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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 Casa 212 Aviocar 200 in Larat

Date & Time: Dec 3, 2011 at 1308 LT
Type of aircraft:
Operator:
Registration:
PK-NCZ
Survivors:
Yes
Schedule:
Langur - Larat
MSN:
274/79N
YOM:
1986
Flight number:
MNA9933
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7500
Captain / Total hours on type:
5500.00
Copilot / Total flying hours:
343
Copilot / Total hours on type:
72
Aircraft flight hours:
26935
Aircraft flight cycles:
30064
Circumstances:
The Casa 212-200 aircraft registered PK-NCZ operated by PT. Merpati Nusantara Airlines on a scheduled flight from Langur to Larat, touched down at 224 meters from runway 09, was bouncing twice to the left of runway centre line, out of the runway and stopped at 607 meters from runway 09 touch down area as final position, and 15 meters to the left of runway edge. The Pilot Flying was First Officer, and after second bouncing, PIC took over, and he tried to bring the aircraft to the centre line of the runway without success. The aircraft continued rolled to the shoulder away from the runway and stopped at the final position. This is the second landing at Larat runway on the same day. There were 15 passengers, 3 children, one baby, Pilot In Command, two First Officers, one First Officer was Pilot Flying from Langur to Larat, one engineer on board. One passenger was serious injured, another one passenger minor injured.
Final Report:

Crash of a Xian MA60 off Kaimana: 25 killed

Date & Time: May 7, 2011 at 1405 LT
Type of aircraft:
Operator:
Registration:
PK-MZK
Survivors:
No
Schedule:
Jayapura - Sorong - Kaimana - Nabire - Biak
MSN:
06 03
YOM:
2008
Flight number:
MZ8968
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
25
Captain / Total flying hours:
24470
Captain / Total hours on type:
199.00
Copilot / Total flying hours:
370
Copilot / Total hours on type:
234
Aircraft flight hours:
615
Aircraft flight cycles:
764
Circumstances:
On 7 May 2011, an Xi ’An MA60 aircraft, registered PK-MZK was being operated by PT. Merpati Nusantara Airline as a scheduled passenger flight MZ 8968, from Domine Eduard Osok Airport, Sorong, Papua Barat to Utarom Airport (WASK), Kaimana1, Papua Barat. The accident flight was part of series of flight scheduled for the crew. The aircraft departed from Sorong at 0345 UTC2 and with estimated arrival time in Kaimana at 0454 UTC. In this flight, the Second in Command (SIC) was as Pilot Flying (PF) and the Pilot in Command (PIC) as Pilot Monitoring (PM). On board the flight were 2 pilots, 2 flight attendants, 2 engineers and 19 passengers consisting of 16 adults, 1 child and 2 infants. The flight from Sorong was planned under the Instrument Flight Rules (IFR)3. The destination, Kaimana, had no published instrument approach procedure. Terminal area operations, including approach and landing, were required to be conducted under the Visual Flight Rules (VFR). At about 0425 UTC, after passing waypoint JOLAM the crew of MZ 8968 contacted Kaimana Radio and informed that the weather at Kaimana was raining, horizontal visibility of 3 to 8 kilometers, cloud Cumulonimbus broken at 1500 feet, south westerly wind at a speed of 3 knots, and ground temperature 29°C. The last communication with the crew of MZ 8968 occurred at about 0450 UTC. The flight crew asked whether there were any changes in ground visibility and the AFIS officer informed them that the ground visibility remained at 2 kilometer. The visual flight rules requires a visibility of minimum 5 km and cloud base higher than 1500 feet. The evidence indicates that during the final segment of the flight, both crew member were looking outside the aircraft to sight the runway. During this period the flight path of the aircraft varied between 376 to 585 feet and the bank angle increased from 11 to 38 degree to the left. The rate of descent then increased significantly up to about 3000 feet per minute and finally the aircraft impacted into the sea. The accident site was about 800 meters south west of the beginning of runway 01 or 550 meters from the coastline. Most of the wreckage were submerged in the shallow sea between 7 down to 15 meter deep. All 25 occupants were fatally injured. The aircraft was destroyed and submerged into the sea.
Probable cause:
FINDINGS:
1. The aircraft was airworthy prior the accident. There is no evidence that the aircraft had malfunction during the flight.
2. The crew had valid flight license and medical certificate. There was no evidence of crew incapacitation.
3. In this flight the SIC acted as Pilot Flying until the PIC took control of the aircraft at the last part of the flight.
4. According to company operation manual (COM), in a VMC (Visual Meteorological Condition), a “minimum, minimum” EGPWS alert while the approach was not stabilized should be followed by the action of abandoning the approach.
5. The cockpit crew did not conduct any crew approach briefing and checklist reading.
6. As it was recorded in the CVR during the final segment of the flight, both crews member were looking out-side to look for the runway. It might reduce the situational awareness.
7. At the final segment of the flight, the FDR recorded as follows:
• The approach was discontinued started at 376 feet pressure altitude (250 feet radio altitude) and reached the highest altitude of 585 feet pressure altitude. While climbing the aircraft was banking to the left reaching a roll angle of 38 degree. The torque of both engines was increased reaching 70% and 82% for the left and right engine respectively.
• During the go-around, the flaps were retracted to 5 and subsequently to 0 position, and the landing gears were retracted. The aircraft started to descend, and the pitch angle reached 13 degree nose down.
• The rate of descend increased significantly reaching about 3000 feet per minute, and finally the aircraft crashed into the shallow sea.
8. The rapid descent was mainly a result of a combination of situations such as high bank angle (up to 38 deg to the left) and the flaps retracted to 5 and subsequently to 0 position, and also the combination of other situations: engine torque, airspeed, and nose-down pitch.
9. The ERS button was determined in the CRUISE mode instead of TOGA mode. This had led the torque reached 70% and 82% during discontinuing the approach.
10. The flaps were retracted to 5 and subsequently to 0, while the MA-60 standard go-around procedure is to set the flaps at 15.
11. There was limited communications between the crew along the flight. This type of interaction indicated that there was a steep trans-cockpit authority gradient.
12. The SIC was trained in the first three batches which was conducted by the aircraft manufacturer instructor and syllabus, while the PIC was trained by Merpati instructor using modified syllabus. Inadequacy/ineffectivity in the training program may lead to actions that deviated from the standard procedure and regression to the previous type.
13. The investigation found that the Flight Crew Operation Manual (FCOM) and Aircraft Maintenance Manual (AMM) used non-standard English Aviation Language. This finding was supported by a review performed by the Australian Transport Safety Bureau (ATSB).
OTHER FINDINGS:
1. The DFDR does not have the Lateral and Longitudinal acceleration. These two parameters which were non safety related items were mandatory according to the CASR parts 121.343 and 121.344, and at the time of the MA 60 certification, the CCAR 121 did not require those two parameters.
2. Due to impact forces and immersion in water, the Emergency Locator Transmitter (ELT) did not transmit any signal.
FACTORS:
Factors contributed to the accident are as follows:
1. The flight was conducted in VFR in condition that was not suitable for visual approach when the visibility was 2 km. In such a situation a visual approach should not have been attempted.
2. There was no checklist reading and crew briefing.
3. The flight crew had lack of situation awareness when tried to find the runway, and discontinued the approach.
4. The missed approach was initiated at altitude 376 feet pressure altitude (250 feet radio altitude), the pilot open power to 70% and 82% torque followed by flap retracted to 5 and subsequently to 0. The rapid descent was mainly caused by continuously increase of roll angle up to 38 degree to the left and the retraction of flaps from 15 to 0 position.
5. Both crew had low experience/flying time on type.
6. Inadequacy/ineffectivity in the training program may lead to actions that deviated from the standard procedure and regression to the previous type.
Final Report:

Crash of a Boeing 737-322 in Manokwari

Date & Time: Apr 13, 2010 at 1055 LT
Type of aircraft:
Operator:
Registration:
PK-MDE
Survivors:
Yes
Schedule:
Ujung Pandang - Sorong - Manokwari
MSN:
24660/1838
YOM:
1990
Flight number:
MZ836
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
103
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16450
Copilot / Total flying hours:
22139
Aircraft flight hours:
54759
Aircraft flight cycles:
38485
Circumstances:
On 13 April 2010, a Boeing B737-300 aircraft registered PK-MDE was being operated by PT. Merpati Nusantara Airline as a scheduled passenger flight MZ 836, from Hasanuddin Airport, Makassar, Sulawesi to Rendani Airport, Manokwari, Papua. It made a transit stop at Domine Eduard Osok Airport, Sorong, Papua. The aircraft departed from Makassar at 2010 UTC and landed at Sorong at 2214 UTC. The scheduled departure time from Sorong was 2235, but due to heavy rain over Manokwari, the departure was delayed for about two hours. The pilot in command was the pilot flying, and the copilot, who also held a command rating on the aircraft, was the support/monitoring pilot. The aircraft subsequently departed Sorong 2 hours and 43 minutes later, at 0118. The observed weather report issued by Badan Meteorologi dan Geofisika (BMG) Manokwari for takeoff and landing at 0100 indicated that the weather was “continuous slight rain, horizontal visibility of 3 to 4 kilometers, cloud overcast cumulus-stratocumulus, westerly wind at 5 knots”. The aircraft’s dispatch release from Sorong indicated that the flight was planned under the Instrument Flight Rules (IFR). The destination, Manokwari, had no published instrument approach procedure. Terminal area operations, including approach and landing, were required to be conducted under the Visual Flight Rules (VFR). At 0146 the crew made the first direct contact with Rendani Radio and reported their position as 14 Nm from Manokwari, and maintaining altitude 10,500 feet. Following this radio contact, Rendani Radio informed the crew that the weather was continuous slight rain, visibility 3 kilometers, cloud overcast with cumulus stratocumulus at 1,400 feet, temperature 24 degrees Celsius, QNH 1012 hectopascals. The transcript of the Rendani Radio communications with the aircraft indicated that controller then instructed the crew to descend and joint right downwind for runway 35, and to report when overhead the airport. Shortly after, the crew reported overhead the airport at 5,000 feet. The controller then instructed the crew to report when they were on final approach for runway 35. The crew acknowledged this instruction. At 0154 the crew reported that they were on final for runway 35. The controller informed them that the wind was calm, runway condition was wet and clear. The crew read back the wind condition and that the runway was clear, but did not mention the wet runway condition. According to the Rendani Airport Administrator’s report to the investigation, the aircraft was observed to make a normal touchdown on the runway at about 0155, about 120 meters from the approach end of runway 35. The report stated that the aircraft’s engine reverser sound was not heard during landing roll. Witnesses on board the aircraft also stated that the aircraft made a smooth landing, and the engine reversers were not heard during the landing roll. During the landing roll, the aircraft veered to the left about 140 meters from the end of runway 35, then overran the departure end of runway 35. At about 0156 it came to a stop 205 meters beyond the end of the runway in a narrow river; the Rendani River. The Observed Weather Report issued by BMG Manokwari for takeoff and landing at 0200 (4 minutes after the accident) indicated that the weather was continuous moderate rain, with a horizontal visibility of 4 kilometers, cloud overcast cumulus stratocumulus, south-westerly wind at 5 knots. The airport rescue and fire fighting unit was immediately deployed to assist the post crash evacuation. Due to the steep terrain 155 meters from the end of runway 35, the rescuers had to turn back and use the airport’s main road to reach the aircraft. The accident site was in an area of shallow muddy water surrounded by mangrove vegetation. The aircraft was substantially damaged. Nearby residents, police and armed forces personnel assisted the evacuation from the aircraft. The Rendani Airport Administrator reported that the passengers and crew members were evacuated and moved from the site by 0230. They were taken to the Manokwari General Hospital, and Manokwari Naval Hospital for further medical treatment.
Final Report:

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 De Havilland DHC-6 Twin Otter 300 near Oksibil: 15 killed

Date & Time: Aug 2, 2009 at 1100 LT
Operator:
Registration:
PK-NVC
Flight Phase:
Survivors:
No
Site:
Schedule:
Jayapura - Oksibil
MSN:
626
YOM:
1979
Flight number:
MZ9760D
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
15
Captain / Total flying hours:
8387
Captain / Total hours on type:
8387.00
Copilot / Total flying hours:
1207
Copilot / Total hours on type:
1207
Aircraft flight hours:
27336
Circumstances:
On the morning of Sunday, 2 August 2009, a de Havilland DHC-6 Twin Otter aircraft, registered PK-NVC, operated by PT. Merpati Nusantara Airlines as flight number MZ-7960D, departed from Sentani Airport, Jayapura for Oksibil Airport. The flight was planned in accordance with the visual flight rules (VFR). There were 15 persons on board; two pilots, one engineer, 10 adult passengers and two infants. The estimated flight time was 50 minutes. The fuel on board was sufficient for 2 hours and 50 minutes flight time. About 15 minutes prior to the estimated time of arrival at Oksibil the crew of another aircraft informed the Twin Otter crew that the weather in the Oksibil area was partly cloudy. There were no further reports of radio transmissions from the Twin Otter, and it did not arrive at Oksibil. A search was initiated at the time the aircraft would have run out of fuel. On the morning of 4 August 2009, searchers located the wreckage of the Twin Otter at an elevation of about 9,300 feet about 6 Nm from Oksibil. The aircraft was destroyed by impact forces, and all of the occupants were fatally injured.
Probable cause:
The pilots did not maintain visual flight procedures when flying below lowest safe altitude, and the aircraft was flown into cloud in the vicinity of gap north west of Oksibil. In conclusion, the accident was consistent with controlled flight into terrain.
Final Report:

Crash of a Casa NC-212-AB4 Aviocar 200 in Banda Neira

Date & Time: Jun 5, 2006 at 1013 LT
Type of aircraft:
Operator:
Registration:
PK-NCL
Survivors:
Yes
Schedule:
Ambon - Bandanaira
MSN:
185/34N
YOM:
1981
Flight number:
MZ9971
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on wet runway 10/28 at Banda Neira Airport, the aircraft slid then veered off runway to the right. While contacting soft ground, the undercarriage collapsed and the aircraft came to rest, broken in two. All 18 occupants escaped with minor injuries. The accident occurred in heavy rain falls.

Crash of a Fokker F27 Friendship 500F in Surabaya: 3 killed

Date & Time: Mar 26, 2001 at 1825 LT
Type of aircraft:
Operator:
Registration:
PK-MFL
Flight Type:
Survivors:
No
Schedule:
Surabaya - Surabaya
MSN:
10609
YOM:
1981
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4506
Copilot / Total flying hours:
4325
Aircraft flight hours:
31300
Aircraft flight cycles:
38200
Circumstances:
The crew was completing a local training flight at Surabaya-Juanda Airport, consisting of touch-and-go manoeuvres. While approaching the airport to complete the eighth landing, at an altitude of 500 feet, the aircraft rolled to the left then stalled and crashed in a pond located 3 km short of runway, bursting into flames. All three pilots were killed. Both captains were operating on Casa-Nurtanio CN-235 (IPTN) and making a transition to Fokker F27.

Crash of a De Havilland DHC-6 Twin Otter 300 in Ilaga

Date & Time: Aug 6, 1999
Operator:
Registration:
PK-NUU
Flight Type:
Survivors:
Yes
MSN:
478
YOM:
1975
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a positioning flight to Ilaga Airport. After touchdown, the twin engine aircraft was unable to stop within the remaining distance. It overran, lost its nose gear and came to rest. Both pilots escaped uninjured and the aircraft was damaged beyond repair.