Date & Time: Nov 6, 2008 at 1033 LT
Type of aircraft:
Dornier DO328
Operator:
Registration:
PK-TXL
Survivors:
Yes
Schedule:
Sorong - Fakfak
MSN:
3037
YOM:
1995
Flight number:
XAR9000
Country:
Indonesia
Region:
Asia
Crew on board:
4
Crew fatalities:
0
Pax on board:
32
Pax fatalities:
0
Other fatalities:
0
Total fatalities:
0
Captain / Total flying hours:
10190
Captain / Total hours on type:
2365
Copilot / Total flying hours:
4673
Copilot / Total hours on type:
15
Aircraft flight hours:
24404
Aircraft flight cycles:
21916
Circumstances:
The aircraft touched down heavily approximately 5 meters before the touch-down area of runway 10 at Torea Airport, Fak-Fak at 01:33. The investigation found that the left main landing gear touched the ground first (5 meters before the end of the runway), and the right main landing gear touched the ground (4.5 meters from the end of the runway). It stopped on the runway, approximately 700 meters from the touch-down area. The left main landing gear fractured in two places; at the front pivot point, and the aft pivot point. The left fuselage contacted the runway surface 200 meters from the touch-down point and the aircraft slid with the left fuselage on the ground for a further 500 meters, before it stopped at the right edge of the runway. The wing tip and left propeller blade tips also touched the runway and were damaged. The passengers and crew disembarked normally; there were no injuries. Following an inspection of the landing gear and temporary replacement of the damaged left main landing gear, the aircraft was moved to the apron on 8 November 2008 at 04:00. The runway was closed for 5 days.
Probable cause:
The Digital Flight Data Recorder data showed evidence that the aircraft descended suddenly and rapidly when it was on short final approach. About 65 seconds before ground impact, the RPM of both propellers commenced to decrease to approximately 70% with the NH increasing to 85%. Propeller RPM then suddenly reduced, followed by an immediate and rapid increase of propeller RPM to 111% left and 97% right, then just as sudden and rapid, the left propeller RPM reduced to 77% and the right to 80%. Given that the propellers are constant speed units, the sudden and rapid changes could not be explained other than the probability that a crew member had made the control inputs.
The PIC (pilot monitoring/flight instructor) did not monitor the operation of the aircraft sufficiently to ensure timely and effective response to the pilot induced excessive sink rate.
The pilots did not communicate appropriately during the approach and landing, resulting is poor crew resource management (CRM).
There was no evidence that any of the pilots had completed any form of CRM training for more than 9 years. Other than the handling pilot, there was no evidence that the other pilots had completed ALAR/CFIT training.
The operator did not have a Line Operations Safety Audit Program (LOSA), and the airport did not meet the ICAO Annex 14 Standard with respect to runway end safety areas.
Final Report:
PK-TXL.pdf448.1 KB