots, 4 cabin crew, and 96 passengers comprised of 85 adults, 7 children and 4 infants.
Probable cause:
The following findings were identified:
1) Flight crew coordination was less than effective. The PIC did not manage the task sharing; crew resource management practices were not followed.
2) The crew focused their attention on troubleshooting the Inertial Reference System (IRS) failure and neither pilot was flying the aircraft.
3) After the autopilot disengaged and the aircraft exceeded 30 degrees right bank, the pilots appeared to have become spatially disoriented.
4) The AdamAir syllabus of pilot training did not cover complete or partial IRS failure.
5) The pilots had not received training in aircraft upset recovery, including spatial disorientation.
Other Causal Factors:
1) At the time of the accident, AdamAir had not resolved the airworthiness problems with the IRS that had been reoccurring on their Boeing 737 fleet for more than 3 months.
2) The AdamAir maintenance engineering supervision and oversight was not effective and did not ensure that repetitive defects were rectified.
Final Report:

Crash of a Boeing 737-4Y0 in Ujung Pandang

Date & Time: Dec 24, 2006 at 2035 LT
Type of aircraft:
Operator:
Registration:
PK-LIJ
Survivors:
Yes
Schedule:
Jakarta - Ujung Pandang
MSN:
24682
YOM:
1990
Flight number:
LNI792
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
157
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Jakarta, the crew started the descent to Makassar (Ujung Pandang) Airport. On approach to runway 31, flaps were selected down from 15° to 30° when the captain observed an asymmetrical condition between both flaps and decided to set back at 15° and to continue the approach in such conditions. The aircraft landed hard to the left of the runway centerline and bounced twice. Out of control, it veered off runway, lost its right main gear and came to rest few dozen metres further. All 164 occupants evacuated safely while the aircraft was damaged beyond repair as the left main gear punctured the fuel tank and the fuselage was deformed.
Probable cause:
The exact cause of the asymmetrical flaps condition on approach is undetermined. Since all the conditions were clearly not met, the pilots should have made the decision to initiate a go-around procedure.

Crash of a Fokker F28 Friendship 4000 in Kendari

Date & Time: May 15, 1998 at 1103 LT
Type of aircraft:
Operator:
Registration:
PK-MGT
Flight Phase:
Survivors:
Yes
Schedule:
Kendari - Ujung Pandang
MSN:
11193
YOM:
1983
Flight number:
MZ715
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
60
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Kendari-Wolter Monginsidi Airport, at Vr speed, the cargo door warning light illuminated on the cockpit panel. The captain decided to abort and initiated an emergency braking procedure. Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage and came to rest 200 metres further. All 64 occupants escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Vickers 816 Viscount in Ambon: 70 killed

Date & Time: Jul 24, 1992 at 1630 LT
Type of aircraft:
Operator:
Registration:
PK-RVU
Survivors:
No
Site:
Schedule:
Jakarta - Surabaya - Ujung Pandang - Ambon
MSN:
434
YOM:
1959
Flight number:
RI660
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
63
Pax fatalities:
Other fatalities:
Total fatalities:
70
Circumstances:
On approach to Ambon-Pattimura Airport, the crew encountered bad weather conditions with heavy rain falls. At an altitude of 2,300 feet, the four engine aircraft struck the slope of Mt Lalaboy located 14 km southwest of runway 04 threshold. The aircraft disintegrated on impact and all 70 occupants were killed.
Probable cause:
Controlled flight into terrain after the crew was approaching the airport at an insufficient altitude, maybe following instrument misreading or malfunction.