Crash of a Casa NC-212-MP Aviocar 200 in Pitu

Date & Time: Nov 27, 2016 at 1000 LT
Type of aircraft:
Operator:
Registration:
U-623
Flight Type:
Survivors:
Yes
Schedule:
Manado - Pitu
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Pitu-Leo Wattimena Airport, the twin engine aircraft went out of control and veered off runway to the right. The left main landing gear collapsed and the right wing broke at the root. All 14 occupants evacuated safely while the aircraft was damaged beyond repair.

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
Captain / Total flying hours:
9336
Captain / Total hours on type:
38.00
Copilot / Total flying hours:
3636
Copilot / Total hours on type:
17
Aircraft flight hours:
2748
Aircraft flight cycles:
5953
Circumstances:
A DHC-4 Caribou aircraft, registered PK-SWW was being operated by Perkumpulan Penerbangan Alfa Indonesia, on 31 October 2016 on an unscheduled cargo flight from Moses Kilangin Airport Timika, with intended destination to Kaminggaru Aerodrome, Ilaga Papua. On board on this flight was 4 persons consisted of two pilots, one company engineer and one flight operation officer. At 2257 UTC, the aircraft departed Timika with intended cruising altitude of 12,500 feet and estimated time of arrival Ilaga at 2327 UTC. At 2323 UTC, the pilot made initial contact with Ilaga Aerodrome Flight Information Services (AFIS) officer and reported that the aircraft position was at Ilaga Pass and informed the estimate time of arrival Ilaga would be on 2327 UTC. Ilaga Aerodrome Flight Information Services (AFIS) officer advised to continue descend to circuit altitude and to report when position on downwind. At 2330 UTC, the AFIS officer called the pilot and was not replied. The AFIS officer asked pilot of another aircraft in the vicinity to contact the pilot of the DHC-4 Caribou aircraft and did not reply. At 0020 UTC, Sentani Aeronautical Information Service (AIS) officer declared the aircraft status as ALERFA. At 0022 UTC, Timika Tower controller received information from a pilot of an aircraft that Emergency Locator Transmitter (ELT) signal was detected approximately at 40 – 45 Nm with radial 060° from TMK VOR (Very High Frequency Omni Range) or approximately at coordinate 4°7’46” S; 137°38’11” E. This position was between Ilaga Pass and Jila Pass. At 0053 UTC, the aircraft declared as DETRESFA. On 1 November 2016, the aircraft wreckage was found on a ridge of mountain between Ilaga Pass and Jila Pass at coordinate 4°5’55.10” S; 137°38’47.60” E with altitude approximately of 13,000 feet. All occupants were fatally injured and the aircraft destroyed by impact force.
Probable cause:
Controlled flight into terrain.
Final Report:

Crash of a Learjet 31A in Jakarta

Date & Time: Sep 25, 2016 at 1946 LT
Type of aircraft:
Operator:
Registration:
PK-JKI
Flight Type:
Survivors:
Yes
Schedule:
Yogyakarta – Jakarta
MSN:
31-213
YOM:
2001
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing an ambulance flight from Yogyakarta-Adisujipto Airport to Jakarta-Halim Perdanakusuma Airport on behalf of the Indonesian Red Cross (Palang Merah Indonesia), carrying one patient, two doctors, two accompanists and three crew members. The approach was completed by night and marginal weather conditions. After touchdown on runway 24, the aircraft skidded on a wet runway. After a course of 1,300 metres, it veered to the right and departed the runway surface. While contacting soft ground, the right main gear was torn off while the left main gear partially collapsed. Then the aircraft bounced and impacted the ground several times, causing the left wing to be bent. Eventually, the right engine partially detached from the pylon. All eight occupants were rescued and the aircraft was damaged beyond repair. There was no fire.

Crash of a Boeing 737-347 in Wamena

Date & Time: Sep 13, 2016 at 0733 LT
Type of aircraft:
Operator:
Registration:
PK-YSY
Flight Type:
Survivors:
Yes
Schedule:
Jayapura – Wamena
MSN:
23597/1287
YOM:
1986
Flight number:
TGN7321
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
23823
Captain / Total hours on type:
9627.00
Copilot / Total flying hours:
650
Copilot / Total hours on type:
480
Aircraft flight hours:
59420
Aircraft flight cycles:
48637
Circumstances:
On 13 September 2016, a Boeing 737-300 Freighter, registered PK-YSY was being operated by PT. Trigana Air Service on a scheduled cargo flight from Sentani Airport, Jayapura (WAJJ) to Wamena Airport, Wamena (WAVV), Papua, Indonesia. Approximately 2130 UTC, during the flight preparation, the pilot received weather information which stated that on the right base runway 15 of Wamena Airport, on the area of Mount Pikei, low cloud was observed with the cloud base was increasing from 200 to 1000 feet and the visibility was 3 km. At 2145 UTC, the aircraft departed Sentani Airport with flight number IL 7321 and cruised at altitude 18,000 feet. On board the aircraft was two pilots and one Flight Operation Officer (FOO) acted as loadmaster. The aircraft carried 14,913 kg of cargo. The Pilot in Command (PIC) acted as Pilot Flying (PF) while the Second in Command (SIC) acted as Pilot Monitoring (PM). There was no reported or recorded aircraft system abnormality during the flight until the time of occurrence. After passing point MALIO, the aircraft started to descend. The pilot observed the weather met the criteria of Visual Meteorological Condition (VMC). The pilots able to identify another Trigana flight from Sentani to Wamena in front of them. While passing altitude 13,500 feet, approximately over PASS VALLEY, the Wamena Tower controller instructed the pilot to report position over JIWIKA. When the aircraft position was over point JIWIKA, the Wamena Tower controller informed to the pilot that the flight was on sequence number three for landing and instructed the pilot to make orbit over point X, which located at 8 Nm from runway 15. The pilot made two orbits over Point X to make adequate separation with the aircraft ahead prior to received approach clearance. About 7,000 feet (about 2,000 feet above airport elevation), the pilot could not identify visual checkpoint mount PIKEI and attempted to identify a church which was a check point of right base runway 15. The pilot felt that the aircraft position was on right side of runway centerline. About 6,200 feet (about 1,000 feet above airport elevation), the PF reduced the rate of descend and continued the approach. The PM informed to the PF that runway was not in sight and advised to go around. The PF was confident that the aircraft could be landed safely as the aircraft ahead had landed. Approximately 5,600 feet altitude (about 500 feet above airport elevation) and about 2 Nm from runway threshold the PF was able to see the runway and increased the rate of descend. The pilot noticed that the Enhanced Ground Proximity Warning System (EGPWS) aural warning “SINK RATE” active and the PF reduced the rate of descend. While the aircraft passing threshold, the pilot felt the aircraft sunk and touched down at approximately 125 meters from the beginning runway 15. The Flight Data Recorder recorded the vertical acceleration was 3.25 g on touchdown at 2230 UTC. Both of main landings gear collapsed. The left main landing gear detached and found on runway. The engine and lower fuselage contacted to the runway surface. The aircraft veer to the right and stopped approximately 1,890 meters from the beginning of the runway 15. No one was injured on this occurrence and the aircraft had substantially damage. Both pilots and the load master evacuated the aircraft via the forward left main cargo door used a rope.
Probable cause:
Refer to the previous aircraft that was landed safely, the pilot confidence that a safe landing could be made and disregarding several conditions required for go around.
Final Report:

Crash of a Cessna 208B Grand Caravan EX in Lolat

Date & Time: Jun 14, 2016 at 0758 LT
Type of aircraft:
Operator:
Registration:
PK-RCK
Flight Type:
Survivors:
Yes
Schedule:
Wamena – Lolat
MSN:
208B-5149
YOM:
2014
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
53
Circumstances:
The single engine airplane departed Wamena Airport at 0739LT on a cargo flight to Lolat, carrying two passengers, one pilot and a load of building materials for a total weight of 1,190 kilos. On short final to Lolat Airfield, the aircraft impacted the roof of a wooded house and crashed, bursting into flames. All three occupants of the airplane evacuated safely while three people in the house were injured. The aircraft was totally destroyed by a post crash fire.

Ground collision with an ATR42-600 in Jakarta

Date & Time: Apr 4, 2016 at 1957 LT
Type of aircraft:
Operator:
Registration:
PK-TNJ
Flight Phase:
Survivors:
Yes
MSN:
1015
YOM:
2014
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
2073
Aircraft flight cycles:
1038
Circumstances:
On 4 April 2016, Boeing 737-800 registration PK-LBS was being operated by Batik Air as scheduled passenger flight with flight number ID 7703 from Halim Perdanakusuma Airport with intended destination Sultan Hasanuddin International Airport, Makassar. An ATR 42-600 aircraft, registration PK-TNJ operated by TransNusa Aviation Mandiri was being repositioned from north to south apron of Halim Perdanakusuma Airport by a ground handling agent PT. Jasa Angkasa Semesta (PT. JAS). The aircraft was towed without aircraft electrical power fed to the system including the radio communication and aircraft lighting system. At the time of occurrence, the ID7703 pilot communicated to Halim Tower controller on frequency 118.6 MHz while the towing car driver communicated using handheld radio on frequency 152.73 KHz and was handled by assistant controller. At 1948 LT (1248 UTC), ID7703 pilot received taxi clearance from Halim Tower controller and after the ID7703 taxi, the towing car driver received clearance for towing and to report when on taxiway C. Afterward the towing car driver was instructed to expedite and to follow ID7703. While the ID7703 backtracking runway 24, the towed aircraft entered the runway intended to cross and to enter taxiway G. At 1256 UTC, ID7703 pilot received takeoff clearance and initiated the takeoff while the towed aircraft was still on the runway. The towing car driver and the pilots took action to avoid the collision. The decision of the pilot and the towing car driver to move away from the centerline runway had made the aircraft collision on the centerline runway (head to head) avoided, however the wings collision was unavoidable. At 1257 UTC, the ID7703 collided with the towed aircraft. The ID7703 pilot rejected the takeoff and stopped approximately 400 meters from the collision point while the towed aircraft stopped on the right of the centerline runway 24. No one injured at this occurrence and both aircraft severely damaged.
Probable cause:
The collision was the result of a poor coordination by ATC staff at Jakarta Airport. The following factors were reported:
- Handling of two movements in the same area with different controllers on separate frequencies without proper coordination resulted in the lack of awareness to the controllers, pilots and towing car driver,
- The communication misunderstanding of the instruction to follow ID 7703 most likely contributed the towed aircraft enter the runway,
- The lighting environments in the tower cab and turning pad area of runway 24 might have diminished the capability to the controllers and pilots to recognize the towed aircraft that was installed with insufficient lightings.
Final Report:

Crash of a Embraer ERJ-190-200LR in Kupang

Date & Time: Dec 21, 2015 at 1746 LT
Type of aircraft:
Operator:
Registration:
PK-KDC
Survivors:
Yes
Schedule:
Ende - Kupang
MSN:
190-00057
YOM:
2006
Flight number:
KD676
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
120
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9800
Captain / Total hours on type:
598.00
Copilot / Total flying hours:
2997
Copilot / Total hours on type:
557
Aircraft flight hours:
16862
Aircraft flight cycles:
14765
Circumstances:
On 21 December 2015, an ERJ 190-200 (Embraer 195) aircraft, registered PK-KDC, was being operated by Kalstar Aviation on a scheduled passenger flight. The crew was scheduled to fly three sectors from I Gusti Ngurah Rai International Airport (WADD) Bali – H. Hasan Aroeboesman Airport (WATE) Ende – El Tari International Airport (WATT) Kupang – Sultan Hasanuddin International Airport (WAAA), Makassar. The aircraft departed Bali at 0734 UTC which was delayed for 74 minutes from the normal schedule, due to late arrival of the aircraft from the previous flight. On the flight from Bali to Ende, the Pilot in Command (PIC) acted as pilot monitoring (PM) and the Second in command (SIC) acted as pilot flying (PF). The aircraft landed in Ende at 0839 UTC. During transit, the PIC received a short message from a flight operations officer of Kalstar Aviation in Kupang which informed him that the visibility at Kupang was 1 km. Considering the weather forecast in the Terminal Aerodrome Forecast (TAFOR) showed that the visibility at Kupang would improve at the time of arrival, the PIC decided to depart to Kupang. Another consideration was the operating hours of Ende which would be closed at 0900 UTC. The operating hours of Ende was extended and the aircraft departed Ende at 0916 UTC, with flight number KD676. On board this flight were two pilots, three flight attendants, and 125 passengers. The PIC acted as PM and the SIC acted as PF. There was no departure briefing performed by the PF. After takeoff, the pilot set the Flight Management System (FMS) to fly direct to KPG VOR and climbed to a cruising altitude of Flight Level (FL) 175 (17,500 feet). During climbing, the PIC instructed the SIC to reduce the aircraft speed by 20 knots with the intention to wait for the weather improvement at Kupang. During cruising, the pilots monitored communication between El Tari Tower controller with another pilot. El Tari Tower controller advised that the visibility at Kupang was 1 km while the minima for approach was 3.9 km. At 0927 UTC, the pilot established communication with El Tari Tower controller and requested for direct to initial approach point SEMAU. At 0932 UTC, the aircraft was at 62 Nm, the aircraft started to descend which was approved to 10,000 feet. When the aircraft passed FL 150, the pilot requested to turn left to fly direct to the inbound track of the VOR/DME approach for runway 07 in order to avoid cloud formation which was indicated by magenta color on the aircraft weather radar. At 0941 UTC, the El Tari Tower controller informed that the visibility on runway 07 was 4 km and issued clearance for RNAV approach to runway 07 and requested that the pilot report when the runway was in sight. Both pilots discussed the plan to make an RNAV approach to runway 07, with landing configuration with flap 5 and auto-brake set to position low. At 0943 UTC, the pilot reported that the runway was in sight when passing 2,500 feet and the El Tari Tower controller informed that the wind was calm and issued a landing clearance. During the approach, the PF noticed that all Precision Approach Path Indicator (PAPI) lights indicated a white color, which indicated that the aircraft was too high for the approach. Recognizing that the aircraft was too high, the crew performed a non-standard configuration setting by extending the landing gear down first with the intention to increase drag. The landing gear was extended at approximately 7 Nm from the runway 07 threshold and afterwards selected the flaps to 1 and 2. The published approach procedure stated that the sequence for establishing landing configuration is by selecting flap 1, flap 2, landing gear down, flap 3 and flap 5. On final approach, the crew noticed the aural warning “HIGH SPEED HIGH SPEED”. The SIC also noticed that the aircraft speed was about 200 knots. The pilots decided to continue the approach considering the runway was 2,500 meters long and would be sufficient for the aircraft to stop with the existing conditions. The pilots compared the runway condition at Kupang with the condition at Ende which had 1,650 meter length runway. On short final approach, the aircraft was on the correct glide path and the speed was approximately 205 knots. The PF noticed the Enhanced Ground Proximity Warning System (EGPWS) warning of “TOO LOW TERRAIN” activated. The aircraft then touched down at approximately the middle of the runway. After touchdown, the PF immediately applied thrust reverser. Realizing that the aircraft was about to overrun the end of the runway, and with the intention to avoid the approach lights on the end of the runway, the PIC turned the aircraft to the right. The aircraft stopped approximately 200 meters from the end of runway 07. At 0946 UTC, the El Tari Tower controller saw the aircraft overrun, then pushed the crash bell and informed the Airport Rescue and Fire Fighting (ARFF).
Probable cause:
Contributing Factors:
- The steep authority gradient resulted in lack of synergy that contributed to least of alternation to correct the improper condition.
- Improper flight management on approach resulted to the aircraft not fully configured for landing, prolong and high speed on touchdown combined with low brake pressure application resulted in insufficient runway for deceleration.
- The deviation of pilot performance was undetected by the management oversight system.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 on Mt Bajaja: 10 killed

Date & Time: Oct 2, 2015 at 1451 LT
Operator:
Registration:
PK-BRM
Flight Phase:
Survivors:
No
Site:
Schedule:
Masamba – Makassar
MSN:
741
YOM:
1981
Flight number:
VIT7503
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
2911
Captain / Total hours on type:
2911.00
Copilot / Total flying hours:
4035
Copilot / Total hours on type:
4035
Aircraft flight hours:
45242
Aircraft flight cycles:
75241
Circumstances:
On 2 October 2015, a DHC-6 Twin Otter, registered PK-BRM, was being operated by PT. Aviastar Mandiri as a scheduled passenger flight with flight number MV 7503. The aircraft departed from Andi Jemma Airport, Masamba (WAFM)1 with the intended destination of Sultan Hasanuddin International Airport, Makassar (WAAA) South Sulawesi, Indonesia. On board the flight were 10 persons consisting of two pilots and eight passengers, including one company engineer. The previous flights were from Makassar – Tana Toraja – Makassar – Masamba – Seko - Masamba and the accident flight was from Masamba to Makassar which was the 6th sector of the day. The aircraft departed from Masamba at 1425 LT (0625 UTC2 ) with an estimated time of arrival at Makassar of 0739 UTC. The Pilot in Command (PIC) acted as Pilot Flying (PF) while the Second in Command (SIC) acted as Pilot Monitoring (PM). The flight was conducted under the Visual Flight Rules (VFR) and cruised at an altitude of 8,000 feet. At 0630 UTC, the pilot reported to Ujung Pandang Information officer that the aircraft passed an altitude of 4,500 feet and was climbing to 8,000 feet. The Ujung Pandang Information officer requested the pilot of the estimate time of aircraft position at 60 Nm out from MKS VOR/DME. At 0632 UTC, the pilot discussed about the calculation of estimate time to reach 60 Nm out from MKS and afterward the pilot informed Ujung Pandang Information officer that the estimate at 60 Nm was at 0715 UTC. At 0633 UTC, the Ujung Pandang Information officer informed the pilot to call when reaching 8,000 feet and was acknowledged by the pilot. At 0636 UTC, the pilot informed the Ujung Pandang Information officer that the aircraft had reached 8,000 feet and requested the squawk number (ATC transponder code). The Ujung Pandang Information officer acknowledged and gave the squawk number of A5616, which was acknowledged by the pilot. At 0637 UTC, the pilots discussed to fly direct to BARRU. BARRU is a town located at about 45 Nm north of Makassar. Both pilots agreed to fly direct and the SIC explained the experience of flying direct on the flight before. At 0651 UTC, the PIC told the SIC that he wanted to climb and one second later the CVR recorded the sound of impact.
Probable cause:
The following findings were identified:
1. The aircraft had valid Certificate of Airworthiness prior to the accident and was operated within the weight and balance envelope.
2. Both pilots had valid licenses and medical certificates.
3. The accident flight from Masamba (WAFM) to Makassar (WAAA) was the 6th sector for the aircraft and the crew that day. The PIC acted as Pilot Flying and the
SIC acted as Pilot Monitoring.
4. The satellite image published by BMKG at 0700 UTC showed that there were cloud formations at the accident area. The local villagers stated that the weather
on the accident area was cloudy at the time of the accident.
5. The aircraft departed Masamba at 0625 UTC (1425 LT), conducted under VFR with cruising altitude of 8,000 feet and estimated time of arrival Makassar at 0739 UTC.
6. After reached cruising altitude, at about 22 Nm from Masamba, the flight deviated from the operator visual route and directed to BARRU on heading 200° toward the area with high terrain and cloud formation based on the BMKG satellite image
7. The pilots decision making process did not show any evidence that they were concerned to the environment conditions ahead which had more risks and required correct flight judgment.
8. The CVR did not record EGPWS aural caution and warning prior to the impact. The investigation could not determine the reason of the absence of the EGPWS.
9. The CVR data and cut on the trees indicated that the aircraft was on straight and level flight and there was no indication of avoid action by climb or turn.
10. The SAR Agency did not receive any crashed signal from the aircraft ELT most likely due to the ELT antenna detached during the impact.
11. Regarding to the operation of the EGPWS for the flight crew, a special briefing was performed however there was no special training.
12. The operational test of TAWS system was not included in the pilot checklist.
13. The investigation could not determine the installation and the last revision of TAWS terrain database.
14. The investigation could not find the functional test result document after the installation of the TAWS.
15. Some of the DHC-6 pilots have not been briefed for the operation of the TAWS and EGPWS.

Contributing Factors:
Deviation from the company visual route without properly considering the elevated risks of cruising altitude lower than the highest terrain and instrument meteorological condition in addition with the absence of the EGPWS warning resulted in the omission of avoidance actions.
Final Report:

Crash of a Boeing 737-3Q8 in Wamena

Date & Time: Aug 28, 2015 at 1547 LT
Type of aircraft:
Operator:
Registration:
PK-BBY
Flight Type:
Survivors:
Yes
Schedule:
Jayapura – Wamena
MSN:
23535/1301
YOM:
1986
Flight number:
8F189
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13880
Captain / Total hours on type:
4877.00
Copilot / Total flying hours:
608
Copilot / Total hours on type:
342
Aircraft flight hours:
54254
Aircraft flight cycles:
38422
Circumstances:
On 28 August 2015 a Boeing 737-300 Freighter, registered PK-BBY was being operated by PT. Cardig Air on a scheduled cargo flight from Sentani Airport (WAJJ) Jayapura to Wamena Airport (WAVV) Papua, Indonesia. At 1234 LT (0334 UTC), the aircraft departed to Wamena and on board the aircraft were two pilots, and 14,610 kg of cargo. The Pilot in Command (PIC) acted as Pilot Flying (PF) while the Second in Command (SIC) who was under line training acted as Pilot Monitoring (PM). There was no reported or recorded aircraft system abnormality during the flight until the time of occurrence. At 0637 UTC, when the aircraft approaching PASS VALLEY, the Wamena Tower controller provided information that the runway in use was runway 15 and the wind was 150°/18 knots, QNH was 1,003 mbs and temperature was 23 °C. At 0639 UTC, the pilot reported position over PASS VALLEY, descended passing FL135. The Wamena Tower controller instructed the pilot to report position over JIWIKA. At 0645 UTC, the pilot reported position over JIWIKA and continued to final runway 15. At 0646 UTC, the pilot reported position on final runway 15 and Wamena Tower controller provided landing clearance with additional information of wind 150°/15 knots and QNH 1,003 mbs. At 0647 UTC, the aircraft touched down about 35 meter before the beginning runway 15 with vertical acceleration of 3.68 G. The left main landing gear collapsed and the left engine contacted to the runway surface. The aircraft stopped at about 1,500 meters from runway threshold. No one was injured on this occurrence.
Probable cause:
According to factual information during the investigation, the Komite Nasional Keselamatan Transportasi determines the findings of the investigation are listed as follows:
1. The pilots held valid licenses and medical certificates.
2. The aircraft had a valid Certificate of Airworthiness (C of A) and Certificate of Registration (C of R), and was operated within the weight and balance envelope.
3. There were no reports of aircraft system abnormalities during the flight.
4. After passed JIWIKA on altitude 10,000 feet, the FDR recorded the engines were on idle, the average rate of descend was approximately 2,000 feet per minute.
5. At altitude approximately 8,000 feet, the flap selected to 40 position and moved to 39.9° one minute 25 seconds later.
6. The BMKG weather report was wind 150°/14-19 knots and the Wamena Tower controller reported to the pilot that the wind was 150°/15 knots. The information of gust wind, which indicated the possibility of windshear, was not reported to the pilot.
7. The EGPWS “CAUTION WINDSHEAR” active on altitude of 5,520 feet.
8. 06:45:43 UTC, the engine power increased when the aircraft altitude was on 5,920 feet prior the EGPWS altitude call “ONE HUNDRED” heard.
9. Started from 06:45:45 UTC, the FDR recorded the CAS increased from 148 knots to 154 knots followed by N1 decreased gradually from 73% to 38%. Three seconds before touched down, the rate of descend was constant on value 1,320 feet per minute followed by EGPWS warning “SINK RATE”.
10. The aircraft touched down at about 35 meters before the beginning runway 15 with the vertical acceleration recorded of 3.68 G.
11. The trunnion link of the left Main Landing Gear (MLG) assembly was found broken and the left main landing gear collapsed.
12. The FDR data contained of 107 flight hours consisted of 170 flight sectors which recorded five times of the vertical acceleration more than 2 G during landing at Wamena. The accumulation of such value of vertical acceleration might lead to landing gear strength degradation.
13. The Visual Approach Slope Indicator (VASI) of runway 15 was not operated after the runway extension.
14. The investigation found several touchdown marks on the pavement before the runway 15.
15. Excessive rubber deposit was found on the surface of runway 15 at about 600 meter started from the runway threshold.
16. The absence of speed correction following the information of headwind of 15 knots and pilot crew briefing after activation of EGPWS caution windshear indicated that the pilot did not aware of the existing windshear, that might be contributed by the absence of gust wind information.
17. The large thrust reduction was not in accordance with the FCOM for windshear precaution and resulted in rapid descend.
18. The accident flight collapsed the landing gear, the FDR recorded the vertical acceleration was 3.683 G which was within the landing gear design limit. This indicated the degradation of landing gear strength.

Contributing Factor:
The large thrust reduction during the windshear resulted in rapid descend and the aircraft touched down with 3.683 G then collapsed the landing gear that had strength degradation.
Final Report:

Crash of an ATR42-300 near Oksibil: 54 killed

Date & Time: Aug 16, 2015 at 1455 LT
Type of aircraft:
Operator:
Registration:
PK-YRN
Flight Phase:
Survivors:
No
Site:
Schedule:
Jayapura - Oksibil
MSN:
102
YOM:
1988
Flight number:
TGN267
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
50
Pax fatalities:
Other fatalities:
Total fatalities:
54
Captain / Total flying hours:
25287
Captain / Total hours on type:
7340.00
Copilot / Total flying hours:
3818
Copilot / Total hours on type:
2640
Aircraft flight hours:
50133
Aircraft flight cycles:
55663
Circumstances:
An ATR 42-300 aircraft registered PK-YRN was being operated by PT Trigana Air Service on 16 August 2015 as scheduled passenger flight with flight number IL267 from Sentani to Oksibil. On board of this flight were 54 persons. This flight was the fifth flight of the day and the second flight from Sentani to Oksibil. The aircraft departed Sentani at 0522 UTC and estimated time of arrival Oksibil was at 0604 UTC. The Second in Command (SIC) acted as Pilot Flying while the Pilot in Command (PIC) acted as Pilot Monitoring. The weather at Oksibil reported that the cloud was broken (more than half area of the sky covered by cloud) and the cloud base was 8,000 feet (4,000 feet above airport elevation) and the visibility was 4 up to 5 km. The area of final approach path was covered by clouds. The flight cruising at 11,500 feet and at 0555 UTC, the pilot made first contact with Oksibil Aerodrome Flight Information Services (AFIS) officer, reported on descent at position Abmisibil and intended to direct left base leg runway 11. At 0600 UTC, Oksibil AFIS officer expected the aircraft would have been on final but the pilot had not reported, the AFIS officer contacted the pilot but did not reply. The AFIS officer informed Trigana in Sentani that they had lost contact with IL267. The aircraft wreckage was found on a ridge of Tanggo Mountain, Okbape District, Oksibil at approximately 8,300 feet AMSL at coordinates of 04°49’17.34” S, 140°29’51.18” E, approximately 10 NM from Oksibil Aerodrome on bearing of 306°. All occupants were fatally injured and the aircraft was destroyed by impact force and post impact fire. The Flight Data Recorder (FDR) and Cockpit Voice Recorder were recovered and transported to KNKT recorder facility. The recovery of FDR data was unsuccessful while the recovery of CVR data successfully retrieved accident flight data. The CVR did not record any crew briefing, checklist reading not EGPWS warning prior to impact. The CVR also did not record EGPWS altitude call out on two previous flights. The investigation concluded that the EGPWS was probably not functioning.
Probable cause:
The following findings were identified:
1. The aircraft had valid Certificate of Airworthiness and was operated within the weight and balance envelope.
2. All crew had valid licenses and medical certificates.
3. The flight plan form was filed with intention to fly under Instrument Flight Rule (IFR), at flight level 155, with route from Sentani to MELAM via airways W66 then to Oksibil. The MORA of W66 between Sentani to MELAM was 18,500 feet.
4. The flight was the 5th flight of the day for the crew with the same aircraft and the second flight on the same route of Sentani to Oksibil.
5. The CVR data revealed that the previous flight from Sentani to Oksibil the flight cruised at altitude of 11,500 feet and the approach was conducted by direct to left base runway 11.
6. The CVR data also revealed that on the accident flight, the flight cruised at altitude 11,500 feet and intended to direct left base leg runway 11 which was deviate from the operator visual guidance approach that described the procedure to fly overhead the airport prior to approach to runway 11.
7. The witness stated that most of the time, the flight crew deviated from the operator visual approach guidance. The deviation did not identify by the aircraft operator.
8. The downloading process to retrieve data from the FDR was unsuccessful due to the damage of the FDR unit that most likely did not record data during the accident flight. The repetition problems of the FDR unit showed that the aircraft operator surveillance to the repair station was not effective.
9. The CVR did not record any crew briefing, checklist reading and EGPWS altitude callout prior to land on two previous flights nor the EGPWS caution and warning prior to impact.
10. The spectrum analysis of the CVR determined that both engines were operating prior to the impact.
11. Several pilots, had behavior of pulling the EGPWS CB to eliminate the nuisance of EGPWS warning. The pilots stated that the reason for pulling the EGPWS CB was due to the pilots considered this warning activation was not appropriate for the flight conditions. The correction to this behavior was not performed prior to the accident.
12. The investigation could not determine the actual EGPWS CB position during the accident flight.
13. The installation of EGPWS by the aircraft operator was not conducted according to the Service Bulletin issued by the aircraft manufacturer.
14. The terrain data base installed in the EGPWS of PK-YRN was the version MK_VIII_Worldwide_Ver_471 that was released in 2014. The Oksibil Airport was not included in the high-resolution update in this version of terrain database.
15. The information for Oksibil published in AIP volume IV (Aerodrome for Light Aircraft/ALA) did not include approach guidance. The operator issued visual guidance of circling approach runway 11 for internal use.
16. The visual approach guidance chart stated that the minimum safe altitude was 8,000 feet while the aircraft impacted with terrain at approximately 8,300 feet. This indicated an incorrect information in the chart. The investigation considered that the pattern on the approach guidance chart was not easy to fly, as many altitudes and heading changes.
17. Several maintenance records such as component status installed on the aircraft and installation of EGPWS was not well documented. This indicated that the maintenance management was not well performed.
18. The investigation could not find any regulation that describes the pilot training requirement for any addition or modification of aircraft system which affect to the aircraft operation.
19. There was no information related to the status of ZX NDB published on NOTAM prior to the accident.
20. Several safety issues indicated that the organization oversight of the aircraft operator by the regulator was not well implemented.
Contributing Factors:
1. The deviation from the visual approach guidance in visual flight rules without considering the weather and terrain condition, with no or limited visual reference to the terrain resulted in the aircraft flew to terrain.
2. The absence of EGPWS warning to alert the crew of the immediate hazardous situation led to the crew did not aware of the situation.
Final Report: