Manado-Sam Ratulangi

Survivors:

Site:

Lake, Sea, Ocean, River

Schedule:

Jakarta – Surabaya – Manado

MSN:

24070

YOM:

1989

Flight number:

DHI574

Location:

Makassar (Ujung Pandang)

South Sulawesi

Country:

Indonesia

Region:

Asia

Crew on board:

Crew fatalities:

Pax on board:

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 an Avro 748-402-2B in Ambon

Date & Time: Jul 11, 1996 at 0900 LT

Type of aircraft:

Avro 748

Operator:

Registration:

PK-IHN

Flight Phase:

Takeoff (climb)

Flight Type:

Survivors:

Site:

Schedule:

Ambon - Manado

MSN:

1794

YOM:

1983

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

During the takeoff roll at Ambon-Pattimura Airport, just before Vr, one of the engine failed. The captain abandoned the takeoff procedure and initiated an emergency braking manoeuvre. Unable to stop with the remaining distance (the runway surface was wet), the aircraft overran and came to rest 180 metres further against a dyke. All 48 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Fokker F27 Friendship 600 near Manado: 13 killed

Date & Time: May 9, 1991 at 0237 LT

Type of aircraft:

Fokker F27 Friendship

Operator:

Registration:

PK-MFD

Flight Phase:

Flight Type:

Survivors:

Site:

Mountains

Schedule:

Ambon - Ternate - Manado

MSN:

10399

YOM:

1969

Flight number:

MZ7533

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The aircraft departed Ternate Airport at 0153LT on the second leg of a flight from Ambon to Manado. While descending by night to Manado-Sam Ratulangi Airport, the crew encountered limited visibility due to poor weather conditions when the aircraft struck the slope of Mt Klabat located 15 km southeast of runway 36 threshold. The aircraft was destroyed upon impact and all 13 occupants were killed. It was raining at the time of the accident and the mountain was shrouded in clouds.

Probable cause:

Controlled flight into terrain.

Crash of a Casa 212 Aviocar 200 near Gorontalo: 1 killed

Date & Time: Jan 30, 1991 at 1300 LT

Type of aircraft:

Casa 212 Aviocar

Operator:

Registration:

PK-NCY

Flight Phase:

Flight

Flight Type:

Survivors:

Site:

Mountains

Schedule:

Manado - Gorontalo

MSN:

258/78N

YOM:

1985

Flight number:

MZ540

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The approach to Gorontalo-Jalaluddin Airport was initiated in thunderstorm activity with heavy rain falls. Too low, the airplane struck the slope of a mountain (1,500 meters high) located about 59 km from the airport. The wreckage was found about 30 meters below the summit. A passenger aged 80 died while all other occupants were rescued.

Probable cause:

For undetermined reasons, the crew started the approach prematurely, causing the aircraft to descend below the minimum safe altitude. The lack of visibility was a contributing factor.

Crash of a Casa 212 Aviocar 100 in Naha: 2 killed

Date & Time: Mar 20, 1986

Type of aircraft:

Casa 212 Aviocar

Operator:

Registration:

PK-NCF

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Manado - Naha

MSN:

108/15N

YOM:

1979

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

On approach to Naha Airport, the crew encountered limited visibility due to low clouds and rain falls. On final, the pilot failed to realize his altitude was insufficient when the aircraft struck trees and crashed on a wooded and hilly terrain located few km from the airport. All 14 passengers were injured while both pilots were killed.

Crash of a Casa 212 Aviocar 200 on Mt Lokon: 6 killed

Date & Time: Jan 24, 1984

Type of aircraft:

Casa 212 Aviocar

Operator:

Registration:

PK-PCL

Flight Phase:

Flight Type:

Survivors:

Site:

Mountains

Schedule:

Luwuk - Manado

MSN:

218/58N

YOM:

1983

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

While descending to Manado-Sam Ratulangi Airport, the crew encountered poor weather conditions and limited visibility. At an altitude of 3,000 feet, the twin engine airplane struck the slope of Mt Lokon located 25 km southwest of Manado Airport. Both pilots and four passengers were killed while three others were injured. For unknown reasons, the crew started the descent prematurely.

Crash of an Avro 748-235-2A in Manado

Date & Time: Dec 10, 1982

Type of aircraft:

Avro 748

Operator:

Registration:

PK-IHI

Flight Phase:

Flight Type:

Survivors:

Site:

MSN:

1626

YOM:

1967

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

After touchdown at Manado-Sam Ratulangi Airport, the nose gear collapsed. The airplane slid on its belly then veered off runway and came to rest. All 45 occupants escaped uninjured while the aircraft was damaged beyond repair.

Probable cause:

The nose gear collapsed on landing for unknown reasons.

Crash of a Vickers 806 Viscount in Manado

Date & Time: Jan 7, 1976

Type of aircraft:

Vickers Viscount

Operator:

Registration:

PK-RVK

Flight Phase:

Flight Type:

Survivors:

Site: