Zone

Crash of an Airbus A320-216 into the Java Sea: 162 killed

Date & Time: Dec 28, 2014 at 0618 LT
Type of aircraft:
Operator:
Registration:
PK-AXC
Flight Phase:
Survivors:
No
Schedule:
Surabaya – Singapore
MSN:
3648
YOM:
2008
Flight number:
QZ8501
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
156
Pax fatalities:
Other fatalities:
Total fatalities:
162
Captain / Total flying hours:
20537
Captain / Total hours on type:
4687.00
Copilot / Total flying hours:
2247
Copilot / Total hours on type:
1367
Aircraft flight hours:
23039
Aircraft flight cycles:
13610
Circumstances:
The aircraft left Surabaya-Juanda Airport at 0535LT and climbed to its assigned altitude of FL320 that he reached 19 minutes later. The crew contacted ATC to obtain the authorization to climb to FL380 and to divert to 310° due to bad weather conditions. At 0617, the radio contact was lost with the crew and a minute later, the transponder stopped when the aircraft disappeared from the radar screen. At this time, the aircraft was flying at the altitude of 36,300 feet and its speed was decreasing to 353 knots. It is believed the aircraft crashed some 80 nautical miles southeast off the Pulau Belitung Island, some 200 km from the Singapore Control Area. The Indonesian Company confirmed there were 156 Indonesian Citizens on board, three South Korean, one Malaysian, one Singapore and one French (the copilot) as well. At the time of the accident, the weather conditions were marginal with storm activity, rain falls and turbulence in the area between Pulau Belitung and Kalimantan. First debris were spotted by the Indonesian Navy some 48 hours later, about 150 NM east-south-east off the Pulau Belitung Island. About forty dead bodies were found up to December 30. The tail was recovered on January 10, 2015 and the black boxes were localized a day later. On January 12 and 13 respectively, the DFDR and the CVR were out of water and sent to Jakarta for analysis and investigations.
Probable cause:
The cracking of a solder joint of both channel A and B resulted in loss of electrical continuity and led to RTLU (rudder travel limiter unit) failure.
The existing maintenance data analysis led to unresolved repetitive faults occurring with shorter intervals. The same fault occurred 4 times during the flight.
The flight crew action to the first 3 faults in accordance with the ECAM messages. Following the fourth fault, the FDR recorded different signatures that were similar to the FAC CB‟s being reset resulting in electrical interruption to the FAC‟s.
The electrical interruption to the FAC caused the autopilot to disengage and the flight control logic to change from Normal Law to Alternate Law, the rudder deflecting 2° to the left resulting the aircraft rolling up to 54° angle of bank.
Subsequent flight crew action leading to inability to control the aircraft in the Alternate Law resulted in the aircraft departing from the normal flight envelope and entering prolonged stall condition that was beyond the capability of the flight crew to recover.
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 737-33A in Surabaya

Date & Time: Feb 21, 2007 at 1525 LT
Type of aircraft:
Operator:
Registration:
PK-KKV
Survivors:
Yes
Schedule:
Jakarta - Surabaya
MSN:
27284/2606
YOM:
1994
Flight number:
DHI172
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
148
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
37936
Aircraft flight cycles:
23824
Circumstances:
The aircraft was on a scheduled passenger flight from Soekarno-Hatta Airport, Jakarta to Juanda Airport, Surabaya, East Java. There were 155 persons on board, consist of 7 crew and 148 passengers. During the flight there was no abnormality declare by the flight crew. Weather condition at Surabaya was thunderstorm and rain, wind 240/7 knots with visibility 8,000 meters. The CVR revealed that there was conversation in the cockpit that was not related to the progress of the flight, the conversation was relating to the company fuel policy and training program until 2000 feet. The CVR did not reveal approach briefing and any checklist reading. On final approach of runway 28 passing 800 feet approach light insight and landing clearance was received. Prior to touchdown, control of the aircraft was transferred from co-pilot to PIC. The CVR recorded that the Ground Proximity Warning Systems (GPWS) warned “Sink Rate” and “Pull Up”. The right wheel track was found out of the runway for about 4 meter away and return to the runway. The aircraft stopped for about 100 meters from taxiway N3. After aircraft touched down, the fuselage aft of passenger seat row 16 was bended down. The passengers were panic. Flight attendants evacuated the passengers via all exits available and door slides were inflated. The two passengers were minor injured, and the aircraft suffered severe damage.
Probable cause:
From the findings, it is concluded that the aircraft experienced excessive sink rate upon the touch-down. The aircraft was in unstable approach even at below 200 feet. The high vertical acceleration caused severe damage to the aircraft structure. The flight crew did not comply to several procedures published by the Boeing company. The flight crew did not respond to the GPWS alert and warnings.
Final Report:

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 McDonnell Douglas MD-82 in Surabaya

Date & Time: Mar 4, 2006 at 1625 LT
Type of aircraft:
Operator:
Registration:
PK-LMW
Survivors:
Yes
Schedule:
Denpasar – Surabaya
MSN:
49443/1291
YOM:
1986
Flight number:
JT8987
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
138
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Prior to departure from Bali to Surabaya, the crew was informed that the left engine's thrust reverser system was out of service. Following an uneventful flight, the crew completed a normal approach to runway 10 then landed according to procedures. After touchdown, the crew activated the thrust reverser when the airplane deviated to the right. The crew elected to counteract but the aircraft veered off runway, lost its undercarriage and came to rest in a grassy area. All 144 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Fokker F27 Friendship 500F in Surabaya: 3 killed

Date & Time: Mar 26, 2001 at 1825 LT
Type of aircraft:
Operator:
Registration:
PK-MFL
Flight Type:
Survivors:
No
Schedule:
Surabaya - Surabaya
MSN:
10609
YOM:
1981
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4506
Copilot / Total flying hours:
4325
Aircraft flight hours:
31300
Aircraft flight cycles:
38200
Circumstances:
The crew was completing a local training flight at Surabaya-Juanda Airport, consisting of touch-and-go manoeuvres. While approaching the airport to complete the eighth landing, at an altitude of 500 feet, the aircraft rolled to the left then stalled and crashed in a pond located 3 km short of runway, bursting into flames. All three pilots were killed. Both captains were operating on Casa-Nurtanio CN-235 (IPTN) and making a transition to Fokker F27.

Crash of a Beechcraft 200 Super King Air in Surabaya

Date & Time: Jan 17, 1993
Operator:
Registration:
PK-TRB
Flight Type:
Survivors:
Yes
Schedule:
Surabaya - Surabaya
MSN:
BB-116
YOM:
1976
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was engaged in a local training flight at Surabaya-Juanda Airport consisting of a series of six landings. On final approach during the 4th landing attempt, the landing gear alarm sounded. Thinking about a technical problem, the pilot-in-command increased engine power and initiated a go-around procedure. In the meantime, the copilot reduced power on both engines, causing the aircraft to lose speed and to stall. It struck the runway surface, veered to the right and eventually came to rest. Both occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Failure of the crew to follow the approach and landing checklist. On final, the pilot-in-command initiated a go-around procedure after the landing gear alarm sounded because the crew forgot to lower the undercarriage. Following a poor crew coordination, the copilot cut the throttle back, causing the aircraft to stall. The crew failed to follow the go-around procedure.

Crash of an Avro 748-234-2A in Surabaya: 16 killed

Date & Time: Jan 9, 1993
Type of aircraft:
Operator:
Registration:
PK-IHE
Survivors:
Yes
Schedule:
Banjarmasin - Surabaya
MSN:
1620
YOM:
1968
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
39
Pax fatalities:
Other fatalities:
Total fatalities:
16
Circumstances:
On short final to Surabaya-Juanda Airport, the right engine failed. The aircraft banked to the right and crashed in a swampy area located 800 metres short of runway. 16 occupants were killed while 28 others were injured.
Probable cause:
Failure of the right engine on short final for undetermined reasons. The relative low approach speed of the aircraft contributed to the stall/right bank.

Crash of a Fokker F28 Friendship 1000 on Mt Bromo: 4 killed

Date & Time: Mar 6, 1979 at 1855 LT
Type of aircraft:
Operator:
Registration:
PK-GVP
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Denpasar - Surabaya
MSN:
11094
YOM:
1975
Flight number:
GA553
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Aircraft flight hours:
7676
Aircraft flight cycles:
6707
Circumstances:
The airplane departed Denpasar-Ngurah Rai Airport at 1829LT on a positioning flight to Surabaya, carrying a crew of four. Following a level off at FL165, the crew was cleared to start the descent to Surabaya-Juanda Airport and passed successively FL100 and FL60 when the airplane struck the slope of Mt Bromo (1,890 meters high) located about 33 km southwest of Probolinggo. The aircraft was destroyed upon impact and all four crew members were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Douglas C-47A-65-DL in Surabaya: 2 killed

Date & Time: Nov 17, 1950
Operator:
Registration:
PK-DPB
Survivors:
Yes
MSN:
19005
YOM:
1943
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
After landing at Juanda Airport, the aircraft went out of control, veered off runway and came to rest into a ditch. Both pilots were killed while all other occupants were injured.