Crash of a Fletcher FU-24-950 in North Rawajitu: 1 killed

Date & Time: May 11, 2013 at 1125 LT
Type of aircraft:
Operator:
Registration:
PK-PNC
Flight Phase:
Survivors:
No
Schedule:
North Rawajitu - North Rawajitu
MSN:
243
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Pilot was engaged in a spraying mission over an oil palm plantation in the region of North Rawajitu, Lampung Province. Less than three minutes after takeoff, the single engine aircraft stalled and crashed in a wooded area, bursting into flames. The aircraft was destroyed by impact forces and a post impact fire and the pilot, sole on board, was killed.

Crash of a Boeing 737-8GP off Denpasar

Date & Time: Apr 13, 2013 at 1510 LT
Type of aircraft:
Operator:
Registration:
PK-LKS
Survivors:
Yes
Schedule:
Bandung - Denpasar
MSN:
38728/4350
YOM:
2013
Flight number:
LNI904
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
101
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
6173.00
Copilot / Total flying hours:
1200
Copilot / Total hours on type:
923
Aircraft flight hours:
142
Aircraft flight cycles:
104
Circumstances:
On 13 April 2013, a Boeing 737-800 aircraft, registered PK-LKS, was being operated by PT. Lion Mentari Airlines (Lion Air) on a scheduled passenger flight as LNI 904. The aircraft departed from Husein Sastranegara International Airport (WICC) Bandung at 0545 UTC to Ngurah Rai International Airport (WADD), Bali, Indonesia. The flight was the last sector of four legs scheduled for the crew on that day which were Palu (WAML) - Balikpapan (WALL) - Banjarmasin (WAOO) - Bandung (WICC) - Bali (WADD). The aircraft flew at FL 390, while the Second in Command (SIC) was the Pilot Flying (PF) and the Pilot in Command (PIC) was the Pilot Monitoring (PM). There were 2 pilots, 5 flight attendants and 101 passengers comprising 95 adults, 5 children and 1 infant making a total of 108 persons on board. The flight from the departure until start of the approach into Bali was uneventful. At 0648 UTC, the pilot made first communications with the Bali Approach controller (Bali Director) when the aircraft was located 80 Nm from BLI VOR. The pilot received clearance to proceed direct to the TALOT IFR waypoint and descend to 17,000 feet. At 0652 UTC, the Bali Director issued a further clearance for the pilot direct to KUTA point and descent to 8,000 feet. At 0659 UTC, the aircraft was vectored for a VOR DME approach for runway 09 and descent to 3,000 feet. At 0703 UTC, while the aircraft was over KUTA point, the Bali Director transferred communications with the aircraft to Bali Control Tower (Ngurah Tower). At 0704 UTC, the pilot contacted Ngurah Tower controller and advised that the aircraft was leaving KUTA point. The Ngurah Tower controller instructed the pilot to continue the approach and to reduce the aircraft speed to provide sufficient separation distance with another aircraft. At 0707 UTC, the Ngurah Tower issued take-off clearance for a departing aircraft on runway 09. At 0708 UTC, with LKS at approximately 1,600 feet AGL, the Ngurah Tower controller saw the aircraft on final approach and gave a landing clearance with additional information that the wind was from 120° at 05 knots. At 0708:47 UTC, the aircraft Enhance Ground Proximity Warning System (EGPWS) aural alert called “ONE THOUSAND”, the SIC said one thousand, stabilized, continue, prepare for go-around missed approach three thousand. The FDR showed that the pilot flown using LNAV (Lateral Navigation) and VNAV (Vertical Navigation) during the approach until disengagement of the Auto Pilot. The sequence of events during the final approach is based on the recorded CVR and FDR data, and information from crew interviews as follows: At 0708:56 UTC, while the aircraft altitude was approximately 900 feet AGL, the SIC commented that the runway was not in sight, whereas the PIC commented “OK. Approach light in sight, continue”. At 0709:33 UTC, after the EGPWS aural alert “MINIMUM” sounded at an aircraft altitude of approximately 550 feet AGL, the SIC disengaged the autopilot and the auto-throttle and then continued the approach. At 0709:43 UTC, the EGPWS called “THREE HUNDRED”. At 0709:47 UTC, the CVR recorded a sound similar to rain hitting the windshield. At 0709:49 UTC, the EGPWS called “TWO HUNDRED”. At 0709:53 UTC, while the aircraft altitude was approximately 150 feet AGL, the PIC took over control of the aircraft. The SIC handed control to the PIC and stated that he could not see the runway. At 0710:01 UTC, after the EGPWS called “TWENTY”, the PIC commanded for go-around. At 0710:02 UTC, the aircraft impacted the water, short of the runway. The aircraft stopped facing to the north at about 20 meters from the shore or approximately 300 meters south-west of the beginning of runway 09. Between 0724 UTC to 0745 UTC, three other aircraft took-off and six aircraft landed using runway 09. At 0750 UTC, the airport was closed until 0850 UTC. At 0755 UTC, all occupants were completely evacuated, the injured passengers were taken to the nearest hospitals and uninjured occupants to the airport crisis centre.
Probable cause:
The National Transportation Safety Committee initial findings on the accident flight are as follows:
- The aircraft was airworthy prior to impact and has an item on the DMI (deferred maintenance item) category C (right engine oil filter).
- All crew has valid licenses and medical certificates.
- The Second in Command (SIC) acted as Pilot Flying (PF).
- The flight performed a VOR DME approach runway 09, and the published Minimum Descent Altitude (MDA) was 465 ft AGL.
- The approach configuration used was flap 40.
- At 900 ft AGL the PF did not have the runway in sight.
- Upon reaching the MDA the flight profile indicated a constant path.
- The PIC took over control of the aircraft at about 150 ft radio altitude.
- The SIC handed over control to the PIC at about 150 ft and stated that he could not see the runway.
- The final approach phase of the flight profile was outside the envelope of the EGPWS warning, therefore no EGPWS warning was recorded on the CVR.
The NTSC concluded in its final report that the accident was caused by the following factors:
- The aircraft flight path became unstable below minimum descends altitude (MDA) with the rate of descend exceeding 1000 feet per minute and this situation was recognized by both pilots.
- The flight crew loss of situational awareness in regards of visual references once the aircraft entered a rain cloud during the final approach below minimum descends altitude (MDA).
- The PIC decision and execution to go-around was conducted at an altitude which was insufficient for the go-around to be executed successfully.
- The pilots of accident aircraft was not provided with timely and accurate weather condition despite the weather around the airport and particularly on final approach to the airport was changing rapidly.
Final Report:

Crash of a PAC 750XL near Yahukimo: 2 killed

Date & Time: Oct 3, 2012 at 1120 LT
Operator:
Registration:
PK-RWT
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Jayapura - Korupun - Dekai
MSN:
157
YOM:
2009
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1546
Captain / Total hours on type:
1315.00
Circumstances:
On 03 October 2012, a Pacific Aerospace LTD, PAC 750 XL aircraft registration PK-RWT was being operated by Yayasan Pelayan Penerbangan Tariku on a cargo supply flight from Koropun to Dekai in Papua area. This flight was the 9 th flight of that day. All flights were performed in accordance to the Visual Flight Rules (VFR). The first flight was from Sentani to Langda which was arrived at 2220 UTC (0720 LT). The aircraft arrived Koropun at 0120 UTC (1020 LT) as reported by the pilot through the company flight following system . The aircraft then departed Koropun to Dekai and lost contact during this flight. On board in this flight were one pilot, one passenger and 975 kg of cargo when departure from Sentani. The distance between Koropun to Dekai is about 24.6 Nm and normally takes about 11 minutes. The weather information issued by Badan Meteorologi Klimatologi and Geofisika/BMKG (Indonesia Meteorology Climatology and Geophysics Agency) between 0200 UTC to 0300 UTC, showed the development of cumulus cloud classified as Middle Cloud formation along the route from Koropun to Dekai. According to the company flight following procedure, the pilot should report after the aircraft lands by mentions “aircraft on the ground” which this means that the aircraft had arrived at destination. After aircraft airborne, the pilot should report aircraft airborne time and give the estimate of time arrival at destination. The last contact of the pilot was “the aircraft on the ground Koropun” at 0120 UTC. Normally, the next report would be within 15 up to 20 minutes after arrival. There was no report from the pilot after 20 minutes of the last report. The flight following officer tried to contact the pilot and was unsuccessful. At 0145 UTC, the Operation Manager of the aircraft operator received information from the New Zealand Search and Rescue Agency that informed that Local User Terminal (LUT) has received ELT distress signal from PK-RWT. This information was followed by information through email, which was received at 0150 UTC. Based on this information, the Indonesia Search and Rescue operation was initiated. The aircraft was found on 5 October 2013, in mountainous area with approximate elevation of 7,000 feet, at coordinate 04°28.62’S 139°39’E. The crew and passenger on board were fatally injured and the aircraft substantially damaged.
Probable cause:
The accident was classified as Controlled Flight into Terrain (CFIT), which most likely the aircraft was flown into the weather environment below the VFR margins.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain near Bontang: 4 killed

Date & Time: Aug 24, 2012 at 0810 LT
Operator:
Registration:
PK-IWH
Flight Phase:
Survivors:
No
Schedule:
Samarinda - Bontang
MSN:
31-7852065
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
17547
Captain / Total hours on type:
4250.00
Aircraft flight hours:
16743
Aircraft flight cycles:
14830
Circumstances:
On 24 August 2012, a Piper Chieftain PA-31-350 aircraft, registered PK-IWH, was being operated by PT. Intan Angkasa Airservice to conduct an aerial survey (aero magnetic) flight at a survey area located north of Bontang, East Kalimantan. There were 4 persons on board; one pilot, one security officer and two surveyors. Based on the flight plan submitted by the Pilot in Command (PIC) to the Briefing Office, the flight was planned with an altitude of 3,000 feet AMSL en-route and 500 feet AGL while surveying the area. The fuel endurance was for 6 hours flight time and the aircraft equipped with an Emergency Locator Transmitter (ELT). The aircraft departed from Temindung Airport (WALS), Samarinda at 0751 local time (LT - 2351 UTC). At 0004 UTC, the pilot informed to the Temindung Control Tower controller (Temindung Tower) that the aircraft was abeam Tanjung Santan descending from 3,000 feet and established contact with Bontang Info officer (Bontang Info). At 0005 UTC, the pilot informed the Bontang Info that the aircraft altitude was 300 feet and estimated over Bontang at 0011 UTC. Bontang info acknowledged this transmission and advised the pilot to report when the flight left the Bontang Area. At 0010 UTC, the SureTrack (flight following system) stopped receiving data from the aircraft. The last recorded information was an aircraft speed of 138 knots, heading 352°, latitude 0°8’33” N and longitude 117°12’54” E. At 0600 UTC, the engineer of the PK-IWH aircraft asked the Temindung Tower about the flight as the fuel endurance had been exceeded. The Temindung Tower contacted Bontang Info to get information about the aircraft. After receiving the request, Bontang Info tried to contact the pilot twice and there was no reply. Bontang Info also contacted the Tanjung Bara Airstrip to request information about the aircraft but there was no information. The Temindung Tower reported that:
• at 0610 UTC declared INCERFA (Uncertainty phase);
• at 0630 UTC declared ALERFA (Alert phase);
• at 0700 UTC declared DETRESFA (Distress phase).
At 0730 UTC, the search and rescue team was assembled; the team consisted of the Temindung Airport Authority, National Search and Rescue, Indonesian Police, Army and Airforce. The search operation was conducted via ground and air using three helicopters. On 26 August 2012 at 0850 UTC, the aircraft wreckage was located by a ground search team on a ridge of Mayang Hill, Bontang at approximately 1,200 feet AMSL at coordinates 00°12’34.3”N, 117°16’57.3”E, 12 NM from Bontang Aerodrome on bearing of 294°. The accident site was within the planned aircraft survey area. All occupants were fatally injured and the aircraft was destroyed by impact force and post impact fire.
Probable cause:
The accident was typical of a Controlled Flight into Terrain (CFIT). Low altitude VFR flying in a low visibility environment limited the pilot’s visibility and increased the probability of impact with terrain.
Final Report:

Crash of a Fokker F27 Friendship 400M in Jakarta: 11 killed

Date & Time: Jun 21, 2012 at 1450 LT
Type of aircraft:
Operator:
Registration:
A-2708
Flight Type:
Survivors:
No
Schedule:
Jakarta - Jakarta
MSN:
10546
YOM:
1976
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The crew (one instructor and six pilot under training) were engaged in a training flight and departed Jakarta-Halim Perdanakusuma Airport at 1310LT for a local flight consisting of touch-and-go manoeuvres. After a circuit, the pilot-in-command completed a last turn to the left to join the glide for runway 18 when the aircraft stalled and crashed onto several houses located less than one km from the runway threshold. The aircraft was destroyed as well as several houses. Six occupants in the aircraft and four people on the ground were killed while the copilot was critically injured. Unfortunately, he did not survive to his severe injuries and died few hours later at hospital.
Probable cause:
It was reported that the approach speed was too low during the last turn, causing the aircraft to stall. The distance between the aircraft and the ground was insufficient to expect recovery.

Crash of a Boeing 737-4Y0 in Pontianak

Date & Time: Jun 1, 2012 at 1235 LT
Type of aircraft:
Operator:
Registration:
PK-CJV
Survivors:
Yes
Schedule:
Jakarta - Pontianak
MSN:
24689/1883
YOM:
1990
Flight number:
SJY188
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
155
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25000
Circumstances:
The approach to Pontianak was unstable and really difficult due to turbulence and poor weather conditions (heavy rain falls). The aircraft landed on wet runway 15 and skidded. It eventually veered off runway to the left and went through a muddy field. The nose gear was torn off while both main gears sank, leaving both engines on the ground. While all 163 occupants were evacuated safely, the aircraft was damaged beyond repair. At the time of the accident, weather conditions were as follow: wind from 230 at 22 knots, visibility 600 metres, few clouds at 900 feet, broken at 700 feet, CB's above the terrain and turbulences.

Crash of a Sukhoï Superjet 100-95 on Mt Salak: 45 killed

Date & Time: May 9, 2012 at 1431 LT
Type of aircraft:
Operator:
Registration:
97004
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Jakarta - Jakarta
MSN:
95004
YOM:
2009
Flight number:
RA36801
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
41
Pax fatalities:
Other fatalities:
Total fatalities:
45
Captain / Total flying hours:
10347
Captain / Total hours on type:
1348.00
Copilot / Total flying hours:
3318
Copilot / Total hours on type:
625
Aircraft flight hours:
843
Aircraft flight cycles:
500
Circumstances:
Aircraft was performing a demo flight and left Jakarta-Halim Perdanakasuma Airport at 1400LT with 41 passengers (potential buyers) on board and a crew of four. About thirty minutes later, while turning around Mount Salak, pilots received the authorization to descend from 10,000 feet to 6,000 feet in low visibility. Aircraft hit the edge of a cliff and crashed few yards further and was totally destroyed by impact and post impact fire. SAR teams arrived on scene 18 hours later and all 45 occupants were killed. At the time of the accident, weather conditions were marginal with clouds shrouding both Mount Salak and Mount Gede. First accident involving a Sukhoi Superjet 100. Present model was manufactured 09AUG2009 and totalized 843 flying hours for 500 cycles. Captain had 10,347 flying hours and was a test pilot by Sukhoi Civil Aircraft Company.
Probable cause:
- The flight crew was not aware of the mountainous area in the vicinity of the flight path due to various factors such as available charts, insufficient briefing and statements of the potential customer that resulted in inappropriate response to the TAWS warning. The impact could have been avoided by appropriate action of the pilot up to 24 seconds after the first TAWS warning.
- The Jakarta Radar service had not established the minimum vectoring altitudes and the Jakarta Radar system was not equipped with functioning MSAW for the particular area around Mount Salak.
- Distraction of the flight crew from prolonged conversation not related to the progress of the flight, resulted in the pilot flying not constantly changing the aircraft heading while in orbit. Consequently, the aircraft unintentionally exited the orbit.
Final Report:

Crash of a Pilatus PC-6/B2-H4 Turbo Porter in Muaritan: 2 killed

Date & Time: Apr 25, 2012 at 1730 LT
Operator:
Registration:
PK-VVQ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Balikpapan - Balikpapan
MSN:
965
YOM:
2009
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1912
Captain / Total hours on type:
81.00
Aircraft flight hours:
2397
Aircraft flight cycles:
3466
Circumstances:
The Pilatus Porter PC-6 aircraft operated by PT. Puji Astuti Aviation (Susi Air) registered PK-VVQ on Areal Survey Flight, departed from Sepinggan-Balikpapan to Melak Area on 25 April 2012 at 0440 UTC (Universal Time Coordinate) or 1240 LT. There were one pilot and one pasenger on board, the estimate flight endurance was seven hours. At 0505 the aircraft reported leaving Balikpapan Approach. At 0910 the aircraft was reported to Melak Radio on radial 060 at the altitude of 3,500 feet, and that it would be leaving Survey after a further twenty minutes. Melak Radio reported that the aircraft lost contact at 0930. At 0922 a text message was sent by the passenger to his employer stating “Run out of fuel, landing on road”. The Search and Rescue Bureau informed that a distress signal was tetected on 1025 at the position of 00 25’.02” N 116.02’.48”E. On 26 April 2012 at 1730 UTC the aircraft was found in Muaritan – Kecamatan Tabang, Kutai Karta Negara at the position 00 25’.03” N 116.01’.55”E. The aircraft was substantially damaged, the pilot and the passenger were fatally injured.
Probable cause:
The engine flamed out caused by lack of fuel supply from main fuel tank to the engine. The pilot likely fixated on the survey flight execution and lost awareness of his fuel situation. The transferring of fuel from the auxiliary tank was not performed during the flight as required. The combination of inexperience of the pilot related to survey flying, fatigue and the highly demanding survey operator contributed to this sequence of events.
Final Report:

Crash of a Boeing 737-36M in Yogyakarta

Date & Time: Dec 20, 2011 at 1713 LT
Type of aircraft:
Operator:
Registration:
PK-CKM
Survivors:
Yes
Schedule:
Jakarta - Yogyakarta
MSN:
28333/2810
YOM:
1996
Flight number:
SJY230
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
131
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
29801
Copilot / Total flying hours:
562
Aircraft flight hours:
31281
Aircraft flight cycles:
21591
Circumstances:
On 20 December 2011, a Boeing 737-300 aircraft, registered PK-CKM, was being operated by PT. Sriwijaya Air on a schedule passenger flight SJ230 from Soekarno Hatta International Airport (WIII) Jakarta to Adisutjipto International Airport (WARJ), Yogyakarta. There were 141 persons on board; two pilots, four cabin crews and 135 passengers consisted124 adult, 7 children and 4 infant. The aircraft departed from Jakarta at 14.00 LT (07.00 UTC), the pilot in command was the pilot flying and the co-pilot was the pilot monitoring. At 08.10 UTC the aircraft made holding at 8 NM from JOG VOR due to bad weather. After the second holding and the weather was deteriorated, the airport authority closed the airport for takeoff and landing. The pilot requested divert to Juanda Airport (WARR), Surabaya and landed at 08.40 UTC. After refuelling and received the information about weather improvement in Yogyakarta then the aircraft departed, at 09.20 UTC, in this sequence of flight the PIC acted as PF, with 137 persons on board consisted of two pilots, four cabin crews and 131 passengers consisted 120 adult, 7 children and 4 infant. The aircraft was on the fifth sequence from seven aircraft approaching Adisucipto airport Yogyakarta. Passing JOG VOR it was seen on radar screen that the aircraft speed was read 203 Kts at 2700 ft. Approach Controller instructed to reduce the speed. At about 1200 ft, the pilot had the runway insight and disengaged the autopilot and auto throttle. The pilot made correction to the approach profile by roll up to 25 degrees and rate of descend up to 2040 ft per minute. The GPWS warning of ‘pull up’ and sink ‘rate were’ activated. Aircraft touched down at speed 156 Kts of 138 Kts target landing speed. During landing roll, the auto-brake and spoiler activated automatically. The thrust reverse were deployed and the N1 were recorded on the FDR increase and decrease to idle before increased to 80% prior to aircraft stop. The PIC noticed that the aircraft would not be able to stop in the runway and decided to turn the aircraft to the left. The aircraft stopped at 75 meter from the end of runway 09 and 54 meter on the left side of the centre line. Most of the passenger evacuated through left and right forward escape slides. All passengers were evacuated safely. The passenger on the stretcher case was evacuated by the airport rescue. 6 passengers reported minor injured while all crew and the remaining passengers were not injured. The aircraft suffered major damage on the right main and nose wheel.
Probable cause:
Findings:
1. The aircraft was airworthy prior the accident. There was no evidence that the aircraft had malfunction during the flight.
2. The crew had valid license and medical certificate. There was no evidence of crew incapacitation.
3. In this flight Pilot in Command acted as Pilot Flying and Second In command acted as Pilot Monitoring.
4. The flight crew did not conduct approach crew briefing.
5. There was no checklist reading.
6. The PIC as Pilot Flying did not have the instrument approach procedure immediately available to review during approach.
7. During the approach, the PIC course indicator was set at 091 and the SIC was at 084.
8. The rate of descend recorded vary and up to 1920 ft per minute and below 500 ft AGL the rate of descend recorded up to 2040 ft per minute.
9. The approach did not meet the stabilize approach criteria as stated in the FCOM.
10. There were several GPWS warning of ‘sink rate’ and ‘pull up’ activated during approach.
11. The aircraft touched down at speed 156 Kt before bounced, instead of 138 Kt target landing speed.
12. The flap extended to 40 after the aircraft touch down.
13. The FDR recorded reduction in N1 during thrust reverser activation after landing.
14. The CRM was not well implemented.
Factors:
Unsuccessful to recognize the two critical elements, namely fixation and complacency affected pilot decision to land the aircraft while the approach was not meet the criteria of stabilized approach.
Final Report:

Crash of a PAC 750XL in Abmisibil: 2 killed

Date & Time: Dec 17, 2011 at 0740 LT
Operator:
Registration:
PK-RCD
Survivors:
Yes
Schedule:
Jayapura - Abmisibil
MSN:
149
YOM:
2009
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
After landing on a wet runway at Abmisibil Airport, the single engine aircraft went out of control, veered off runway and came to rest in a ravine, bursting into flames. The pilot was killed and a passenger died few hours later. All three other occupants were seriously injured and the aircraft was destroyed by impact forces and a post crash fire.