Region

Crash of a Cessna 208B Grand Caravan in Dagi Baru

Date & Time: Oct 29, 2021 at 1030 LT
Type of aircraft:
Registration:
PK-RVH
Flight Type:
Survivors:
Yes
Schedule:
Dekai - Dagi Baru
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Dekai-Nop Goliat Airport for a short cargo flight to the Dagi Baru Airstrip with two pilots on board. Weather conditions were considered as good upon arrival. After landing, the aircraft went out of control, veered off runway and came to rest down a ravine. Both occupants were injured and the aircraft was destroyed.

Crash of a Cessna 208 Caravan I in Ilaga: 1 killed

Date & Time: Oct 25, 2021 at 0810 LT
Type of aircraft:
Operator:
Registration:
PK-SNN
Flight Type:
Survivors:
Yes
Schedule:
Timika - Ilaga
MSN:
208-0556
YOM:
2014
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
On final approach to Ilaga Airport, the crew encountered poor visibility due to foggy conditions. The single engine airplane impacted ground near the runway 25 threshold, lost its undercarriage and slid for few dozen metres before coming to rest on the runway. One of the pilot was killed.

Crash of a De Havilland DHC-6 Twin Otter 300 in Bilogai: 3 killed

Date & Time: Sep 15, 2021 at 0730 LT
Operator:
Registration:
PK-OTW
Flight Type:
Survivors:
No
Site:
Schedule:
Nabire – Bilogai
MSN:
493
YOM:
1976
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
13158
Captain / Total hours on type:
8051.00
Copilot / Total flying hours:
974
Copilot / Total hours on type:
807
Aircraft flight hours:
10333
Aircraft flight cycles:
1569
Circumstances:
On 15 September 2021, a DHC-6-300 (Twin Otter) aircraft registered PK-OTW was being operated for an unscheduled cargo flight from Douw Aturure Airport (WABI), Nabire, Papua to Bilorai Airport (WAYB), Intan Jaya, Papua. The aircraft was operated by two pilots accompanied by one engineer on board. The filed flight plan for the flight indicated that the aircraft would be operated under Visual Flight Rule (VFR) with fuel endurance of 2 hours 30 minutes. The estimate time departure for the flight was at 0640 LT. At 0610 LT, the pilot received weather observation report from the Bilorai aeronautical communication officer (ACO) that the visibility was 5 up to 7 kilometers, several clouds over the airport and all final areas were clear. About 7 minutes later, the ACO updated the observation report which indicated that the visibility changed to 7 up to 8 kilometers (km). After the cargo loading process and the flight preparation had completed, the aircraft taxied to Runway 16. At 0644 LT, the aircraft departed and climbed to the cruising altitude of 9,500 feet. Prior to the departure, there was no record or report of aircraft system malfunction. The Pilot in Command (PIC) acted as Pilot Monitoring (PM) while the Second in Command (SIC) acted as Pilot Flying (PF). At 0658 LT, the PK-OTW pilot reported to the Nabire air traffic control that the aircraft was at 25 Nm with altitude of 9,500 feet. At 0702 LT, the SIC asked the PIC to have the aircraft control as PF. During flight, the PK-OTW pilots monitored weather information provided by the pilots of two other aircraft that flew ahead of the PK-OTW to Bilorai. Both pilots monitored that the first aircraft (Cessna 208B EX) landed using Runway 27 while the second aircraft (Cessna 208B) would use Runway 09. At 0715 LT, the PIC advised the SIC to use the Runway 27 for landing. At 0719 LT, the SIC made initial contact with the ACO and advised that the aircraft was approaching Bilai at altitude of 9,500 feet and the estimate time arrival at Bilorai was 0726 LT. The ACO acknowledged the pilot report and provided current weather observation as follows “…wind westerly 3 until 5 knots, final 09 open with broken fog and final 27 open, visibility 5 until 7 km, blue sky overhead”. The SIC acknowledged the weather information and advised the ACO would report when the aircraft position was on left downwind Runway 27. At 0721 LT, the SIC read the descent checklist included the item of Landing Data/Approach Briefing and was replied by completed. The Cockpit Voice Recorder (CVR) did not record any pilot’s discussion regarding to the airport minimum safe altitude since the beginning of the recording. At 0723 LT, a pilot of DHC-6-400 aircraft registered PK-OTJ, asked the PK-OTW pilot of the weather condition in Bilorai. The PK-OTJ flew behind the PK-OTW with from Nabire to Bilorai. The SIC then responded that the PK-OTW was on descend and would fly through clouds about 5 Nm to Bilorai. Thereafter, the ACO provided traffic information to PK-OTW pilot that there was an aircraft (Cessna 208B aircraft) on final Runway 09. The PIC who acted as PF acknowledged the traffic information and advised to the ACO that the PK-OTW would join left downwind Runway 27 for the landing approach. At 0725 LT, the SIC advised to the ACO that the aircraft was on left downwind Runway 27. The ACO then advised the PK-OTW pilot to report when on final Runway 27. At 07:26:12 LT, a stall warning recorded in the Cockpit Voice Recorder (CVR) then the PIC asked to the SIC to check the aircraft speed. The SIC responded the aircraft speed was 65 knots. At 07:26:16 LT, the PIC asked to the SIC to advise the ACO that they were making a go around. The SIC then advised the ACO that the PK-OTW was making a go around and was responded to report when on final. The CVR did not record pilot’s discussion about the plan maneuver of the go around. At 07:26:45 LT, the PIC informed that they were making a go around to the PK-OTJ pilot. The PK-OTJ pilot responded that the aircraft was approaching Homeyo and would reduce the speed to make enough separation with the PK-OTW. The PIC then advised the PK-OTJ that the PK-OTW would attempt to land using Runway 09. Based on the data transmitted from the flight following system, at 07:27:57 LT, the aircraft was about 3 Nm outbound from Bilorai on direction of 238°. At 07:28:22 LT, the PK-OTJ pilot advised to the ACO that the aircraft was about 6 nm to Bilai and the pilot intended to make holding maneuver over Bilai to make enough separation with the PK-OTW. At 07:28:33 LT, the SIC advised the PIC that the aircraft was at 8,200 feet and was responded that the PIC initiated turning the aircraft. A few second later, the SIC advised to the PIC that the aircraft was turning, and the aircraft was at 3.2 Nm outbound from Bilorai. At 07:28:38 LT, the last data of the flight following system recorded that the aircraft was on direction of 110°. At 07:29:25 LT, the SIC advised the PIC to fly left. Thereafter, the SIC advised the PIC that the aircraft was passing 8,000 feet. At 07:29:35 LTC, the PIC asked to the SIC about the distance to Bilorai and was responded 2.5 Nm. The SIC, reminded the PIC to fly left as the aircraft flew too close to the terrain. At 07:29:49 LT, the CVR recorded the first impact sound and the CVR recording stopped at 07:29:55 LT. At 0730 LT, the ACO asked the PK-OTW pilot intention as the aircraft was not visible from the ACO working position, and the pilot did not respond the ACO. At about the same time, the ACO heard impact sound that was predicted coming from terrain area on west of Bilorai. The ACO then called the PK-OTW pilot several times without response. Several pilots also attempted to contact the PK-OTW with the same result. The PK-OTW was found on a ridge at elevation of 8,100 feet, about 2 Nm on bearing 260° from Bilorai.

Crash of a Boeing 737-4Y0 in Jakarta

Date & Time: Mar 20, 2021 at 1126 LT
Type of aircraft:
Operator:
Registration:
PK-YSF
Flight Type:
Survivors:
Yes
Schedule:
Jakarta - Makassar
MSN:
23869/1639
YOM:
1988
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6228
Captain / Total hours on type:
5208.00
Copilot / Total flying hours:
1255
Copilot / Total hours on type:
1084
Aircraft flight hours:
55982
Aircraft flight cycles:
65005
Circumstances:
On 20 March 2021, a Boeing 737-400F, registered PK-YSF, was being operated by Trigana Air Service on a non-schedule cargo flight from Halim Perdanakusuma International Airport (WIHH), Jakarta, Indonesia with intended destination of Sultan Hasanuddin International Airport (WAAA), South Sulawesi, Indonesia. On board in this flight was two pilots, one engineer and one Flight Operation Officer (FOO). According to the weight and balance sheet, the flight carried 16,672 kgs of general cargo, takeoff fuel of 11,100 kg and the takeoff weight was 60,695 kg (133,835 lbs). The Pilot in Command (PIC) acted as Pilot Flying (PF) and the Second in Command (SIC) acted as Pilot Monitoring (PM). At 0328 UTC (1028 LT), the PM requested clearance to Halim Tower controller (the controller) to pushback and start the engines. At 1031 LT, the PM requested to the controller for taxi clearance. There was no report of aircraft system abnormality prior to the aircraft departure. At 1047 LT, the controller issued clearance to the PK-YSF pilot to enter and to backtrack Runway 24. At 1051 LT, the PM reported ready for departure to the controller. The controller issued takeoff clearance with additional departure clearance that after takeoff, turn left to heading 180° and initially climb to altitude of 3,000 feet. The PM acknowledged the clearance. The takeoff was conducted with reduced takeoff thrust by assumed temperature of 40°C and the aircraft became airborne at 10:52:57 LT. At 1055 LT, the controller advised the pilot to report when established on heading 180°. The PM reported that they were experiencing right engine failure and requested to fly to AL NDB . The controller advised the PM to turn left heading 060° and to climb to 2,500 feet. Furthermore, the controller asked the pilot intention whether to hold over AL NDB or direct for landing approach. The PM replied that they would hold over AL NDB and added the information that no fire was detected. The controller issued clearance to fly to AL NDB at altitude of 2,500 feet. The controller assumed that PK-YSF would return to Halim and advised the Airport Rescue and Fire-Fighting (ARFF) personnel that PK-YSF experienced right engine failure and would return to Halim. At 1058 LT, the controller requested the information of time required for holding over AL NDB and was replied by the PM that holding would require about 15 minutes. Furthermore, the controller requested whether the pilot able to hold at a point about 15 to 20 Nm from AL NDB and was replied by the PM that they did not objection to the proposal. The controller instructed the pilot to maintain outbound heading up to 15 Nm, at altitude of 2,500 feet. This was intended by the controller to manage the departure and arrival aircraft to and from Halim. At 1116 LT, the PM reported that they were ready to turn left for approach. The controller advised the pilot to turn left and to intercept localizer of the Instrument Landing System (ILS) Runway 24. At 1125 LT, the PM reported to the controller that the Runway was in sight. The controller advised that the wind was from 060° at velocity of 6 knots, QNH 1,007 mbs and issued landing clearance. The aircraft touched down on the touchdown zone and shortly after, both wheels of the right main landing gear detached. The controller noticed spark appeared from the aircraft and pressed the crash bell. At 1127 LT, the controller informed pilots of the other aircraft that the runway blocked by the landing aircraft and identified fire on one of the engines. Few seconds later, the PM called the controller whether any fire and was replied by the controller that fire was visible on the left side of the aircraft.

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 Quest Kodiak 100 off Sentani: 1 killed

Date & Time: May 12, 2020 at 0628 LT
Type of aircraft:
Operator:
Registration:
PK-MEC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Jayapura - Mamit
MSN:
100-0026
YOM:
2009
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1357
Captain / Total hours on type:
185.00
Aircraft flight hours:
4707
Aircraft flight cycles:
9379
Circumstances:
On 12 May 2020, a Quest Kodiak 100 aircraft, registration PK-MEC, was being operated by Mission Aviation Fellowship (MAF) as a cargo flight from Sentani Airport (WAJJ), Jayapura, Papua with intended destination of Mamit Airstrip (WAVS) Tolikara, Papua. The pilot was the only person on board for this flight and the aircraft carried 694 kgs of cargo goods. At 0622 LT (2122 UTC), the pilot of PK-MEC aircraft requested clearance to the Sentani Tower controller to start aircraft engine and flying to Mamit at radial 241° with intended cruising altitude 10,000 feet. The Sentani Tower controller approved the request. At 0627 LT, on daylight condition, the aircraft took off from runway 12 of Sentani Airport, thereafter, the Sentani Tower controller advised to the pilot of PK-MEC to contact Jayapura Radar controller. At 0628LT, the pilot of PK-MEC declared “MAYDAY” on Jayapura Radar radio frequency. The Jayapura Radar controller tried to contact pilot of PK-MEC four times but no answer. At 0630 LT, the Jayapura Radar Controller requested the pilot of PK-RCE that was just took off from Sentani to visually observe the position of PK-MEC aircraft. Few minutes later, the pilot of PK-RCE reported to Jayapura Radar controller that some debris were seen on Sentani Lake and some boats were moving toward the debris location. The pilot of PK-RCE assumed that PK-MEC aircraft had crashed to the lake. The pilot fatally injured. The wreckages have been recovered including the Global Positioning System (GPS) data card.

Crash of a De Havilland DHC-6 Twin Otter 400 near Kampung Mamontoga: 4 killed

Date & Time: Sep 18, 2019 at 1100 LT
Operator:
Registration:
PK-CDC
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Timika - Ilaga
MSN:
950
YOM:
2016
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The twin engine airplane departed Timika Airport at 1036LT on a cargo flight to Ilaga, carrying one passenger, a crew of four and a load of 1,7 ton of rice. At 1054LT, the crew gave his ETA at Ilaga Airport when the contact was lost about six minutes later. As the airplane failed to arrive at destination, SAR operations were initiated. The wreckage was found four days later in a mountainous terrain, at an altitude of 4,115 meters, about 10 km from Kampung Mamontoga. The aircraft was totally destroyed and all four occupants were killed.

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 Pacific Aerospace PAC 750XL near Oksibil: 8 killed

Date & Time: Aug 11, 2018 at 1420 LT
Operator:
Registration:
PK-HVQ
Survivors:
Yes
Site:
Schedule:
Tanah Merah – Oksibil
MSN:
144
YOM:
2009
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
13665
Captain / Total hours on type:
1468.00
Aircraft flight hours:
4574
Aircraft flight cycles:
5227
Circumstances:
On 11 August 2018, a PAC 750XL aircraft registered PK-HVQ was being operated by PT. Marta Buana Abadi (Dimonim Air) on unscheduled passenger flight from Tanah Merah to Oksibil. At the day of the occurrence the meteorological condition at Oksibil was below the requirement of Visual Flight Rule (VFR) weather minima and did not improve. Being aware that some flights had performed flight to Tanah Merah to Oksibil and returned, the pilot decided to fly to Oksibil. At 1342 LT, on daylight condition the PK-HVQ aircraft departed from Tanah Merah to Oksibil, on board the aircraft were one pilot, one observer pilot and 7 passengers. According to the passenger and cargo manifest, the total weight of passenger and the baggage were 473 kg. Prior to the departure, there was no record or report of aircraft system malfunction. At 1411 LT, the PK-HVQ pilot made initial contact to Oksibil Tower controller and reported that the aircraft was maintaining altitude of 7,000 feet over and the estimate time arrival at Oksibil would be 0520 UTC (1420 LT). The Oksibil Tower controller advised the pilot of the latest meteorological condition that the visibility was 1 up to 2 km and most of the area were covered by cloud. At 1416 LT, the pilot reported that the aircraft position was over Oksibil Aiport and the Oksibil Tower controller instructed the pilot to continue the flight to the final runway 11 and to report when the runway had in sight. The Oksibil Tower controller and pilots of other aircraft called the pilot but no reply. On the following day, the aircraft was found on a ridge of mountain about 3.8 Nm north west of Oksibil on bearing 331° with elevation about 6,800 feet. Eight occupants were fatally injured and one occupant was seriously injured.
Probable cause:
The KNKT concluded the contributing factors as follows:
- The VFR weather minimum requirement that was not implemented properly most likely had made the pilot did not have a clear visual to the surrounding area.
- Considering that the Pilot in Command (PIC) had lack knowledge of the terrain surrounding the Oksibil area, and the absence of voice alert from the TAWS when the aircraft flying close to terrain, resulted in the PIC did not have adequate awareness to the surrounding terrain while flying into clouds and continued to fly below the terrain height until the aircraft impacted the terrain.
Final Report:

Ground collision with an ATR72-500 in Medan

Date & Time: Aug 3, 2017 at 1100 LT
Type of aircraft:
Operator:
Registration:
PK-WFF
Flight Phase:
Survivors:
Yes
Schedule:
Medan – Meulaboh
MSN:
869
YOM:
2009
Flight number:
IW1252
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
67
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13006
Captain / Total hours on type:
624.00
Copilot / Total flying hours:
263
Copilot / Total hours on type:
109
Aircraft flight hours:
14321
Aircraft flight cycles:
16132
Circumstances:
On 3 August 2017, a Boeing 737-900 ER aircraft, operated by PT. Lion Mentari Airlines (Lion Air) as a scheduled passenger flight from Sultan Iskandar Muda International Airport, Banda Aceh (WITT) to Kualanamu International Airport, Medan (WIMM) as flight number JT 197. JT197 departed at 1010 LT (0310 UTC) in daylight condition, with 151 persons on board. Meanwhile, an ATR 72-500 aircraft, operated by PT. Wings Abadi Airlines (Wings Air) as scheduled passenger flight from Medan with intended destination to Cut Nyak Dien Airport, Meulaboh (WITC) as flight number IW1252. On board IW1252 were two pilots, one observer pilot, two flight attendants and 67 passengers. At 0356 UTC, the IW1252 pilot requested taxi clearance to runway 23 from the Medan Ground controller and was instructed to follow U2 taxi route, the IW1252 pilot requested to depart via intersection taxiway D which was approved by Medan Tower controller. At 0357 UTC, JT197 was on landing approach and received landing clearance. At 04:00:01 UTC, the Medan Tower controller issued conditional clearance to the IW1252 pilot, to enter the runway after the JT197 had landed. This conditional clearance was combined with the air traffic control route clearance. IW1252 continued to taxi and entered the runway. At 04:00:50 UTC, JT197 touched down on runway 23 and a few second later impacted with the IW1252. There were no injuries during this occurrence, but both aircraft were substantially damaged. After impact, debris from the impact aircraft remained on the runway. Prior to the runway inspection, one aircraft departed and one aircraft landed.
Probable cause:
The communication misunderstanding of the conditional clearance to enter runway while the IW1252 pilots did not aware of JT197 had received landing clearance and the unobserved IW1252 aircraft movement made the IW1252 aircraft entered the runway.
Final Report: