Region

Crash of a De Havilland DHC-6 Twin Otter 400 near Kampung Mamontoga: 4 killed

Date & Time: Sep 18, 2019 at 1100 LT
Operator:
Registration:
PK-CBC
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Timika - Ilaga
MSN:
950
YOM:
2016
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The twin engine airplane departed Timika Airport at 1036LT on a cargo flight to Ilaga, carrying one passenger, a crew of four and a load of 1,7 ton of rice. At 1054LT, the crew gave his ETA at Ilaga Airport when the contact was lost about six minutes later. As the airplane failed to arrive at destination, SAR operations were initiated. The wreckage was found four days later in a mountainous terrain, at an altitude of 4,115 meters, about 10 km from Kampung Mamontoga. The aircraft was totally destroyed and all four occupants were killed.

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 Pacific Aerospace PAC 750XL near Oksibil: 8 killed

Date & Time: Aug 11, 2018 at 1420 LT
Operator:
Registration:
PK-HVQ
Flight Phase:
Survivors:
Yes
Site:
MSN:
144
YOM:
2009
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
At 1411LT, the crew contacted Oksibil Airport, reported his altitude at 7,000 feet and received the last weather bulletin for Oksibil. Nine minutes later, the single engine aircraft struck trees and crashed in a dense wooded area located in the region of Oksibil. A 12-year old boy was injured while eight other occupants were killed.

Crash of a Boeing 737-301F in Wamena

Date & Time: Jul 18, 2017 at 1239 LT
Type of aircraft:
Operator:
Registration:
PK-YGG
Flight Type:
Survivors:
Yes
Schedule:
Timika – Wamena
MSN:
23743/1510
YOM:
5
Flight number:
TMG103
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was performing a cargo flight from Timika, carrying a load of various goods, among them building materials. Following an uneventful approach, the airplane bounced twice upon landing on runway 15. It then veered off runway to the left and while contacting a soft ground, lost its both main gears before coming to rest on its belly with the right engine partially sheared off. All five crew members evacuated safely while the aircraft was considered as damaged beyond repair.

Crash of a Pilatus PC-6/B2-H4 Turbo Porter near Wamena: 5 killed

Date & Time: Jul 5, 2017 at 1110 LT
Operator:
Registration:
PK-RCX
Flight Phase:
Survivors:
No
Site:
Schedule:
Wamena – Derakma
MSN:
922
YOM:
1998
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The single engine aircraft departed Wamena Airport at 1100LT with three passengers, two crew members and 508 kg of various goods. Ten minutes later, the airplane struck the slope of a mountain at an altitude of 2,300 meters. It was scheduled to arrive at Derakma at 1125LT. The wreckage was found a day later by the crew of a helicopter. All five occupants have been killed. At the time of the accident, VMC conditions prevailed.

Crash of a Cessna 208 Caravan I near Oksibil: 1 killed

Date & Time: Apr 12, 2017 at 1245 LT
Type of aircraft:
Operator:
Registration:
PK-FSO
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Tanahmerah – Oksibil
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot was performing a cargo flight from Tanahmerah to Oksibil and the single aircraft was carrying a load of various goods for a total weight of 1,225 kilos. After passing Oksibil, the aircraft continued to the north at an altitude of 7,100 feet and collided with the south slope of Mt Botak located about 10 km north of Oksibil. The wreckage was found in a dense wooded area and the pilot was killed.

Crash of a Lockheed C-130H Hercules in Wamena: 13 killed

Date & Time: Dec 18, 2016 at 0609 LT
Type of aircraft:
Operator:
Registration:
A-1334
Flight Type:
Survivors:
No
Site:
Schedule:
Timika – Wamena
MSN:
4785
YOM:
1978
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
13
Circumstances:
The four engine aircraft left Timika-Moses Kilangin Airport at 0535LT bound for Wamena. While approaching Wamena, the crew encountered marginal weather conditions and the aircraft descended through several cloud layers when it crashed in a hilly terrain about four minutes before ETA at 0613LT. The aircraft was destroyed by impact forces and a post crash fire and all 13 occupants were killed.

Crash of a PZL-Mielec M28 Skytruck off Tanjungpinang: 13 killed

Date & Time: Dec 3, 2016 at 1022 LT
Type of aircraft:
Operator:
Registration:
P-4201
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Pangkal Pinang – Batam
MSN:
AJE003-03
YOM:
2004
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
13
Circumstances:
The twin engine aircraft left Pangkal Pinang Airport at 0924LT bound for Hang Nadim Airport on the Batam Island. En route, the aircraft disappeared from radar screens and crashed into the sea about 74 km southeast of Tanjunpinang, in the Riau Islands. An hour later, around 1130LT, few debris and body parts were found by fishermen on the waters off Pulau Senayang. All 13 occupants have been killed.

Crash of a Casa NC-212-MP Aviocar 200 in Pitu

Date & Time: Nov 27, 2016 at 1000 LT
Type of aircraft:
Operator:
Registration:
U-623
Flight Type:
Survivors:
Yes
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing at Pitu-Leo Wattimena Airport, the twin engine aircraft went out of control and veered off runway to the right. The left main landing gear was sheared off and the right wing broke at the root. All 14 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-4T Caribou near Ilaga: 4 killed

Date & Time: Oct 31, 2016 at 0830 LT
Type of aircraft:
Registration:
PK-SWW
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Timika - Ilaga
MSN:
303
YOM:
1972
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The twin turbo Caribou left Timika at 0757LT on a cargo flight to Ilaga, carrying four crew members and a load of construction materials. While approaching the Ilaga Pass and flying at an altitude of about 3,650 meters, the aircraft hit the slope of a mountain and disintegrated on impact. The wreckage was found a day later about 12 km south of the intended destination. All four occupants have been killed.