Crash of a PZL-Mielec M28 Skytruck off Tanjung Pinang: 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 departed Pangkal Pinang Airport at 0924LT bound for the Hang Nadim Airport located on the Batam Island. En route, the aircraft disappeared from radar screens and crashed in the sea about 74 km southeast of Tanjun Pinang, in the Riau Islands. An hour later, around 1130LT, few debris and bodies were found by fishermen floating on water off Pulau Senayang. All 13 occupants were killed.

Crash of a Casa 212 Aviocar 100 near Tanjung Pinang: 5 killed

Date & Time: Feb 12, 2011 at 1342 LT
Type of aircraft:
Operator:
Registration:
PK-ZAI
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Batam - Tanjung Pinang
MSN:
120/18N
YOM:
1980
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
13027
Captain / Total hours on type:
3311.00
Copilot / Total flying hours:
2577
Copilot / Total hours on type:
152
Aircraft flight hours:
29990
Aircraft flight cycles:
35128
Circumstances:
On 12 February 2011, a CASA C212-100 aircraft, registered PK-ZAI, operated by Sabang Merauke Raya Air Charter (SMAC), departed from Hang Nadim Airport, Batam (BTH/WIDD) at 1318 LT (0618 UTC)1 for a test flight following an engine replacement to the engine number one. The test flight was conducted over Tanjung Pinang Island area. There were five persons on board consisted of two pilots, and three company engineers. At 0628 UTC the aircraft appeared on Tanjung Pinang Approach radar display and was flying toward Tanjung Pinang area. Tanjung Pinang Approach controller informed that the aircraft was identified flying over Tanjung Pinang at 2000 feet. At 0633 UTC the aircraft received clearance to climb to 4000 feet. At 0644 UTC the aircraft disappeared from Tanjung Pinang radar display. The last position of the aircraft identified on the radar display was on 16 miles radial 010º from Tanjung Pinang airport. Tanjung Pinang Approach controller could not communicate with the PK-ZAI. At 0705 UTC, the controller requested relay by another aircraft to search PK-ZAI. The other aircrafts could not communicate with PK-ZAI. At 0706 UTC Tanjung Pinang Approach controller received information from Indonesian Air Force Base at Gunung Bintan that an aircraft had crashed at Gunung Kijang forest, Bintan Island. After receiving the information, Tanjung Pinang Airport staff coordinated with SAR Bureau, local police, and Indonesian Army for search and rescue operation. The aircraft was found at Gunung Kijang forest, Bintan Island at coordinate 1° 10’ 45” N; 104° 34’ 22” E, about 30 km north of Tanjung Pinang Airport. All occupants were fatally injured in this accident. The aircraft was substantially damaged.
Probable cause:
Factors contributed to the accident are as follows:
• The flight test was not properly well prepared; there was no flight test plan.
• The current and applicable CMM is dissimilar the According to the CASA 212-100 and Garrett TPE331-5 Maintenance Manuals related to flight test requirement after the change of only one engine.
• The left engine was shut down using normal/ ground shut down procedure. It used the fuel shut off switches off followed by pulling the Power Lever rearward to reverse, as indicated by the propeller pitch.
• The right engine most likely shut down by wind milling prior the impact, it was indicated the propellers piston distance position to the cylinder was about normal flight range position and no indication of rotating impact on the blades.
• The Casa Service Bulletin No. 212-76-07 Revision 1 issued dated 23 December 1991 (Anti Reverse) that applicable for Casa 212 -100/200, was not incorporated to this aircraft.
• The PIC with pareses or paralysis vestibular organ or system could not response normally to the three dimensional motion or movement. This condition may the subject more sensitive to suffer Spatial Disorientation (SDO). The SDO is the pilot could not perceived rightly his position motion and attitude to the earth horizontal or to his aircraft or other aircraft and could as the dangerous precondition for unsafe action.
• The Director (DGCA) decree No 30/II/200 issued on 20 February 2009 stated that for issuing medical certificate for pilot after 60th birthday require several additional medical examination items. Point 1.b of this decree states the Video Nystagmography examination.(differed the ICAO Doc 8984).
Final Report:

Crash of a Boeing 737-408 in Batam

Date & Time: Mar 10, 2008 at 1020 LT
Type of aircraft:
Operator:
Registration:
PK-KKT
Survivors:
Yes
Schedule:
Jakarta - Batam
MSN:
24353/1721
YOM:
1989
Flight number:
DHI292
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
171
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 10 March 2008, a Boeing Company 737-400 aircraft, registered PK-KKT, was being operated by Adam SkyConnection Airlines (Adam Air) as scheduled passenger flight with flight number DHI292. The flight departed Soekarno – Hatta Airport, Jakarta at 01:30 UTC with destination Hang Nadim Airport, Batam and the estimated time of arrival was 03:05 UTC. On board in this flight were 177 people consisted of two pilots, four flight attendants, and 171 passengers. The Pilot in Command (PIC) acted as pilot flying (PF) and the Second in Command (SIC) acted as pilot monitoring (PM). The flight until commencing descend was uneventful. Prior to descend, the flight crew received weather information indicating that the weather was fine. At 0302 UTC the flight crew contacted Hang Nadim tower controller and informed them that the visibility was 1,000 meters and they were sequence number three for landing runway 04. The flight crew of the aircraft on sequence number two informed to Hang Nadim tower controller that the runway was insight at an altitude of about 500 feet. The Hang Nadim tower controller forwarded the information to the flight crew of DHI 292, and followed this by issuing landing clearance, and additional information that the wind velocity was 360 degrees at 8 knots and heavy rain. The DHI 292 flight crew acknowledged the information. The landing configuration used flaps 40 degrees with landing speed of 136 knots. The flight crew were able to see the runway prior to the Decision Altitude (DA), however the PIC was convinced that continuing the approach to landing was unsafe and elected to go around. The Hang Nadim tower controller instructed the flight crew to climb to 3000 feet, maintain runway heading, and contact Singapore Approach. At 0319 UTC, DHI 292 was established on the localizer runway 04, and the Hang Nadim tower controller informed them that the visibility improved to 2,000 meters. While on final approach, the flight crew DHI 292 reported that the runway was in sight and the Hang Nadim tower controller issued a landing clearance. On touchdown, the crew felt that the main wheels barely touch the runway first. During the landing roll, as the ground speed decreased below 30 knots, the aircraft yawed to the right. The flight crew attempted to steer the aircraft back to centerline by applying full left rudder. The aircraft continued yaw to the right and came to stop on the runway shoulder at approximately 40 meters from the right side of the runway edge, and 2,760 meters from the runway 04 threshold. No one was injured in this accident. The aircraft was seriously damaged with the right main landing gear assembly detached and collapsing backward and damaging the right wing and flaps. The right engine was displaced from its attachment point.
Probable cause:
The Flight Data Recorder (FDR) and the Cockpit Voice Recorder (CVR) data were downloaded. The CVR data showed that the aircraft was flying below the correct glide path indicated by a glide slope aural warning, and the crew had difficulty in recovering the condition. The CVR also recorded landing gear warning after touchdown which indicated the landing gear had collapsed. The FDR data showed that the vertical acceleration during landing was 2.97 g, however this amount of vertical acceleration should not damage the landing gear. The FDR data showed that just after touchdown, the right main landing gear collapsed. The FDR also recorded that the aircraft experienced hard landing and had bounced on a previous flight, and the value of the vertical acceleration recorded was 1.78 g. It was most likely that the hard landing and bounce had affected the strength of the landing gear. The examination of the failed landing gear also found corrosion on the fracture surface of the right main landing gear strut.
Final Report:

Crash of a Boeing 737-291 in Pekanbaru

Date & Time: Jan 14, 2002 at 1015 LT
Type of aircraft:
Operator:
Registration:
PK-LID
Flight Phase:
Survivors:
Yes
Schedule:
Pekanbaru - Batam
MSN:
20363
YOM:
1969
Flight number:
JT386
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
96
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17266
Copilot / Total flying hours:
3700
Copilot / Total hours on type:
2500
Aircraft flight hours:
68133
Aircraft flight cycles:
66998
Circumstances:
The flight was a second route of four routes on a first day of two days schedule flight for the crew. All crew have flight schedule on the previous day and returned to Jakarta. The first flight was from Jakarta to Pekanbaru with departure schedule on 08.00 LT (01.00 UTC). All crew did the pre-flight check completely but did not check the audio warning and departed Jakarta on schedule. The flight was normal and landed in Pekanbaru on schedule. There was no problem reported. Transit in Pekanbaru for about 30 minutes and the flight was ready to continue the next flight to Batam. At 10.15 LT (03.05) the boarding process has been completed and all flight documents have ready. First Officer asked for start clearance and received weather information in Syarif Kasim Airport. The weather was fine, wind calm and clear. After start completed, the aircraft taxi to the beginning of runway 18. Flight crews have set the V1, VR, V2 and V2+15 speed bugs according to the load sheet. Take off power decide to use “reduced take off power” with assumed temperature 35o C while the actual temperature was 27° C. flight Attendant have completed the passenger briefing includes rearrange seat for the seats near the “over wing exit windows”. The checklist was done, but flight crews were not sure the indication of flap setting. When ready for take off, flight crew gave a warning to the flight attendants to take their seats. First Officer acted as “Pilot Flying”. PIC opened the power and adjusted to the required take off power setting. The aircraft rolled normal and there was no abnormal indication. PIC called “V1” and “ROTATE” at speed bugs value setting, and the First Officer rotated the control column and set to 150 ANU (Aircraft Nose Up) pitch. The aircraft’s nose was lifted up but the aircraft did not airborne. Flight attendant who was sitting at the rear felt that the nose was higher than normal. Officer also felt stick shaker, warning for approaching stall. First Officer suddenly noticed a warning light illuminated and cross-checked. He found than the warning came from the problem on the air conditioning system. Both pilots also felt pain in the ear. Recognizing this situation, PIC decided to continue the take off and called to the First Officer “disregard”. Realized that the aircraft did not airborne PIC added the power by moving power levers forward. The speed was increasing and passed the speed bug setting for V2+15 ( ± 158 KIAS) but the aircraft did not get airborne. PIC noticed that the runway end getting closer and he thought that the aircraft would not airborne, he decided to abort the take off and called “STOP”. PIC retarded the power levers to idle and set to reverse thrust, extended the speed brake and applied brake. Nose of the aircraft went down hard and made the front left door (L1) opened and 2 trolleys at front galley move forward and blocked the cockpit door. Flight crew turns the aircraft slightly to the right to avoid approach lights ahead. The aircraft moved out or the runway to the right side of the approach lights. After hit some trees the aircraft stopped at ± 275 meters from the end of runway on heading 285°. One passenger had serious injury and the rest had minor injury, all crew were safe and not injured. No one killed in this accident, while the aircraft considered total loss.
Probable cause:
Findings:
1. The flight crews have proper qualification to fly the aircraft.
2. The aircraft did not exceed its Maximum Take-Off Weight limitation specified in the AOM.
3. Cockpit area microphone did not function at the time of the accident. Therefore, the only sounds/conversations recorded were only when there were radio transmissions.
4. FDR data show that the engines operated normally.
5. FDR data show similar trajectory with an aircraft of the type and loading condition tried to take-off with zero flap.
6. The aircraft flap system was found to function normally. Therefore, should the flap selector moved to non-zero position, the flap should move to the selected position.
7. The crew did not perform Before Take-off Checklist as stated in the Boeing 737-200 Pilot’s Handbook, Chapter Normal Operating Procedures.
8. The aural warning system, except its circuit breaker, function normally. Therefore, the cause of the absence of take-off warning is the wear out latch on the CB that caused it to open.
9. The food trolley safety lock and food trolley safety strap on the front galley did not function properly that the trolley loose upon impact and blocking the cockpit door.
10. The escape slides fail to deploy. All the slides have no expiration date or marked last inspection date-as regulated in CASR 121.309.
11. Shear pins on the engines mounting function properly to separate the engine from the wing and therefore minimize the risk of fire in the accident.
Final Remarks:
Since there is no indication that flaps system failure or flap asymmetry contributes in the failure of flap to travel to take-off configuration, the most probable cause for the failure is the improper execution of take-off checklist. Failure of the maintenance to identify the real problem on the aural warning CB, causes the CB to open during the accident and therefore is a contributing factor to the accident.
Final Report:

Ground accident of an Antonov AN-12BP in Batam

Date & Time: Aug 19, 1998
Type of aircraft:
Operator:
Registration:
UR-11528
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
3 34 10 05
YOM:
1963
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Suffered an accident while taxiing at Batam-Hang Nadim Airport. There were no casualties but the aircraft was damaged beyond repair.