Crash of a Casa 212 Aviocar 200 near Bohorok: 18 killed

Date & Time: Sep 29, 2011 at 0750 LT
Type of aircraft:
Operator:
Registration:
PK-TLF
Flight Phase:
Survivors:
No
Site:
Schedule:
Medan - Kuta Cane
MSN:
88N/283
YOM:
1989
Flight number:
NBA823
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
18
Captain / Total flying hours:
5935
Captain / Total hours on type:
3730.00
Copilot / Total flying hours:
2500
Copilot / Total hours on type:
1100
Aircraft flight hours:
11329
Aircraft flight cycles:
13626
Circumstances:
On 29 September 2011, a CASA 212-200 aircraft registered PK-TLF was being operated by Nusantara Buana Air as a non-scheduled passenger flight from Polonia International Airport (MES/WIMM), Medan - North Sumatera1 to Alas Leuser Airstrip Kuta Cane, South East Aceh. The flight was conducted under Visual Flight Rules (VFR) The aircraft departed from Medan at 0728 LT (0028 UTC) and scheduled to be arrived at Kuta Cane at 0058 UTC. There were 18 person on board consisted of two pilots and 16 passengers including two children and two infants. The aircraft radar target was last observed on the radar screen at about 0050 UTC, while at position on radial 262˚ and 35 NM from MDN VOR. The aircraft was found impacted to a of 70º slope terrain at 5,055 feet altitude in the Leuser Mountain National Park, direction of 109 and 16 Nm from Kuta Cane on coordinate N 030 24’ 00” E 0980 01’ 00”. All 18 occupants were fatally injured and the aircraft was severely damage.
Probable cause:
Factors:
1. The flight was in VFR however both pilots agreed to fly into the cloud, consequently, the flight crew had lack of situation awareness due to lost of visual references to the ground and no or late recovery action prior to impact due to low visibility.
2. There was lack of good crew coordination due to steep cockpit transition gradient.
3. There was no checklist reading and crew briefing.
Final Report:

Crash of a GAF Nomad N.22B off Sabang: 5 killed

Date & Time: Dec 30, 2007 at 1130 LT
Type of aircraft:
Operator:
Registration:
P-833
Survivors:
Yes
Schedule:
Sabang - Medan
MSN:
168
YOM:
1983
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The twin engine aircraft departed Sabang-Maimum Saleh airport at 1110LT on a maritime survey flight to Medan. About 15 minutes into the flight, the crew informed ATC about engine problems and elected to return to Sabang. On final approach in poor weather conditions, the aircraft crashed in the sea and sank about 200 metres offshore. Two people were rescued while five others were killed.

Crash of a Boeing 737-230 in Medan: 149 killed

Date & Time: Sep 5, 2005 at 1015 LT
Type of aircraft:
Operator:
Registration:
PK-RIM
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Medan - Jakarta
MSN:
22136
YOM:
1981
Flight number:
RI091
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
112
Pax fatalities:
Other fatalities:
Total fatalities:
149
Captain / Total flying hours:
7522
Captain / Total hours on type:
7302.00
Copilot / Total flying hours:
2353
Copilot / Total hours on type:
685
Aircraft flight hours:
51599
Aircraft flight cycles:
51335
Circumstances:
On 5 September 2005, at 03:15 UTC, Mandala Airlines registered PK-RIM, operating as flight number MDL 091, a Boeing 737-200 departing for Soekarno-Hatta Airport, Jakarta from Medan. The previous flight was from Jakarta and arrived at Medan uneventfully. The same crew have flight schedule on the same day and returned to Jakarta. The flight was a regular scheduled passenger flight and was attempted to take-off from Polonia Airport, Medan, North Sumatra to Jakarta and it was the second trip of the day for the crew. At 02.40 UTC information from dispatcher, those embarking passengers, cargo process and all flight documents were ready. At 02.52 UTC, Mandala/MDL 091 asked for push back and start up clearance bound for Jakarta from the Air Traffic Controller/ATC, after received the approval from the ATC they began starting the engines. At 02.56 UTC, the controller cleared MDL 091 taxi into position on runway 23 via Alpha. At 03.02 UTC, MDL 091 received clearance for take off with additional clearance from ATC to turn left heading 120º and maintain 1500 ft. The MDL 091 read back the clearance heading 120º and maintains 1000 ft. The ATC corrected the clearance one thousand five hundred feet. The MDL 091 reread back as 1500 ft. Some of the passengers and other witnesses stated that the aircraft has lifted its nose in an up attitude and take off roll was longer than that normally made by similar airplanes. Most of them stated that the aircraft nose began to lift-off about few meters from the end of the runway. The ATC tower controller recalled that after rotation the plane began to “roll” or veer to the left and to the right. Some witnesses on the ground recalled that the airplane left wing struck a building before it struck in the busy road, then heard two big explosions and saw the flames. Persons on board in MDL 091, 5 crew and 95 passengers were killed, 15 passengers seriously injured and 2 passengers (a mother and child) were reported survived without any injuries; and other 49 persons on ground were killed and 26 grounds were serious injured.
Probable cause:
The National Transportation Safety Committee determines that probable causes of this accident are:
• The aircraft took-off with improper take off configuration namely with retracted flaps and slats causing the aircraft failed to lift off.
• Improper checklist procedure execution had lead to failure to identify the flap in retract position.
• The aircraft’s take off warning horn was not heard on the CAM channel of the CVR. It is possible that the take-off configuration warning horn was not sounding.
Final Report:

Crash of an Airbus A300B4-600 in Medan: 234 killed

Date & Time: Sep 26, 1997 at 1334 LT
Type of aircraft:
Operator:
Registration:
PK-GAI
Survivors:
No
Site:
Schedule:
Jakarta - Medan
MSN:
214
YOM:
1982
Flight number:
GA152
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
222
Pax fatalities:
Other fatalities:
Total fatalities:
234
Captain / Total flying hours:
11978
Captain / Total hours on type:
782.00
Copilot / Total flying hours:
709
Copilot / Total hours on type:
709
Aircraft flight hours:
27095
Aircraft flight cycles:
16593
Circumstances:
On 26 September 1997 the Garuda Indonesia Flight GA 152, PK-GAI Airbus A300-B4 departed from the Jakarta Soekarno-Hatta International Airport at 04:41 UTC. The aircraft was on a regular scheduled passengers flight to Polonia International Airport of Medan, North Sumatera with estimated time of arrival 06:41 UTC. Flight GA 152 was flying under Instrument Flight Rules during daylight. Before the flight, the flight crew reported to Garuda Indonesia Flight Operations office to receive flight briefings, including Notice to Airmen (NOTAM), weather conditions and forecast en-route, at destination and alternate airports, as well as the flight plan. The NOTAM stated that the MDN VOR was overdue for maintenance and advised to use the facility ‘with caution', although the Medan VOR has been calibrated with both ground and flight calibration on 14 June 1997 and valid until 14 December 1997, the use of Medan VOR was classified as “restricted due to radial course alignment at 270 degrees radial”. At the time of flight-planning, the visibility from Medan TAFOR (26 September 1997, 00.00 UTC – 24.00 UTC) was 1000 meters in smoke. The dispatcher stated that he received information through company channel that the actual visibility at Medan was 400 meters in smoke, which was below the minimum required visibility for runway 05 ILS of 800 meters. At 06:12:51 GA 152 requested a descend clearance to Medan Control. Medan Control cleared the aircraft to descend to FL 150. On passing FL 150, GA 152 was informed that the aircraft was in radar contact, at a distance of 43 nautical miles from MDN VOR/DME. The crew was then instructed to descend to 3000 ft for a landing on Runway 05 and to reduce the speed to 220 knots to allow Bouraq flight BO 683 to takeoff from Runway 23 at 06:20:47. GA152 requested a speed of 250 knots below 10000 feet which was approved. At 6:27:12, Medan Approach instructed GA 152 to maintain altitude on heading to Medan VOR/DME. GA 152 confirmed this instruction at 6:27:21. At 06:27:50 Medan Approach transmitted an instruction “Merpati one five two you er .. turn left heading two four zero vectoring for intercept ILS runway zero five from the right side traffic now er.. rolling”. There was no response by any aircraft to this transmission. At 06:28:06 Medan Approach enquired “Indonesia one five two do you read”. GA 152 asked the ATC to repeat the message. At 06:28:13 Medan Approach instructed GA 152 to “Turn left heading er.. two four zero two three five now vectoring for intercept ILS runway zero five”. This instruction was acknowledged by GA 152. At 06:28:52 the PIC asked the Medan Approach whether the aircraft was clear from the mountainous area northwest from Medan. This was confirmed by Medan Approach, and GA 152 was instructed to continue turning left on heading 215°M. At 06:29:41, GA 152 was instructed to descend to 2000 ft and the crew acknowledged it. Recorded FDR information indicates the aircraft is essentially wings level, heading approx 225M° and passing through 3000 feet on descent. Then at 06:30:04 GA 152 was instructed to turn right heading 046 degrees, and to report when established on the localizer. This was acknowledged by GA 152, but misread the heading “Turn right heading zero four zero Indonesia one five two check established”. Meanwhile recorded FDR information indicates the aircraft commences a roll to the left, heading reducing indicating a left turn and passing through 2600 feet on descent. At 6:30:33, while turning left, First Officer reminded the Captain to turn right. Two seconds later GA 152 queried Medan Approach whether the turn is to the left or to the right onto heading 046 degrees. At 6:30:39 Medan Approach replied “Turning right Sir”, which was acknowledged by GA 152. FDR data shows that the aircraft began to roll to wings level. At 06:30:51 Medan Approach asked whether GA 152 was making a left turn or a right turn. Recorded FDR information indicates the aircraft was wings level and rolling to the right, heading approximately 135°M and increasing, at 2035 feet pressure altitude on descent. GA 152 responded “We are turning right now”. At 06:31:05 Medan Approach instructed GA 152 to continue turning left. Recorded FDR information showed that at this point the aircraft had passed the assigned 2000 ft altitude and continued descending. GA 152 replied “Err...confirm turning left we are starting to turn right now”. During the interview, the controller stated that it was around this time that he recognized that the aircraft went below the required altitude (1800 ft and descending). Recorded FDR information indicates the aircraft reduced right roll from approx 24.3º to 10.2° and then rolled right again to approx 25°, while heading was increasing indicated a right turn was being maintained and the aircraft continued descending. At 06:31:32 the sound of tree impact is recorded. The elevation of the initial impact with the trees was at about 1550 ft above sea level. The final impact on the bottom of a ravine approximately 600 meters from the first tree impact destroyed the aircraft, and 234 people on board of the aircraft perished. There were no ground casualties.
Probable cause:
There was confusion regarding turning direction of left turn instead of right turn at critical position during radar vectoring that reduced the flight crew’s vertical awareness while they were concentrating on the aircraft’s lateral changes. These caused the aircraft to continue descending below the assigned altitude of 2,000 feet and hit treetops at 1,550 feet above mean sea level.
Final Report:

Crash of a Casa 212-A4 Aviocar 100 near Gunung Antara: 1 killed

Date & Time: Oct 3, 1995 at 0800 LT
Type of aircraft:
Operator:
Registration:
PK-ZAG
Flight Phase:
Survivors:
Yes
Schedule:
Medan - Meulobah
MSN:
158/28N
YOM:
1981
Flight number:
SMC1994
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Thirty minutes into the flight from Medan to Meulaboh, the hydraulic pressure dropped and the crew decided to shut down the left engine and to feather its propeller. Unable to maintain the prescribed altitude and because the aircraft became unstable, the crew also shut down the right engine and attempted an emergency landing when the aircraft struck trees and crashed in a swampy area. A pilot was killed while 13 other occupants were injured.
Probable cause:
Loss of oil pressure for undermined reasons.

Crash of a Short SC.7 Skyvan 3 Variant 100 on Mt Kapur: 14 killed

Date & Time: Jan 31, 1993
Type of aircraft:
Operator:
Registration:
9M-PID
Flight Phase:
Survivors:
No
Site:
Schedule:
Medan - Banda Aceh
MSN:
1961
YOM:
1978
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
14
Circumstances:
En route from Medan to Banda Aceh, the crew encountered poor weather conditions with limited visibility due to clouds. The crew informed ATC about his altitude at 8,500 feet when, three minutes later, the aircraft struck the slope of Mt Kapur located about 130 km northwest of Medan. The wreckage was found few hours later and all 14 occupants were killed.
Probable cause:
Controlled flight into terrain because the crew was flying below the minimum prescribed altitude in poor visibility due to clouds. On the route from Medan to Banda Aceh, published procedures fix a minimum altitude of 9,500 feet during the first portion of 160 km then 11,500 feet for the rest of the route. At the time of the accident, sky was overcast from 4,000 to 12,000 feet and the crew was obviously unaware of his insufficient altitude.

Crash of a Douglas DC-9-32 in Medan: 23 killed

Date & Time: Apr 4, 1987 at 1440 LT
Type of aircraft:
Operator:
Registration:
PK-GNQ
Survivors:
Yes
Schedule:
Banda Aceh - Medan
MSN:
47741
YOM:
1976
Flight number:
GA035
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
37
Pax fatalities:
Other fatalities:
Total fatalities:
23
Circumstances:
On final approach to Medan-Polonia Airport, pilots encountered poor weather conditions with thunderstorm activity, turbulences and heavy rain falls. On final, the aircraft became unstable and lost height. The pilot increased engine power when the aircraft struck a television antenna, stalled and crashed in a field, bursting into flames. 23 occupants were killed while 22 others were injured.
Probable cause:
Loss of control on final approach probably caused by windshear and microburst.

Crash of a Lockheed L-188C Electra in Medan

Date & Time: Nov 30, 1985
Type of aircraft:
Operator:
Registration:
PK-RLG
Survivors:
Yes
Schedule:
Jakarta - Padang
MSN:
2008
YOM:
1959
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
37
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Padang-Tabing Airport, both wheels on the right main gear detached and fell on a watch manufacture located in the approach path. The captain decided to divert to Medan-Polonia Airport more suitable for an emergency landing. Following a normal approach, the four engine aircraft belly landed and slid for few dozen meters before coming to rest. All 45 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
Loss of both right wheels for unknown reasons.

Crash of a Lockheed C-130H-MP Hercules on Mt Sibayak: 10 killed

Date & Time: Nov 21, 1985
Type of aircraft:
Operator:
Registration:
A-1322
Flight Type:
Survivors:
No
Site:
Schedule:
Jakarta - Medan
MSN:
4898
YOM:
1981
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
While descending to Medan-Polonia in poor weather conditions, the four engine aircraft struck the slope of Mt Sibayak and was destroyed upon impact. All 10 occupants were killed.

Crash of a Fokker F28 Fellowship 1000 on Mt Sibayak: 61 killed

Date & Time: Jul 11, 1979 at 1900 LT
Type of aircraft:
Operator:
Registration:
PK-GVE
Survivors:
No
Site:
Schedule:
Palembang - Medan
MSN:
11055
YOM:
1972
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
57
Pax fatalities:
Other fatalities:
Total fatalities:
61
Aircraft flight hours:
14154
Aircraft flight cycles:
14084
Circumstances:
The Fellowship christened 'Mamberamo' departed Palembang Airport at 1732LT on a schedule flight to Medan. After the crew was cleared for an NDB approach to runway 05 at Polonia Airport, he started the descent in a limited visibility. While descending at an altitude of 5,560 feet by night, the airplane struck the slope of Mt Sibayak (2,194 meters high) located about 38 km southwest of Medan-Polonia Airport. The aircraft was totally destroyed upon impact and all 61 occupants were killed.
Probable cause:
For unknown reasons, the crew started the descent prematurely and continued the approach below the glide, resulting in a controlled flight into terrain. The lack of visibility was considered as a contributing factor.