Country
code

Special Region of West Papua

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.

Crash of a PAC 750XL nearn Korupun: 2 killed

Date & Time: Oct 3, 2012 at 1115 LT
Operator:
Registration:
PK-RWT
Flight Phase:
Survivors:
No
Site:
Schedule:
Jayapura - Korupun - Dekai
MSN:
157
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Aircraft was on its way from Jayapura to Dekai with an intermediate stop at Korupun on behalf of a missionnary group. The plane crashed shortly after it stopped over in Korupun, in the Papua district of Yahukimo. It was supposed to land in the neighboring subdistrict of Dekai 15 minutes from departing Korupun, at 1115LT. Rescuers arrived on scene two days later and found only two dead bodies.

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:
603
YOM:
2007
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 737-300 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:
Aircraft was on 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 pilot in command was the pilot flying, and the copilot, who also held a command rating on the aircraft, was the support/monitoring pilot for the sector to Manokwari. Due to heavy rain over Manokwari, the departure from Sorong was delayed for about two hours. Approaching Manokawari the crew were informed 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. When the crew reported that they were on final for runway 35 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.Witnesses stated that the aircraft made a normal touchdown on the runway, about 120 meters from the approach end of runway 35, but the aircraft’s engine reverser sound was not heard during landing roll. The aircraft overran the departure end of runway 35, and came to a stop 205 meters beyond the end of the runway in a narrow river; the Rendani River. Due to the steep terrain 155 meters from the end of runway 35, the airport rescue and fire fighting service had to turn back and use the airport’s main road to reach the aircraft, taking about 10 minutes 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 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.The investigation is continuing and will include analysis of data from the flight data and cockpit voice recorders. Operational documentation and training with respect to aircraft performance, stabilized approach criteria, and operations into wet and contaminated runways will be examined. Runway conditions and safety systems including rescue and fire fighting services, and the system for ensuring flight crews have sufficient and appropriate information to aid their decision making will also be examined. The role of the aviation regulator in providing timely, appropriate and effective oversight of the operator and the aerodrome is being examined.The National Transportation Safety Committee issued a number of recommendations to PT. Merpati Nusantara and the Directorate General of Civil Aviation with the Preliminary Report, covering adequacy of documentation and training, and regulatory oversight of the airline and the airport.
Probable cause:
Runway excursion still under investigation.
Final Report:

Crash of a Dornier DO328 in Fakfak

Date & Time: Nov 6, 2008 at 1033 LT
Type of aircraft:
Operator:
Registration:
PK-TXL
Survivors:
Yes
Schedule:
Sorong - Fakfak
MSN:
3037
YOM:
1995
Flight number:
XAR9000
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10190
Captain / Total hours on type:
2365.00
Copilot / Total flying hours:
4673
Copilot / Total hours on type:
15
Aircraft flight hours:
24404
Aircraft flight cycles:
21916
Circumstances:
The aircraft touched down heavily approximately 5 meters before the touch-down area of runway 10 at Torea Airport, Fak-Fak at 01:33. The investigation found that the left main landing gear touched the ground first (5 meters before the end of the runway), and the right main landing gear touched the ground (4.5 meters from the end of the runway). It stopped on the runway, approximately 700 meters from the touch-down area. The left main landing gear fractured in two places; at the front pivot point, and the aft pivot point. The left fuselage contacted the runway surface 200 meters from the touch-down point and the aircraft slid with the left fuselage on the ground for a further 500 meters, before it stopped at the right edge of the runway. The wing tip and left propeller blade tips also touched the runway and were damaged. The passengers and crew disembarked normally; there were no injuries. Following an inspection of the landing gear and temporary replacement of the damaged left main landing gear, the aircraft was moved to the apron on 8 November 2008 at 04:00. The runway was closed for 5 days.
Probable cause:
The Digital Flight Data Recorder data showed evidence that the aircraft descended suddenly and rapidly when it was on short final approach. About 65 seconds before ground impact, the RPM of both propellers commenced to decrease to approximately 70% with the NH increasing to 85%. Propeller RPM then suddenly reduced, followed by an immediate and rapid increase of propeller RPM to 111% left and 97% right, then just as sudden and rapid, the left propeller RPM reduced to 77% and the right to 80%. Given that the propellers are constant speed units, the sudden and rapid changes could not be explained other than the probability that a crew member had made the control inputs.
The PIC (pilot monitoring/flight instructor) did not monitor the operation of the aircraft sufficiently to ensure timely and effective response to the pilot induced excessive sink rate.
The pilots did not communicate appropriately during the approach and landing, resulting is poor crew resource management (CRM).
There was no evidence that any of the pilots had completed any form of CRM training for more than 9 years. Other than the handling pilot, there was no evidence that the other pilots had completed ALAR/CFIT training.
The operator did not have a Line Operations Safety Audit Program (LOSA), and the airport did not meet the ICAO Annex 14 Standard with respect to runway end safety areas.
Final Report:

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

Date & Time: Sep 30, 1996 at 1215 LT
Operator:
Registration:
PK-YPF
Survivors:
Yes
MSN:
210
YOM:
1969
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0

Crash of a De Havilland DHC-6 Twin Otter in Bintuni: 1 killed

Date & Time: Jul 17, 1995 at 1200 LT
Operator:
Registration:
PK-NUT
Flight Phase:
Survivors:
Yes
Schedule:
Bintuni-Manaokwari
MSN:
473
YOM:
1975
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
1

Crash of a Fokker F28 in Sorong: 41 killed

Date & Time: Jul 1, 1993 at 1200 LT
Type of aircraft:
Operator:
Registration:
PK-GFU
Survivors:
Yes
Schedule:
Djakarta-Surabaya-Ujung Pandang-Amboine-Sorong
MSN:
11131
YOM:
1978
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
39
Pax fatalities:
Other fatalities:
Total fatalities:
41