Crash of a Boeing 737-33A in Surabaya

Date & Time: Feb 21, 2007 at 1525 LT
Type of aircraft:
Operator:
Registration:
PK-KKV
Survivors:
Yes
Schedule:
Jakarta - Surabaya
MSN:
27284/2606
YOM:
1994
Flight number:
DHI172
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
148
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
37936
Aircraft flight cycles:
23824
Circumstances:
The aircraft was on a scheduled passenger flight from Soekarno-Hatta Airport, Jakarta to Juanda Airport, Surabaya, East Java. There were 155 persons on board, consist of 7 crew and 148 passengers. During the flight there was no abnormality declare by the flight crew. Weather condition at Surabaya was thunderstorm and rain, wind 240/7 knots with visibility 8,000 meters. The CVR revealed that there was conversation in the cockpit that was not related to the progress of the flight, the conversation was relating to the company fuel policy and training program until 2000 feet. The CVR did not reveal approach briefing and any checklist reading. On final approach of runway 28 passing 800 feet approach light insight and landing clearance was received. Prior to touchdown, control of the aircraft was transferred from co-pilot to PIC. The CVR recorded that the Ground Proximity Warning Systems (GPWS) warned “Sink Rate” and “Pull Up”. The right wheel track was found out of the runway for about 4 meter away and return to the runway. The aircraft stopped for about 100 meters from taxiway N3. After aircraft touched down, the fuselage aft of passenger seat row 16 was bended down. The passengers were panic. Flight attendants evacuated the passengers via all exits available and door slides were inflated. The two passengers were minor injured, and the aircraft suffered severe damage.
Probable cause:
From the findings, it is concluded that the aircraft experienced excessive sink rate upon the touch-down. The aircraft was in unstable approach even at below 200 feet. The high vertical acceleration caused severe damage to the aircraft structure. The flight crew did not comply to several procedures published by the Boeing company. The flight crew did not respond to the GPWS alert and warnings.
Final Report:

Crash of a Boeing 737-4Y0 in Ujung Pandang

Date & Time: Dec 24, 2006 at 2035 LT
Type of aircraft:
Operator:
Registration:
PK-LIJ
Survivors:
Yes
Schedule:
Jakarta - Ujung Pandang
MSN:
24682
YOM:
1990
Flight number:
LNI792
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
157
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Jakarta, the crew started the descent to Makassar (Ujung Pandang) Airport. On approach to runway 31, flaps were selected down from 15° to 30° when the captain observed an asymmetrical condition between both flaps and decided to set back at 15° and to continue the approach in such conditions. The aircraft landed hard to the left of the runway centerline and bounced twice. Out of control, it veered off runway, lost its right main gear and came to rest few dozen metres further. All 164 occupants evacuated safely while the aircraft was damaged beyond repair as the left main gear punctured the fuel tank and the fuselage was deformed.
Probable cause:
The exact cause of the asymmetrical flaps condition on approach is undetermined. Since all the conditions were clearly not met, the pilots should have made the decision to initiate a go-around procedure.

Crash of a Boeing 737-230 in Medan: 149 killed

Date & Time: Sep 5, 2005 at 1015 LT
Type of aircraft:
Operator:
Registration:
PK-RIM
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Medan - Jakarta
MSN:
22136
YOM:
1981
Flight number:
RI091
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
112
Pax fatalities:
Other fatalities:
Total fatalities:
149
Captain / Total flying hours:
7522
Captain / Total hours on type:
7302.00
Copilot / Total flying hours:
2353
Copilot / Total hours on type:
685
Aircraft flight hours:
51599
Aircraft flight cycles:
51335
Circumstances:
On 5 September 2005, at 03:15 UTC, Mandala Airlines registered PK-RIM, operating as flight number MDL 091, a Boeing 737-200 departing for Soekarno-Hatta Airport, Jakarta from Medan. The previous flight was from Jakarta and arrived at Medan uneventfully. The same crew have flight schedule on the same day and returned to Jakarta. The flight was a regular scheduled passenger flight and was attempted to take-off from Polonia Airport, Medan, North Sumatra to Jakarta and it was the second trip of the day for the crew. At 02.40 UTC information from dispatcher, those embarking passengers, cargo process and all flight documents were ready. At 02.52 UTC, Mandala/MDL 091 asked for push back and start up clearance bound for Jakarta from the Air Traffic Controller/ATC, after received the approval from the ATC they began starting the engines. At 02.56 UTC, the controller cleared MDL 091 taxi into position on runway 23 via Alpha. At 03.02 UTC, MDL 091 received clearance for take off with additional clearance from ATC to turn left heading 120º and maintain 1500 ft. The MDL 091 read back the clearance heading 120º and maintains 1000 ft. The ATC corrected the clearance one thousand five hundred feet. The MDL 091 reread back as 1500 ft. Some of the passengers and other witnesses stated that the aircraft has lifted its nose in an up attitude and take off roll was longer than that normally made by similar airplanes. Most of them stated that the aircraft nose began to lift-off about few meters from the end of the runway. The ATC tower controller recalled that after rotation the plane began to “roll” or veer to the left and to the right. Some witnesses on the ground recalled that the airplane left wing struck a building before it struck in the busy road, then heard two big explosions and saw the flames. Persons on board in MDL 091, 5 crew and 95 passengers were killed, 15 passengers seriously injured and 2 passengers (a mother and child) were reported survived without any injuries; and other 49 persons on ground were killed and 26 grounds were serious injured.
Probable cause:
The National Transportation Safety Committee determines that probable causes of this accident are:
• The aircraft took-off with improper take off configuration namely with retracted flaps and slats causing the aircraft failed to lift off.
• Improper checklist procedure execution had lead to failure to identify the flap in retract position.
• The aircraft’s take off warning horn was not heard on the CAM channel of the CVR. It is possible that the take-off configuration warning horn was not sounding.
Final Report:

Crash of a McDonnell Douglas MD-82 in Surakarta: 25 killed

Date & Time: Nov 30, 2004 at 1815 LT
Type of aircraft:
Operator:
Registration:
PK-LMN
Survivors:
Yes
Schedule:
Jakarta – Surakarta
MSN:
49189
YOM:
1984
Flight number:
JT583
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
156
Pax fatalities:
Other fatalities:
Total fatalities:
25
Aircraft flight hours:
56674
Aircraft flight cycles:
43940
Circumstances:
While descending to Surakarta-Adisumarmo Airport, the crew was informed about stormy conditions at destination with cumulonimbus and heavy rain falls over the airport with a ceiling at 1,500 feet. The approach was continued and after touchdown on runway 26, the crew started the braking procedure and activated the thrust reverser systems. ON a wet runway, the aircraft was unable to stop within the remaining distance. It overran, lost its undercarriage and slid for few dozen metres, collided with equipments of the localizer antenna, a fence and came to rest in a cemetery. Both pilots and 23 passengers were killed while 70 other occupants were injured. 68 occupants escaped unhurt. The aircraft was destroyed.
Probable cause:
The following findings were identified:
- About 3 mm of water was stagnating on the runway surface, reducing the braking action,
- The crew completed the landing procedure with a 13 knots tailwind component,
- Airbrakes deployed after touchdown but retracted few seconds later due to wrong position of the power levers,
- Power levers were not in idle position after touchdown but slightly forward, so the flight computer increased power,
- Heavy rain falls,
- The crew failed to initiate a go-around procedure.

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:
TGN304
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.