Crash of an Antonov AN-72 in Wamena

Date & Time: Apr 21, 2002 at 0913 LT
Type of aircraft:
Operator:
Registration:
ES-NOP
Flight Type:
Survivors:
Yes
Schedule:
Jayapura – Wamena
MSN:
36572010905
YOM:
1980
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7744
Captain / Total hours on type:
800.00
Copilot / Total flying hours:
8500
Copilot / Total hours on type:
100
Aircraft flight hours:
1897
Aircraft flight cycles:
1376
Circumstances:
At 23:40 UTC / 08:40 LT (WIT) on Sunday April 21, 2002, the ES-NOP departed Sentani Airport, Jayapura, bound for Wamena. The aircraft, an Antonov AN-72, was being operated by PT Trigana Air Services as a cargo carrying charter transport flight. The flight crews of four included three cockpit crew personnel and a loadmaster. The flight was the third flight of eight flights planned for the day between Sentani Airport and Wamena airport. The first flight departed Sentani airport at 21:05 UTC / 06:05 LT. Arriving at Wamena at 21:40 UTC / 06:40 LT. The return flight from Wamena bound for Sentani, departing Wamena at 22:22 UTC/ 07:22 LT arrived at Sentani at 22:52 UTC/07:52 LT. The flights were reported normal, and the weather along the route was reported clear. The third return flight, from Sentani to Wamena departed Sentani at 23:40 UTC / 08:40 LT carrying a load of 7,481 kg. The weather at Jayapura and along the route was clear. The cruise altitude during the flight was 16,000 ft. After waypoint ‘Maleo’ the airplane over-flew the so called ‘north-gap’ and the descent was initiated while passing the ‘pass valley’. Three other airplanes were reported to be in the area, one Fokker F27 PK-YPQ which was enroute from Wamena airport to Jayapura, and two Antonov A26 aircraft, registration ER-AFQ and ER-AFE. Flying over ‘Yiwika’ 7 Nm from Wamena airport, and descending through 12,000 ft with speed of 330 km/hr, the ES-NOP overtook the ER-AFE. The flight crew had the runway in sight. The PIC acting as pilot flying, flew an ‘S’ approach pattern during the final flight path of Wamena airport. (arriving Wamena 24:15 UTC/09:15 LT). On final and at an altitude of 100 meters, the airplane was lined up to the runway 15-center line. The airplane touched down while still within the touchdown zone. The airplane bounced twice, the second and last bounce reported to be more severe than the first one. The airplane rolled down the runway, with the flight crew noticing an unusual nose down attitude. The PIC/Pilot Flying applied reverse power and brakes, controlling the aircraft by using rudder inputs. During the roll, the loadmaster, sitting behind the PIC’s seat saw black smoke coming from the floor of the forward side of the cargo compartment. The crew reported that the smoke hurt their eyes. The airplane decelerated with smoke emitted from the forward cargo compartment. After stopping, the loadmaster opened the airplane door taking the extinguisher to extinguish the fire. The PIC shut down the engines after the airplane came to a standstill then opened the left cockpit window. PIC then left the cockpit assisting the loadmaster extinguishing the fire, the F/O completed the shutdown procedure, as the smoke blocked out his vision. The Flight Engineer attempted unsuccessfully opened the overhead emergency exit. The F/O and Flight Engineer then evacuated through the left cockpit window, while the PIC and loadmaster exited through the door. Observing the occurrence, and as the crash bell was unserviceable, the ATC on duty called the Deputy Chief of the airport, and alerted the fire fighting brigade. The fire fighting personnel failed to start the fire truck, and after recharging the truck’s battery for about 10 minutes reattempt to start for a second time. This attempt again failed, and the battery was again recharged, while fire fighting personnel ran the airplanes final position carrying portable fire extinguisher. After another ten minutes of battery charging, the fire fighting truck was finally started, immediately proceeding to the accident site. After a refill of the fireextinguishing agent the fire was finally extinguished. Firefighting personnel extinguished the fire in about 30 minutes time. The airplane was seriously damaged, with the front side of the airplane completely burnt out, the fire cutting a hole from behind the cockpit roof until approximately the middle of the cabin in front of the roof. The cargo was totally consumed by fire. No one was injured during the accident. After the occurrence, Wamena airport was closed for Fokker 27 or bigger aircraft but opened for DHC-6 (Twin Otter) or smaller aircraft. The NTSC investigator team embarked to Wamena on that day (Sunday, April 21 2002). On Monday, April 22 2002, at 02.00 PM (LT), the investigator team give the clearance to remove the aircraft from the runway, at 05.00 PM (LT) the airport authority personnel started the efforts to removed the aircraft by big back hoe, at 08.30 PM (LT) ES-NOP has cleared from runway. On Tuesday April 23rd 2002, the Wamena airport activities back to normal as usual.
Probable cause:
The following findings were identified:
- The crew performed visual approach to Wamena airport at airspeed exceeded the provision on AN-72 manual.
- The crew failure to estimate distance to start the final turn properly made the unable to decrease speed and therefore unable to extend flap to landing configuration.
- The high rate of descent and flap configuration upon final activated GPWS warning.
- The landing (touchdown) speed was exceeded the prescribed value in the AN-72 manual and the aircraft has slight drift angle at first touchdown.
- After the first touch the aircraft bounced three times. This and the fact that the aircraft was at high loading lead to the failure of the nose gear.
- The fire was caused by the heat from the friction as the aircraft components skidding on the runway and the presence of hydraulic fluid leaking from the damaged system.
- There is no indication of any malfunction in the aircraft system that could contribute to the accident.
- There is no indication of misconduct in the maintenance of the aircraft that could contribute to the accident.
- The fire brigade at Wamena airport was not in ready condition at the time of the accident, which leads to failure to extinguish the fire in time. The failure resulted in heavy fire damage on the aircraft.
- The fire brigade was not able the handle the fire due to non-serviceable equipment and lack of training for the personnel.
- Government check pilot need to perform close supervision (onboard the flight or give exams) to AN72 crew according to CASR 121 and CASR 61. By the time the report is written, the investigation could not find the necessary document that stated whether PT. Trigana has the authority to represent the government on the matter.
Safety Threats:
It is to be noted that there is blank radio transmission area at the gap. The Aviation Safety of Department of Communication plan to install relay antenna to resolve the problem. In the meantime, the authority required all aircraft passing the gap to perform blind transmission. It is to be noted that the lack of type certificate made the investigation progress very slow. The difficulty was due to lack of knowledge in the Indonesian authority on the technical aspect of the aircraft. Indonesian DGAC stated that the special permit for non-TC aircraft to operate in Papua will only valid until 2004.
Final Report:

Crash of a Pilatus PC-6/B2-H4 Turbo Porter in Bugalaga

Date & Time: Jan 18, 2002 at 1000 LT
Operator:
Registration:
PK-YPC
Flight Type:
Survivors:
Yes
Schedule:
Nabire - Bugalaga
MSN:
726
YOM:
1971
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
8500
Circumstances:
Upon landing on runway 06, the single engine aircraft bounced twice then veered off runway and came to rest in bushes. Both pilots escaped unhurt while the aircraft was damaged beyond repair.
Probable cause:
The crew completed the landing roll with a tailwind component and the runway was in poor conditions at the time of the accident, which remained a contributing factor.

Crash of a Boeing 737-3Q8 in Yogyakarta: 1 killed

Date & Time: Jan 16, 2002 at 1200 LT
Type of aircraft:
Operator:
Registration:
PK-GWA
Survivors:
Yes
Schedule:
Mataram-Jogjakarta
MSN:
24403
YOM:
1989
Flight number:
GA421
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
54
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
27701
Aircraft flight cycles:
24139
Circumstances:
On January 16, 2002, at approximately 09:24 UTC, a Boeing 737-300, PK-GWA, ditched into the waters of the Bengawan Solo River, Central Java during a forced landing, following loss of power on both engines as the aircraft was descending through 19,000 ft. The dual engine flame out occurred shortly after the aircraft entered severe cumulonimbus cloud formations with turbulence and heavy rain and ice. The aircraft, owned and operated by PT Garuda Indonesia as Flight GA 421, had departed Ampenan at 08:32 UTC, on a regular scheduled commercial flight with destination Yogyakarta. At departure VMC conditions prevailed. The flight from Ampenan was reported uneventful until its arrival in the Yogyakarta area. The crew stated that they observed cumulonimbus cloud formations on their weather radar. The aircraft descended from cruise altitude of 31,000 ft to 28,000ft as instructed by BALI ATC at 09.08 UTC due to traffic on eastbound at FL290. As they began their descent from FL 280 at 09.13 UTC, prior to entering the clouds at 23,000 feet, the crew noted at the radar screen red cells with two green and yellow areas to the left and right of their intended flight path. The Pilot Flying decided to take the left opening above PURWO NDB. The flight crew prepared to enter turbulence by setting turbulence speed at 280 knots, seatbelt on, engine ignitions on FLT and anti-ice on. Then the Pilot Flying requested to BALI ATC to descend to FL 190 and was cleared by Semarang APP at 09.13 UTC. Shortly after the aircraft entered the area covered by Cumulonimbus cells, the crew noted severe turbulence and heavy precipitation. According to the flight crew interview, the crew noted aircraft electrical power generators loss and they were only having primary engine instrument indications and captain flight instruments, which finally identified both engines flame-out. While in the precipitation, the flight crew attempted at least two engine relights, and one attempt of APU start. As the APU start was initiated, the crew noted total electrical loss of the aircraft. The aircraft descended into VMC conditions at about 8,000 ft altitude. The PIC spotted the Bengawan Solo River and decided to land the aircraft on the river. The crew announced to the flight attendant to prepare emergency landing procedure. The aircraft landed successfully between two iron bridges in the upstream direction, and came to a stop with its nose pointing to the right of the landing path. The aircraft settled down on its belly, with the wings and control surfaces largely intact, and was partially submerged. The evacuation following the landing was successful. Twelve passengers suffered injuries, the flight crew and two flight attendants were uninjured, one flight attendant suffered serious injuries, and another flight attendant was found in the waters of the river and fatally injured.
Probable cause:
The NTSC determines that the probable causes of the accident were the combination of:
1) The aircraft had entered severe hail and rain during weather avoidance which subsequently caused both engines flame out;
2) Two attempts of engine-relight failed because the aircraft was still in the precipitation beyond the engines’ certified capabilities; and
3) During the second attempt relight, the aircraft suffered run-out electrical power.
Final Report:

Crash of a Boeing 737-291 in Pekanbaru

Date & Time: Jan 14, 2002 at 1015 LT
Type of aircraft:
Operator:
Registration:
PK-LID
Flight Phase:
Survivors:
Yes
Schedule:
Pekanbaru - Batam
MSN:
20363
YOM:
1969
Flight number:
JT386
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
96
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17266
Copilot / Total flying hours:
3700
Copilot / Total hours on type:
2500
Aircraft flight hours:
68133
Aircraft flight cycles:
66998
Circumstances:
The flight was a second route of four routes on a first day of two days schedule flight for the crew. All crew have flight schedule on the previous day and returned to Jakarta. The first flight was from Jakarta to Pekanbaru with departure schedule on 08.00 LT (01.00 UTC). All crew did the pre-flight check completely but did not check the audio warning and departed Jakarta on schedule. The flight was normal and landed in Pekanbaru on schedule. There was no problem reported. Transit in Pekanbaru for about 30 minutes and the flight was ready to continue the next flight to Batam. At 10.15 LT (03.05) the boarding process has been completed and all flight documents have ready. First Officer asked for start clearance and received weather information in Syarif Kasim Airport. The weather was fine, wind calm and clear. After start completed, the aircraft taxi to the beginning of runway 18. Flight crews have set the V1, VR, V2 and V2+15 speed bugs according to the load sheet. Take off power decide to use “reduced take off power” with assumed temperature 35o C while the actual temperature was 27° C. flight Attendant have completed the passenger briefing includes rearrange seat for the seats near the “over wing exit windows”. The checklist was done, but flight crews were not sure the indication of flap setting. When ready for take off, flight crew gave a warning to the flight attendants to take their seats. First Officer acted as “Pilot Flying”. PIC opened the power and adjusted to the required take off power setting. The aircraft rolled normal and there was no abnormal indication. PIC called “V1” and “ROTATE” at speed bugs value setting, and the First Officer rotated the control column and set to 150 ANU (Aircraft Nose Up) pitch. The aircraft’s nose was lifted up but the aircraft did not airborne. Flight attendant who was sitting at the rear felt that the nose was higher than normal. Officer also felt stick shaker, warning for approaching stall. First Officer suddenly noticed a warning light illuminated and cross-checked. He found than the warning came from the problem on the air conditioning system. Both pilots also felt pain in the ear. Recognizing this situation, PIC decided to continue the take off and called to the First Officer “disregard”. Realized that the aircraft did not airborne PIC added the power by moving power levers forward. The speed was increasing and passed the speed bug setting for V2+15 ( ± 158 KIAS) but the aircraft did not get airborne. PIC noticed that the runway end getting closer and he thought that the aircraft would not airborne, he decided to abort the take off and called “STOP”. PIC retarded the power levers to idle and set to reverse thrust, extended the speed brake and applied brake. Nose of the aircraft went down hard and made the front left door (L1) opened and 2 trolleys at front galley move forward and blocked the cockpit door. Flight crew turns the aircraft slightly to the right to avoid approach lights ahead. The aircraft moved out or the runway to the right side of the approach lights. After hit some trees the aircraft stopped at ± 275 meters from the end of runway on heading 285°. One passenger had serious injury and the rest had minor injury, all crew were safe and not injured. No one killed in this accident, while the aircraft considered total loss.
Probable cause:
Findings:
1. The flight crews have proper qualification to fly the aircraft.
2. The aircraft did not exceed its Maximum Take-Off Weight limitation specified in the AOM.
3. Cockpit area microphone did not function at the time of the accident. Therefore, the only sounds/conversations recorded were only when there were radio transmissions.
4. FDR data show that the engines operated normally.
5. FDR data show similar trajectory with an aircraft of the type and loading condition tried to take-off with zero flap.
6. The aircraft flap system was found to function normally. Therefore, should the flap selector moved to non-zero position, the flap should move to the selected position.
7. The crew did not perform Before Take-off Checklist as stated in the Boeing 737-200 Pilot’s Handbook, Chapter Normal Operating Procedures.
8. The aural warning system, except its circuit breaker, function normally. Therefore, the cause of the absence of take-off warning is the wear out latch on the CB that caused it to open.
9. The food trolley safety lock and food trolley safety strap on the front galley did not function properly that the trolley loose upon impact and blocking the cockpit door.
10. The escape slides fail to deploy. All the slides have no expiration date or marked last inspection date-as regulated in CASR 121.309.
11. Shear pins on the engines mounting function properly to separate the engine from the wing and therefore minimize the risk of fire in the accident.
Final Remarks:
Since there is no indication that flaps system failure or flap asymmetry contributes in the failure of flap to travel to take-off configuration, the most probable cause for the failure is the improper execution of take-off checklist. Failure of the maintenance to identify the real problem on the aural warning CB, causes the CB to open during the accident and therefore is a contributing factor to the accident.
Final Report:

Crash of a Lockheed C-130 Hercules in Lhokseumawe

Date & Time: Dec 20, 2001 at 0935 LT
Type of aircraft:
Operator:
Registration:
A-1329
Flight Type:
Survivors:
Yes
Schedule:
Jakarta - Lhokseumawe
MSN:
4824
YOM:
1979
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
83
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Lhokseumawe-Malikussaleh Airport, the four engine aircraft went out of control, veered off runway and came to rest in a marshy area, bursting into flames. All 95 occupants were rescued, among them seven passengers were injured. The aircraft was destroyed by a post crash fire.

Crash of a Transall C-160NG in Jayapura: 1 killed

Date & Time: Jun 16, 2001 at 1430 LT
Type of aircraft:
Operator:
Registration:
PK-VTP
Survivors:
Yes
Schedule:
Jayapura – Wamena
MSN:
F234
YOM:
1985
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
After takeoff from Jayapura-Sentani Airport, while climbing, the crew informed ATC about engine problems and was cleared for an immediate return. Following a 180 turn, the crew initiated an approach to runway 30. After touchdown, the crew started the braking procedure and reduced the engine power when a technical problem occurred on the right engine. The aircraft went out of control, veered off runway to the left, collided with a drainage ditch and came to rest against palm trees located 72 metres to the left of the runway centerline and 1,050 metres from the runway threshold. 18 occupants were injured and a passenger was killed. The aircraft was written off.
Probable cause:
A technical failure occurred on the right engine whose rotation could not be reduced below 14,200 rpm after touchdown, for reasons unknown.

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 Casa NC-212M Aviocar 200 in Pondok Cabe

Date & Time: Feb 11, 2001
Type of aircraft:
Operator:
Registration:
A-9119
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
101
YOM:
1978
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll, the twin engine aircraft deviated to the left, veered off runway and came to rest. All 14 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Casa NC-212MP Aviocar 200 near Timika: 9 killed

Date & Time: Jan 8, 2001
Type of aircraft:
Operator:
Registration:
U-614
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Timika - Jayapura
MSN:
223/63N
YOM:
1984
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
About 12 minutes after takeoff from Timika Airport, while cruising at an altitude of 11,800 feet, the twin engine aircraft struck the slope of Mt Trikora. All nine occupants were killed, among them high ranking Police and Navy officers.
Probable cause:
Controlled flight into terrain.

Crash of a Britten-Norman BN-2B-21 Islander in Datah Dawai

Date & Time: Nov 18, 2000 at 1053 LT
Type of aircraft:
Operator:
Registration:
PK-VIY
Flight Phase:
Survivors:
Yes
Schedule:
Datah Dawai - Samarinda
MSN:
2133
YOM:
1981
Flight number:
AW3130
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7560
Captain / Total hours on type:
3632.00
Aircraft flight hours:
21336
Aircraft flight cycles:
20374
Circumstances:
The aircraft departed from Datah Dawai Airport for a regular commercial flight with destination airport, Samarinda, East Kalimantan. There were 18 persons on board including the pilot. Minutes after airborne, the aircraft crashed at a location of about 2 km north of the runway 02 extension. The pilot and 11 passengers were found seriously injured, while six sustained minor injuries or none. Weather was reported clear at the time of the occurrence.
Probable cause:
The following findings were identified:
- There are no signs of engine failure prior to the impact,
- The aircraft exceeded its manufacturer's MTOW on the flight from Datah Dawai to Samarinda,
- The aircraft center of gravity is near the aft limit of the CG flight envelope,
- The PIC apparently has a wrong perception on takeoff procedure. He thought that the optimum takeoff performance could be achieved by taking-off with a higher velocity. Meanwhile, in achieving high velocity one has to roll closer to the obstacle, which forced the aircraft to maintain a higher rate of climb,
- The PIC and Datah Dawai ground crews have endangered his passengers by letting more passengers loaded into the aircraft than the number of seats available,
- The PIC and Datah Dawai ground crews have endangered their passengers by improperly calculating the weight of aircraft payload,
- The operator did not have proper supervision system that may prevent such practice to happen,
- The operator has never filled out Flight Clearance, for its Samarinda - Datah Dawai operation,
- There are a lot more passengers or demand than the capacity of the Pioneer Flight Samarinda - Datah Dawai,
- There are not enough flight operation documents published (such as visual track and single engine emergency return guidance) to fly safely in and out of Datah Dawai,
- The exceeding MTOW, small stability margin, PIC takeoff habit, and lack of published safety documents for the area are the contributing factors to the accident.
There were found indications of practices that fit into the category of negligence, willful misconduct and violations of existing flight safety rules and regulations.
Final Report: