Country
code

South Sulawesi

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 737-301 in Ujung Pandang

Date & Time: Dec 21, 2009 at 0151 LT
Type of aircraft:
Operator:
Registration:
PK-MDH
Survivors:
Yes
Schedule:
Surabaya – Ujung Pandang
MSN:
23932/1554
YOM:
1988
Flight number:
MZ766
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
102
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Surabaya-Juanda Airport, the crew started a night approach to Ujung Pandang-Sultan Hasanuddin Airport (Makassar). On short final, at a height of 50 feet, the aircraft descended fast and landed nose first. A tyre burst on impact and the aircraft was stopped following a normal landing course. All 108 occupants evacuated safely and the aircraft was damaged beyond repair due to fuselage damages.

Crash of a Boeing 737-4Q8 off Ujung Pandang: 102 killed

Date & Time: Jan 1, 2007 at 1459 LT
Type of aircraft:
Operator:
Registration:
PK-KKW
Flight Phase:
Survivors:
No
Schedule:
Jakarta – Surabaya – Manado
MSN:
24070
YOM:
1989
Flight number:
DHI574
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
96
Pax fatalities:
Other fatalities:
Total fatalities:
102
Captain / Total flying hours:
13356
Captain / Total hours on type:
3856.00
Copilot / Total flying hours:
4200
Copilot / Total hours on type:
998
Aircraft flight hours:
45371
Aircraft flight cycles:
26725
Circumstances:
On 1 January 2007, a Boeing Company 737-4Q8 aircraft, registered PK-KKW, operated by Adam SkyConnection Airlines (AdamAir) as flight number DHI574, was on a scheduled passenger flight from Surabaya (SUB), East Java to Manado (MDC), Sulawesi, at FL350 (35,000 feet) when it disappeared from radar. The aircraft departed from Djuanda Airport, Surabaya at 05:59 Coordinated Universal Time (UTC) under the instrument flight rules (IFR), with an estimated time of arrival (ETA) at Sam Ratulangi Airport, Manado of 08:14. The fuel endurance on departure from Surabaya was hours 30 minutes, and the crew had flight planned for an alternate of Gorontalo (GTO). The pilot in command (PIC) was the pilot flying for the sector to Manado and the copilot was the monitoring/support pilot. There were 102 people on board; two pilots, 4 cabin crew, and 96 passengers comprised of 85 adults, 7 children and 4 infants.
Probable cause:
The following findings were identified:
1) Flight crew coordination was less than effective. The PIC did not manage the task sharing; crew resource management practices were not followed.
2) The crew focused their attention on troubleshooting the Inertial Reference System (IRS) failure and neither pilot was flying the aircraft.
3) After the autopilot disengaged and the aircraft exceeded 30 degrees right bank, the pilots appeared to have become spatially disoriented.
4) The AdamAir syllabus of pilot training did not cover complete or partial IRS failure.
5) The pilots had not received training in aircraft upset recovery, including spatial disorientation.
Other Causal Factors:
1) At the time of the accident, AdamAir had not resolved the airworthiness problems with the IRS that had been reoccurring on their Boeing 737 fleet for more than 3 months.
2) The AdamAir maintenance engineering supervision and oversight was not effective and did not ensure that repetitive defects were rectified.
Final Report:

Crash of a Boeing 737-4Y0 in Ujung Pandang

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

Crash of a Fokker F28 Friendship 4000 in Kendari

Date & Time: May 15, 1998 at 1103 LT
Type of aircraft:
Operator:
Registration:
PK-MGT
Flight Phase:
Survivors:
Yes
Schedule:
Kendari - Ujung Pandang
MSN:
11193
YOM:
1983
Flight number:
MZ715
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
60
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Kendari-Wolter Monginsidi Airport, at Vr speed, the cargo door warning light illuminated on the cockpit panel. The captain decided to abort and initiated an emergency braking procedure. Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage and came to rest 200 metres further. All 64 occupants escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Grumman HUI-16A Albatross off Makassar: 5 killed

Date & Time: Jan 23, 1986
Operator:
Registration:
IR-0222
Survivors:
Yes
MSN:
G-441
YOM:
1960
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
Crashed in unknown circumstances the Makassar Harbor. Five crew members were killed and three others were injured.

Crash of an Avro 748-2A-235 in Ujung Pandang

Date & Time: Feb 9, 1977
Type of aircraft:
Operator:
Registration:
PK-IHK
Survivors:
Yes
MSN:
1633
YOM:
1968
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
46
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following a wrong approach configuration, the airplane landed very hard 985 metres past the runway 13 threshold. Upon touchdown, the nose gear collapsed and the airplane slid for several metres before coming to rest. All 51 occupants were evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
It was determined that the approach was completed at an excessive speed and with a sink rate of 720 feet per minute.

Crash of a Consolidated PBY-5A Catalina off Pomelaa Harbour: 9 killed

Date & Time: Oct 1, 1943
Type of aircraft:
Operator:
Registration:
A24-67
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Darwin - Darwin
MSN:
1444
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
The crew was completing a torpedo attack on enemy ships in Pomelaa Harbour when the aircraft was shot down by anti-aircraft fire and crashed into the sea. Eight crew members were killed while two others were rescued. One of the survivor died a day later.
Crew (20th Squadron):
F/O Norman Falkner Dwyer, †
F/O Ronald Frank Dickinson, †
P/O Douglas Graham McDiarmed, †
Sgt Frank Haydock Thomson, †
Sgt Thomas Stephen McMahon, †
Cpl Samuel James Carnell, †
F/Lt Jack Robert Hyde, †
Lt Palgrave Ebden Carr,
F/Lt John Malcolm Barnes, †
W/Cdr Stanley Gordon Stilling. †
Probable cause:
Shot down by enemy fire.