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Crash of a Boeing 737-524 off Jakarta: 62 killed

Date & Time: Jan 9, 2021 at 1440 LT
Type of aircraft:
Operator:
Registration:
PK-CLC
Flight Phase:
Survivors:
No
Schedule:
Jakarta - Pontianak
MSN:
27323/2616
YOM:
1994
Flight number:
SJY182
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
56
Pax fatalities:
Other fatalities:
Total fatalities:
62
Captain / Total flying hours:
17904
Captain / Total hours on type:
9023.00
Copilot / Total flying hours:
5107
Copilot / Total hours on type:
4957
Aircraft flight hours:
62983
Aircraft flight cycles:
40383
Circumstances:
On 9 January 2021, a Boeing 737-500 aircraft, registration PK-CLC, was being operated by PT. Sriwijaya Air on a scheduled passenger flight from Soekarno-Hatta International Airport (WIII), Jakarta to Supadio International Airport (WIOO), Pontianak . The flight number was SJY182. According to the flight plan filed, the fuel endurance was 3 hours 50 minutes. At 0736 UTC (1436 LT) in daylight conditions, Flight SJY182 departed from Runway 25R of Jakarta. There were two pilots, four flight attendants, and 56 passengers onboard the aircraft. At 14:36:46 LT, the SJY182 pilot contacted the Terminal East (TE) controller and was instructed “SJY182 identified on departure, via SID (Standard Instrument Departure) unrestricted climb level 290”. The instruction was read back by the pilot. At 14:36:51 LT, the Flight Data Recorder (FDR) data recorded that the Autopilot (AP) system engaged at altitude of 1,980 feet. At 14:38:42 LT, the FDR data recorded that as the aircraft climbed past 8,150 feet, the thrust lever of the left engine started reducing, while the thrust lever position of the right engine remained. The FDR data also recorded the left engine N1 was decreasing whereas the right engine N1 remained. At 14:38:51 LT, the SJY182 pilot requested to the TE controller for a heading change to 075° to avoid weather conditions and the TE controller approved the request. At 14:39:01 LT, the TE controller instructed SJY182 pilot to stop their climb at 11,000 feet to avoid conflict with another aircraft with the same destination that was departing from Runway 25L. The instruction was read back by the SJY182 pilot. At 14:39:47 LT, the FDR data recorded the aircraft’s altitude was about 10,600 feet with a heading of 046° and continuously decreasing (i.e., the aircraft was turning to the left). The thrust lever of the left engine continued decreasing. The thrust lever of the right engine remained. At 14:39:54 LT, the TE controller instructed SJY182 to climb to an altitude of 13,000 feet, and the instruction was read back by an SJY182 pilot at 14:39:59 LT. This was the last known recorded radio transmission by the flight. At 14:40:05 LT, the FDR data recorded the aircraft altitude was about 10,900 feet, which was the highest altitude recorded in the FDR before the aircraft started its descent. The AP system then disengaged at that point with a heading of 016°, the pitch angle was about 4.5° nose up, and the aircraft rolled to the left to more than 45°. The thrust lever position of the left engine continued decreasing while the right engine thrust lever remained. At 14:40:10 LT, the FDR data recorded the autothrottle (A/T) system disengaged and the pitch angle was more than 10° nose down. About 20 seconds later the FDR stopped recording. The last aircraft coordinate recorded was 5°57'56.21" S 106°34'24.86" E. At 14:40:37 LT, the TE controller called SJY182 to request for the aircraft heading but did not receive any response from the pilot. At 14:40:48 LT, the radar target of the aircraft disappeared from the TE controller radar screen. At 14:40:46 LT, the TE controller again called SJY182 but did not receive any response from the pilot. The TE controller then put a measurement vector on the last known position of SJY182 and advised the supervisor of the disappearance of SJY182. The supervisor then reported the occurrence to the operation manager. The TE controller repeatedly called SJY182 several times and also asked other aircraft that flew near the last known location of SJY182 to call the SJY182. The TE controller then activated the emergency frequency of 121.5 MHz and called SJY182 on that frequency. All efforts were unsuccessful to get any responses from the SJY182 pilot. About 1455 LT, the operation manager reported the occurrence to the Indonesian Search and Rescue Agency (Badan Nasional Pencarian dan Pertolongan/BNPP). At 1542 LT, the Air Traffic Services (ATS) provider declared the uncertainty phase (INCERFA) of the SJY182. The distress phase of SJY182 (DETRESFA) was subsequently declared at 1643 LT.
Probable cause:
The following contributing factors were identified:
• The corrective maintenance processes of the A/T problem were unable to identify the friction or binding within the mechanical system of the thrust lever and resulted in the prolonged and unresolved of the A/T problem.
• The right thrust lever did not reduce when required by the A/P to obtain selected rate of climb and aircraft speed due to the friction or binding within the mechanical system, as a result, the left thrust lever compensated by moving further backward which resulted in thrust asymmetry.
• The delayed CTSM activation to disengage the A/T system during the thrust asymmetry event due to the undervalued spoiler angle position input resulted in greater power asymmetry.
• The automation complacency and confirmation bias might have led to a decrease in active monitoring which resulted in the thrust lever asymmetry and deviation of the flight path were not being monitored.
• The aircraft rolled to the left instead of to the right as intended while the control wheel deflected to the right and inadequate monitoring of the EADI might have created assumption that the aircraft was rolling excessively to the right which resulted in an action that was contrary in restoring the aircraft to safe flight parameters.
• The absence of the guidance of the national standard for the UPRT, may have contributed to the training program not being adequately implemented to ensure that pilots have enough knowledge to prevent and recover of an upset condition effectively and timely.
Final Report:

Crash of a Boeing 737-33A in Manokwari

Date & Time: May 31, 2017 at 0851 LT
Type of aircraft:
Operator:
Registration:
PK-CJC
Survivors:
Yes
Schedule:
Ujung Pandang – Sorong – Manokwari
MSN:
24025/1556
YOM:
1988
Flight number:
SJY570
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
146
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13371
Captain / Total hours on type:
3110.00
Copilot / Total flying hours:
5570
Copilot / Total hours on type:
2523
Aircraft flight hours:
60996
Circumstances:
On 31 May 2017, a Boeing 737-300 aircraft registration PK-CJC was being operated by PT. Sriwijaya Air as a scheduled passenger flight from Hasanuddin Airport (WAHH), Makassar, South Sulawesi to Rendani Airport (WAUU), Manokwari, West Papua, with one transit stop at Domine Eduard Osok Airport (WASS) Sorong, West Papua. The flight was uneventful since the first departure from Makassar until commencing the approach at Manokwari. At 0815 LT (2315 UTC), the aircraft departed Sorong to Manokwari. On board in the flight were two pilots, four flight attendants and 146 passengers. On this flight, the Second in Command (SIC) acted as Pilot Flying (PF) and the Pilot in Command (PIC) acted as Pilot Monitoring (PM). At 2331 UTC, the pilot made first contact to Rendani Tower controller and informed that the aircraft was descending from FL 230 (altitude 23,000 feet) and requested the weather information. The Rendani Tower controller informed to the pilot that the wind was calm, ground visibility 6 km, cloud FEW CB 1,400 feet, temperature and dew point 26/25°C. At 2336 UTC, Rendani Tower controller instructed to the pilot to descend to 11,000 feet and to report when on Visual Meteorological Condition (VMC). At 2338 UTC, the pilot informed that they were on VMC condition and passed altitude 13,000 feet while position was 32 Nm from ZQ NDB (Non-Directional Beacon). Rendani Tower controller instructed to fly maintain on visual condition, fly via overhead, descend to circuit altitude, join right downwind runway 35, and to report when overhead Manokwari. At 2344 UTC, the pilot reported that the aircraft was over Manokwari and Rendani Tower controller informed to the pilot that the visibility changed to 5 km. Two minutes later Rendani Tower controller instructed to the pilot to continue approach and to report on right base runway 35. At 2349 UTC, at approximately 600 feet, the PIC as PM took over control by called “I have control” and the SIC replied “You have control”. A few seconds later the pilot reported that the aircraft was on final runway 35, and Rendani Tower controller instructed to the pilot to report when the runway 35 insight. The pilot immediately replied that the runway was in sight and acknowledged by Rendani Tower controller who then issued landing clearance with additional information that the wind was calm and the runway condition wet. At approximately 550 feet, the PIC instructed the SIC turn on the wiper and reconfirmed to SIC that the runway was in sight. Between altitude 500 feet to 200 feet, the EGPWS aural warnings “Sink Rate” and “Pull Up” sounded. At 2350 UTC, the aircraft touched down and rolled on runway 35. The spoiler deployed and the pilot activated the thrust reversers. The crew did not feel significant deceleration. The aircraft stopped at approximate 20 meters from the end of runway pavement. After the aircraft stopped, the PIC commanded “Evacuate” through the Passenger Address (PA) system. The Rendani Tower Controller saw that the aircraft was overrun and activated the crash bell then informed the Airport Rescue and Fire Fighting (ARFF) that there was an aircraft overrun after landing on runway 35. All the flight crew and passengers evacuated the aircraft and transported to the terminal building safely.
Probable cause:
According to factual information during the investigation, the Komite Nasional Keselamatan Transportasi identified initial findings as follows:
1. The aircraft was airworthy prior to the accident, there was no report or record of aircraft system abnormality during the flight. The aircraft had a valid Certificate of Airworthiness (C of A) and Certificate of Registration (C of R).
2. The aircraft operator had a valid Air Operator Certificate (AOC) to conduct a scheduled passenger transport.
3. The crew held valid licenses and medical certificates.
4. The weather conditions during aircraft approach and landing was slight rain with cumulonimbus viewed nearby the airport, wind was calm and runway was wet.
5. In this flight Second in Command (SIC) acted as Pilot Flying (PF) and the Pilot in Command (PIC) acted as Pilot Monitoring (PM). The PIC took over control from the SIC during approach at altitude approximately 600 feet.
6. At approximate 550 feet, the PIC instructed the SIC to turn on the wiper and reconfirmed to SIC that the runway was in sight.
7. Between altitude 500 feet to 200 feet, the EGPWS aural warnings “Sink Rate” and “Pull Up” sounded.
8. The CCTV recorded water splash when aircraft on landing roll.
9. Several area of the runway warp in approximate 2 - 5 meters square meters with standing waters on the runway of Rendani Airport.
10. Several runway lights covered by grass with the height approximately of 30-40 cm.
11. Rendani Aerodrome Manual (AM) as general guidelines in the airport operation had not been approved by the DGCA at the time of accident.
12. Rendani Airport (WAUU), Fire fighting category III refer to AIP amended on April 2015.
Final Report:

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 (heavy rain falls). The aircraft landed on wet runway 15 and skidded. It eventually veered off runway to the left and went through a muddy field. The nose gear was torn off while both main gears sank, leaving both engines on the ground. While all 163 occupants were evacuated safely, the aircraft was damaged beyond repair. At the time of the accident, weather conditions were as follow: wind from 230 at 22 knots, visibility 600 metres, few clouds at 900 feet, broken at 700 feet, CB's above the terrain and turbulences.

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 Boeing 737-2H6 in Jambi: 1 killed

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:
124
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7794
Captain / Total hours on type:
6238.00
Copilot / Total flying hours:
5254
Copilot / Total hours on type:
4143
Aircraft flight hours:
49996
Aircraft flight cycles:
54687
Circumstances:
On 27 August 2008, a Boeing 737-200 aircraft, registered PK-CJG, was being operated on a scheduled passenger service from Soekarno-Hatta International Airport, Jakarta to Sultan Thaha Airport, Jambi with flight number SJY062. On board the flight were two pilots, four flight attendants, and 124 passengers. The Pilot in Command (PIC) acted as Pilot Flying (PF) while the Second in Command (SIC) acted as Pilot Monitoring (PM). The flight time from Jakarta to Jambi was estimated to be about one hour and the aircraft was dispatched with approximately 4 hours of fuel endurance. The number one electrical engine driven generator was unserviceable, as such the Auxiliary Power Unit (APU) generator was used during the flight to maintain two generators operation. Prior to descent into Jambi, the PIC conducted the crew briefing and stated a plan for Makinga straight-in approach to runway 31 with flap 40°, reviewed the go-around procedures and stated that Palembang was the alternate airport.There was no abnormality recorded nor reported until the PIC commenced the approach to Jambi. At 09:18 UTC, the SIC contacted Thaha Tower controller and reported that the aircraft was descending and passing FL160 and had been cleared by Palembang Approach control to descend to 12,000 feet. The Thaha Tower controller issued a clearance to descend to 2500 feet and advised that runway 31 was in use. The SIC asked about the weather conditions and was informed that the wind was calm, rain over the field and low cloud on final approach to runway 31. The PIC flew the aircraft direct to intercept the final approach to runway 31. While descending through 2500 feet, and about 8 miles from the VOR, the flap one degree and flap 5° were selected. Subsequently the landing gear was extended and flap 15° was selected. 13 seconds after flap 15 selection, the pilots noticed that the hydraulic system A low pressure warning light illuminated, and also the hydraulic system A quantity indicator showed zero. The PIC commanded the SIC to check the threshold speed for the existing configuration of landing, weight and with flap 15°. The SIC called out that the threshold speed was 134 kts and the PIC decided to continue with the landing. The PIC continued the approach and advised the SIC that he aimed to fly the aircraft slightly below the normal glide path in order to get more distance available for the landing roll. The aircraft touched down at 0930 UTC and during the landing roll, the PIC had difficulty selecting the thrust reversers. The PIC the applied manual braking. During the subsequent interview, the crew reported that initially they felt a deceleration then afterward a gradual loss of deceleration. The PIC reapplied the brakes and exclaimed to the SIC about the braking condition, then the SIC also applied the brakes to maximum in responding to the situation. The aircraft drifted to the right of the runway centre line about 200 meters prior to departing off the end of the runway, and stopped about 120 meters from the end of the runway 31 in a field about 6 meters below the runway level. Three farmers who were working in that area were hit by the aircraft. One was fatally injured and the other two were seriously injured. The pilots reported that, after the aircraft came to a stop, they executed the Emergency on Ground Procedure. The PIC could not put both start levers to the cut-off position, and also could not pull the engines and APU fire warning levers. The PIC also noticed that the speed brake lever did not extend. The radio communications and the interphone were also not working. The flight attendants noticed a significant impact before the aircraft stopped. They waited for any emergency command from the PIC before ordering the evacuation. However, the passengers started to evacuate the aircraft through the right over-wing exit window before commanded by the flight attendants. The flight attendants subsequently executed the evacuation procedure without command from the PIC. The left aft cabin door was blocked by the left main landing gear that had detached from the aircraft and the flight attendants were unable to open the door. The right main landing gear and both engines were also detached from the aircraft. The Airport Rescue and Fire Fighting (ARFF) come to the crash site and activated the extinguishing agent while the passengers were evacuating the aircraft. The PIC, SIC and FA1 were the last persons to evacuate the aircraft. The APU was still running after all passengers and crew evacuation completed, afterward one company engineer went to the cockpit and switched off the APU. All crew and passengers safely evacuated the aircraft. No significant property damage was reported.
Probable cause:
Contributing Factors:
- When the aircraft approach for runway 31, the Loss of Hydraulic System A occurred at approximately at 1,600 feet. At this stage, there was sufficient time for pilots to conduct a missed approach and review the procedures and determine all the consequences prior to landing the aircraft.
- The smooth touchdown with a speed 27 kts greater than Vref and the absence of speed brake selection, led to the aircraft not decelerating as expected.
Final Report: