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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
Circumstances:
The aircraft departed Jakarta-Soekarno-Hatta Airport runway 25R at 1435LT on a flight to Pontianak. During initial climb, the crew initiated a right turn according to published procedures and continued climbing over the sea after being cleared to climb to FL290. At an altitude of 11,000 feet and at a speed of 284 knots, the aircraft entered an uncontrolled descent and crashed in the sea of Java about seven km offshore, some five minutes after takeoff. Few debris were found floating on water and the aircraft apparently disintegrated on impact. The accident was not survivable.

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 Boeing 737-36N near Palembang: 104 killed

Date & Time: Dec 19, 1997 at 1613 LT
Type of aircraft:
Operator:
Registration:
9V-TRF
Flight Phase:
Survivors:
No
Schedule:
Jakarta - Singapore
MSN:
28556
YOM:
1997
Flight number:
MI185
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
97
Pax fatalities:
Other fatalities:
Total fatalities:
104
Captain / Total flying hours:
7173
Captain / Total hours on type:
3614.00
Copilot / Total flying hours:
2501
Copilot / Total hours on type:
2311
Aircraft flight hours:
2238
Aircraft flight cycles:
1306
Circumstances:
On 19 December 1997, a SilkAir Boeing B737-300 aircraft, registration 9V-TRF, was on a scheduled commercial international passenger flight under Instrument Flight Rules (IFR), routing Singapore – Jakarta – Singapore. The flight from Singapore to Jakarta operated normally. After completing a normal turnaround in Jakarta the aircraft departed Soekarno-Hatta International Airport for the return leg. At 08:37:13 (15:37:13 local time) the flight (MI185) took off from Runway 25R with the Captain as the handling pilot. The flight received clearance to climb to 35,000 feet (Flight Level 350) and to head directly to Palembang. At 08:47:23 the aircraft passed FL245. Ten seconds later, the crew requested permission to proceed directly to PARDI2. The air traffic controller instructed MI 185 to standby, to continue flying directly to Palembang and to report when reaching FL350. At 08:53:17, MI185 reported reaching FL350. Subsequently, the controller cleared MI185 to proceed directly to PARDI and to report when abeam Palembang. At 09:05:15.6, the cockpit voice recorder (CVR) ceased recording. According to the Jakarta ATC transcript, at 09:10:18 the controller informed MI 185 that it was abeam Palembang. The controller instructed the aircraft to maintain FL350 and to contact Singapore Control when at PARDI. The crew acknowledged this call at 09:10:26. There were no further voice transmissions from MI 185. The last readable data from the flight data recorder (FDR) was at 09:11:27.4. Jakarta ATC radar recording showed that MI185 was still at FL350 at 09:12:09. The next radar return, eight seconds later, indicated that MI185 was 400 feet below FL350 and a rapid descent followed. The last recorded radar data at 09:12:41 showed the aircraft at FL195. The empennage of the aircraft subsequently broke up in flight and the aircraft crashed into the Musi river delta, about 50 km (30 nm) north-northeast of Palembang at about 09:13. The accident occurred in daylight and in good weather conditions. All 104 occupants were killed. The accident was not survivable.
Probable cause:
- The NTSC investigation into the MI 185 accident was a very extensive, exhaustive and complex investigation to find out what happened, how it happened, and why it happened. It was an extremely difficult investigation due to the degree of destruction of the aircraft resulting in highly fragmented wreckage, the difficulties presented by the accident site and the lack of information from the flight recorders during the final moments of the accident sequence.
- The NTSC accident investigation team members and participating organizations have done the investigation in a thorough manner and to the best of their conscience, knowledge and professional expertise, taking into consideration all available data and information recovered and gathered during the investigation.
- Given the limited data and information from the wreckage and flight recorders, the NTSC is unable to find the reasons for the departure of the aircraft from its cruising level of FL350 and the reasons for the stoppage of the flight recorders.
- The NTSC has to conclude that the technical investigation has yielded no evidence to explain the cause of the accident.
Final Report:

Crash of an Airbus A300B4-600 in Medan: 234 killed

Date & Time: Sep 26, 1997 at 1334 LT
Type of aircraft:
Operator:
Registration:
PK-GAI
Survivors:
No
Site:
Schedule:
Jakarta - Medan
MSN:
214
YOM:
1982
Flight number:
GA152
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
222
Pax fatalities:
Other fatalities:
Total fatalities:
234
Captain / Total flying hours:
11978
Captain / Total hours on type:
782.00
Copilot / Total flying hours:
709
Copilot / Total hours on type:
709
Aircraft flight hours:
27095
Aircraft flight cycles:
16593
Circumstances:
On 26 September 1997 the Garuda Indonesia Flight GA 152, PK-GAI Airbus A300-B4 departed from the Jakarta Soekarno-Hatta International Airport at 04:41 UTC. The aircraft was on a regular scheduled passengers flight to Polonia International Airport of Medan, North Sumatera with estimated time of arrival 06:41 UTC. Flight GA 152 was flying under Instrument Flight Rules during daylight. Before the flight, the flight crew reported to Garuda Indonesia Flight Operations office to receive flight briefings, including Notice to Airmen (NOTAM), weather conditions and forecast en-route, at destination and alternate airports, as well as the flight plan. The NOTAM stated that the MDN VOR was overdue for maintenance and advised to use the facility ‘with caution', although the Medan VOR has been calibrated with both ground and flight calibration on 14 June 1997 and valid until 14 December 1997, the use of Medan VOR was classified as “restricted due to radial course alignment at 270 degrees radial”. At the time of flight-planning, the visibility from Medan TAFOR (26 September 1997, 00.00 UTC – 24.00 UTC) was 1000 meters in smoke. The dispatcher stated that he received information through company channel that the actual visibility at Medan was 400 meters in smoke, which was below the minimum required visibility for runway 05 ILS of 800 meters. At 06:12:51 GA 152 requested a descend clearance to Medan Control. Medan Control cleared the aircraft to descend to FL 150. On passing FL 150, GA 152 was informed that the aircraft was in radar contact, at a distance of 43 nautical miles from MDN VOR/DME. The crew was then instructed to descend to 3000 ft for a landing on Runway 05 and to reduce the speed to 220 knots to allow Bouraq flight BO 683 to takeoff from Runway 23 at 06:20:47. GA152 requested a speed of 250 knots below 10000 feet which was approved. At 6:27:12, Medan Approach instructed GA 152 to maintain altitude on heading to Medan VOR/DME. GA 152 confirmed this instruction at 6:27:21. At 06:27:50 Medan Approach transmitted an instruction “Merpati one five two you er .. turn left heading two four zero vectoring for intercept ILS runway zero five from the right side traffic now er.. rolling”. There was no response by any aircraft to this transmission. At 06:28:06 Medan Approach enquired “Indonesia one five two do you read”. GA 152 asked the ATC to repeat the message. At 06:28:13 Medan Approach instructed GA 152 to “Turn left heading er.. two four zero two three five now vectoring for intercept ILS runway zero five”. This instruction was acknowledged by GA 152. At 06:28:52 the PIC asked the Medan Approach whether the aircraft was clear from the mountainous area northwest from Medan. This was confirmed by Medan Approach, and GA 152 was instructed to continue turning left on heading 215°M. At 06:29:41, GA 152 was instructed to descend to 2000 ft and the crew acknowledged it. Recorded FDR information indicates the aircraft is essentially wings level, heading approx 225M° and passing through 3000 feet on descent. Then at 06:30:04 GA 152 was instructed to turn right heading 046 degrees, and to report when established on the localizer. This was acknowledged by GA 152, but misread the heading “Turn right heading zero four zero Indonesia one five two check established”. Meanwhile recorded FDR information indicates the aircraft commences a roll to the left, heading reducing indicating a left turn and passing through 2600 feet on descent. At 6:30:33, while turning left, First Officer reminded the Captain to turn right. Two seconds later GA 152 queried Medan Approach whether the turn is to the left or to the right onto heading 046 degrees. At 6:30:39 Medan Approach replied “Turning right Sir”, which was acknowledged by GA 152. FDR data shows that the aircraft began to roll to wings level. At 06:30:51 Medan Approach asked whether GA 152 was making a left turn or a right turn. Recorded FDR information indicates the aircraft was wings level and rolling to the right, heading approximately 135°M and increasing, at 2035 feet pressure altitude on descent. GA 152 responded “We are turning right now”. At 06:31:05 Medan Approach instructed GA 152 to continue turning left. Recorded FDR information showed that at this point the aircraft had passed the assigned 2000 ft altitude and continued descending. GA 152 replied “Err...confirm turning left we are starting to turn right now”. During the interview, the controller stated that it was around this time that he recognized that the aircraft went below the required altitude (1800 ft and descending). Recorded FDR information indicates the aircraft reduced right roll from approx 24.3º to 10.2° and then rolled right again to approx 25°, while heading was increasing indicated a right turn was being maintained and the aircraft continued descending. At 06:31:32 the sound of tree impact is recorded. The elevation of the initial impact with the trees was at about 1550 ft above sea level. The final impact on the bottom of a ravine approximately 600 meters from the first tree impact destroyed the aircraft, and 234 people on board of the aircraft perished. There were no ground casualties.
Probable cause:
There was confusion regarding turning direction of left turn instead of right turn at critical position during radar vectoring that reduced the flight crew’s vertical awareness while they were concentrating on the aircraft’s lateral changes. These caused the aircraft to continue descending below the assigned altitude of 2,000 feet and hit treetops at 1,550 feet above mean sea level.
Final Report:

Crash of a Fokker F27 Friendship in Bandung: 28 killed

Date & Time: Jul 17, 1997 at 1155 LT
Type of aircraft:
Operator:
Registration:
PK-YPM
Survivors:
Yes
Site:
Schedule:
Bandung - Jakarta
MSN:
10415
YOM:
1969
Flight number:
SG304
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
45
Pax fatalities:
Other fatalities:
Total fatalities:
28
Circumstances:
The aircraft departed Bandung-Husein Sastranegara Airport on a regular schedule flight to Jakarta, carrying 45 passengers and 5 crew members. Shortly after takeoff, the captain informed ATC that the left engine lost power and elected to diver to the Bandung-Sulaiman AFB for an emergency landing. On final approach to runway 13, the crew was unable to maintain a safe altitude when the aircraft struck roofs and crashed. Twenty occupants were rescued while 28 others were killed, including all five crew members. All occupants were Indonesian citizens except for one passenger from Singapore.
Probable cause:
Failure of the left engine for unknown reasons.

Crash of a BAe ATP in Tanjung Pandan: 15 killed

Date & Time: Apr 19, 1997 at 0739 LT
Type of aircraft:
Operator:
Registration:
PK-MTX
Survivors:
Yes
Schedule:
Jakarta - Tanjung Pandan
MSN:
2048
YOM:
1992
Flight number:
MZ106
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
48
Pax fatalities:
Other fatalities:
Total fatalities:
15
Circumstances:
On final approach to Tanjung Pandan-Buluh Tumbang Airport runway 36, at an altitude of 2,000 feet, the aircraft rolled to the left to angle of 80°, lost height and crashed in a coconut grove located about 1,500 metres short of runway. Fifteen occupants were killed, among them four crew members, while all other occupants were rescued.
Probable cause:
For unknown reasons, the left engine failed on approach and its propeller was feathered when control was lost.

Crash of a Boeing 737-281 in Yogyakarta

Date & Time: Jan 16, 1995 at 1930 LT
Type of aircraft:
Operator:
Registration:
PK-JHF
Survivors:
Yes
Schedule:
Jakarta – Yogyakarta – Denpasar
MSN:
20508/287
YOM:
1971
Flight number:
SG416
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
52
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on wet runway 09, the aircraft was unable to stop within the remaining distance. It overran, lost its nose gear and came to rest 100 metres further. All 58 occupants escaped uninjured while the aircraft was damaged beyond repair. A thunderstorm just passed over Yogyakarta Airport before the flight SG416 arrived from Jakarta and the approach was completed in a 30° flaps down configuration. Apparently, the braking action was poor.

Crash of a Fokker F28 Fellowship 4000 in Semarang

Date & Time: Nov 30, 1994 at 1845 LT
Type of aircraft:
Operator:
Registration:
PK-GKU
Survivors:
Yes
Schedule:
Jakarta - Semarang
MSN:
11210
YOM:
1984
Flight number:
MZ422
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
79
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach to Semarang-Ahmad Yani Airport was completed by night and poor weather conditions with heavy rain falls and strong winds. The aircraft landed too far down a wet runway and was unable to stop within the remaining distance. It overran and came to rest in a ravine, broken in three. All 85 occupants were evacuated, among them three passengers were injured.
Probable cause:
Following a wrong approach configuration, the crew landed the aircraft too far down a wet runway. In such conditions, the aircraft could not be stopped within the remaining distance. The following contributing factors were reported:
- The crew failed to follow the approach checklist,
- Poor crew coordination,
- Lack of discipline,
- The crew failed to initiate a go-around procedure,
- Poor approach planning,
- The runway surface was wet and the braking action was poor,
- Aquaplaning,
- Poor weather conditions.

Crash of a Douglas DC-9-32 in Denpasar

Date & Time: Dec 30, 1984
Type of aircraft:
Operator:
Registration:
PK-GNI
Survivors:
Yes
Schedule:
Jakarta - Denpasar
MSN:
47636
YOM:
1974
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
69
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following several errors during the final approach, the aircraft altitude over the runway 09 threshold was too high. The pilot-in-command decided to continue the landing and the touchdown was completed 1,800 meters past the runway threshold. Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage and came to rest in a mangrove, broken in three. All 75 occupants were evacuated, some of them were injured. The aircraft was destroyed.
Probable cause:
Wrong approach configuration on part of the flying crew.

Crash of a Vickers 832 Viscount in Semarang

Date & Time: May 1, 1981
Type of aircraft:
Operator:
Registration:
PK-RVN
Survivors:
Yes
Schedule:
Jakarta - Semarang
MSN:
415
YOM:
1959
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
40
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the four engine airplane landed hard at Semarang-Ahmad Yani Airport. On touchdown, the right main gear and the nose gear were torn off. Out of control, the airplane veered off runway to the right and came to rest. All 44 occupants escaped uninjured while the aircraft was damaged beyond repair.