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City District of Jakarta

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 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 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.

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 Fokker F27 Friendship 400M in Jakarta: 11 killed

Date & Time: Jun 21, 2012 at 1450 LT
Type of aircraft:
Operator:
Registration:
A-2708
Flight Type:
Survivors:
No
Schedule:
Jakarta - Jakarta
MSN:
10546
YOM:
1976
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The crew (one instructor and six pilot under training) were engaged in a training flight and departed Jakarta-Halim Perdanakusuma Airport at 1310LT for a local flight consisting of touch-and-go manoeuvres. After a circuit, the pilot-in-command completed a last turn to the left to join the glide for runway 18 when the aircraft stalled and crashed onto several houses located less than one km from the runway threshold. The aircraft was destroyed as well as several houses. Six occupants in the aircraft and four people on the ground were killed while the copilot was critically injured. Unfortunately, he did not survive to his severe injuries and died few hours later at hospital.
Probable cause:
It was reported that the approach speed was too low during the last turn, causing the aircraft to stall. The distance between the aircraft and the ground was insufficient to expect recovery.

Crash of a Lockheed C-130H-30 Hercules in Jakarta: 135 killed

Date & Time: Oct 5, 1991 at 1500 LT
Type of aircraft:
Operator:
Registration:
A-1324
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Jakarta - Bandung
MSN:
4927
YOM:
1982
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
122
Pax fatalities:
Other fatalities:
Total fatalities:
135
Circumstances:
The four engine aircraft was returning to Bandung, carrying 122 airmen who had just took part to the annual Armed Forces Day ceremony at Jakarta-Halim Perdanakusuma Airport. One minute after takeoff, while in initial climb, the crew declared an emergency and reported engine problems. After being cleared to return for an emergency landing, the crew lost control of the airplane that stalled and crashed on a building housing the Department of Labour. A passenger survived while 133 other occupants were killed as well as two security guards working in the building.
Probable cause:
Loss of control after the engine n°3 caught fire during initial climb for unknown reasons.

Crash of a Douglas DC-9-32 in Jakarta

Date & Time: Jun 11, 1984
Type of aircraft:
Operator:
Registration:
PK-GNE
Flight Type:
Survivors:
Yes
MSN:
47561/674
YOM:
1972
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the aircraft landed hard and bounced three times. On the third impact, the aircraft recorded a positive aerodynamic force of 5,8 g that caused the fuselage to break in two between sections 737 and 756. All five crew members escaped uninjured while the aircraft was written off.

Crash of a Fokker F27 Friendship 600 in Jakarta: 3 killed

Date & Time: Sep 26, 1972
Type of aircraft:
Operator:
Registration:
PK-GFP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Jakarta - Jakarta
MSN:
10462
YOM:
1971
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Aircraft flight hours:
2095
Aircraft flight cycles:
1478
Circumstances:
The crew was engaged in a local training flight from Jakarta-Kemayoran Airport. Shortly after takeoff from runway 35, while in initial climb, the airplane banked right and crashed 90 meters to the right of the runway. The aircraft was destroyed and all three pilots were killed.

Crash of a NAMC YS-11-102 in Jakarta

Date & Time: Apr 1, 1971
Type of aircraft:
Operator:
Registration:
PK-MYN
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Jakarta - Jakarta
MSN:
2011
YOM:
1965
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was engaged in a local training mission at Jakarta-Kemayoran Airport. After completing several touch-and-go manoeuvres with one engine voluntarily inoperative, the pilot-in-command made a new landing successfully. After rotation, during initial climb, the airplane stalled and crashed in a gear-up and flaps-down configuration onto the runway before coming to rest. All three crew members were injured and the aircraft was damaged beyond repair.