Indonesia

On the morning of 9 April 2009, a British Aerospace BAe 146-300 aircraft, registered PK-BRD, was being operated by PT. Aviastar Mandiri Airlines as a scheduled passenger and cargo flight from Sentani Airport to Wamena Airport, Papua. The crew consisted of two pilots, two flight attendants, an engineer, and a load master. The aircraft performed a go-around from the initial landing approach on runway 15 at Wamena. The flight crew positioned the aircraft on a right downwind leg for another landing approach. As the aircraft was turned towards the final approach for the second landing approach at Wamena it impacted terrain and was destroyed. All of the occupants were fatally injured. The Enhanced Ground Proximity Warning System (EGPWS) manufacturer performed simulations using data from the flight recorders, and two separate terrain data sources. The manufacturer informed the investigation that “the GPWS/EGPWS alerts recorded in the CVR were issued as designed”. However the enhanced Look-Ahead function appeared to have been inhibited following the go around. There was no evidence from the CVR that the crew had deliberately inhibited the terrain function of the EGPWS. The investigation determined that the EGPWS issued appropriate warnings to the flight crew, in the GPWS mode. The pilot in command did not take appropriate remedial action in response to repeated EGPWS warnings. The investigation concluded that flight crew’s lack of awareness of the aircraft’s proximity with terrain, together with non conformance to the operator’s published operating procedures, resulted in the aircraft’s impact with terrain. As a consequence of this accident, the operator took safety action to address deficiencies in its documentation for missed approach procedures at Wamena. As a result of this accident, the National Transportation Safety Committee (NTSC) also issued safety recommendations to the operator and to the Directorate General Civil Aviation (DGCA) to ensure that relevant documented safety procedures are implemented. During the investigation, safety issues were identified concerning modification of aircraft and DGCA approval of those modifications. While those safety issues did not contribute to the accident, they nevertheless are safety deficiencies. Accordingly, the NTSC report includes recommendations to address those identified safety issues.

The aircraft was performing a paratroopers/skydiving mission in the region of Bandung, taking part to a military program with members of the Special Forces on board. While approaching runway 29 with 20 knots crosswind, the aircraft went out of control and crashed onto a hangar, bursting into flames. All 24 occupants were killed, among them 17 paratroopers, one instructor and 6 crew members.

Lion Mentari Airline (Lion Air) as flight number LNI-793, departed from Sultan Hasanuddin Airport (WAAA), Makassar, Ujung Pandang, Sulawesi at 0636 UTC for Soekarno-Hatta International Airport (WIII), Jakarta. The estimated flight hour from Makassar to Jakarta was 2 hours. The crew consisted of two pilots and four flight attendants. There were 166 adult passengers. The copilot was the pilot flying for the sector, and the pilot in command (PIC) was the support/monitoring pilot. During the approach to runway 25L at Jakarta, the weather at the airport was reported as wind direction 200 degrees, wind speed 20 knots, visibility 1,000 meters, and rain. The PIC reported that he decided to take over control from the copilot. The PIC later reported that he had the runway in sight passing through 1,000 feet on descent, and he disengaged the autopilot at 400 feet. At about 50 feet the aircraft drifted to the right and the PIC initiated corrective action to regain the centreline. The aircraft touched down to the left of the runway 25L centerline and then commenced to drift to the right. The PIC reported that he immediately commenced corrective action by using thrust reverser, but the aircraft increasingly crabbed along the runway with the tail to the right of runway heading. The investigation subsequently found that the right thrust reverser was deployed, but left thrust reverser was not deployed. The aircraft stopped at 0835 on the right side of the runway 25L, 1,095 meters from the departure end of the runway on a heading of 152 degrees; 90 degrees to the runway 25L track. The main landing gear wheels collapsed, and still attached to the aircraft, were on the shoulder of the runway and the nose wheel was on the runway. The passengers and crew disembarked via the front right escape slide and right emergency exit windows. None of the occupants were injured

The aircraft touched down heavily approximately 5 meters before the touch-down area of runway 10 at Torea Airport, Fak-Fak at 01:33. The investigation found that the left main landing gear touched the ground first (5 meters before the end of the runway), and the right main landing gear touched the ground (4.5 meters from the end of the runway). It stopped on the runway, approximately 700 meters from the touch-down area. The left main landing gear fractured in two places; at the front pivot point, and the aft pivot point. The left fuselage contacted the runway surface 200 meters from the touch-down point and the aircraft slid with the left fuselage on the ground for a further 500 meters, before it stopped at the right edge of the runway. The wing tip and left propeller blade tips also touched the runway and were damaged. The passengers and crew disembarked normally; there were no injuries. Following an inspection of the landing gear and temporary replacement of the damaged left main landing gear, the aircraft was moved to the apron on 8 November 2008 at 04:00. The runway was closed for 5 days.

On 27 August 2008, a Boeing 737-200 aircraft, registered PK-CJG, was being operated on a scheduled passenger service from Soekarno-Hatta International Airport, Jakarta to Sultan Thaha Airport, Jambi with flight number SJY062. On board the flight were two pilots, four flight attendants, and 124 passengers. The Pilot in Command (PIC) acted as Pilot Flying (PF) while the Second in Command (SIC) acted as Pilot Monitoring (PM). The flight time from Jakarta to Jambi was estimated to be about one hour and the aircraft was dispatched with approximately 4 hours of fuel endurance. The number one electrical engine driven generator was unserviceable, as such the Auxiliary Power Unit (APU) generator was used during the flight to maintain two generators operation. Prior to descent into Jambi, the PIC conducted the crew briefing and stated a plan for Makinga straight-in approach to runway 31 with flap 40°, reviewed the go-around procedures and stated that Palembang was the alternate airport.There was no abnormality recorded nor reported until the PIC commenced the approach to Jambi. At 09:18 UTC, the SIC contacted Thaha Tower controller and reported that the aircraft was descending and passing FL160 and had been cleared by Palembang Approach control to descend to 12,000 feet. The Thaha Tower controller issued a clearance to descend to 2500 feet and advised that runway 31 was in use. The SIC asked about the weather conditions and was informed that the wind was calm, rain over the field and low cloud on final approach to runway 31. The PIC flew the aircraft direct to intercept the final approach to runway 31. While descending through 2500 feet, and about 8 miles from the VOR, the flap one degree and flap 5° were selected. Subsequently the landing gear was extended and flap 15° was selected. 13 seconds after flap 15 selection, the pilots noticed that the hydraulic system A low pressure warning light illuminated, and also the hydraulic system A quantity indicator showed zero. The PIC commanded the SIC to check the threshold speed for the existing configuration of landing, weight and with flap 15°. The SIC called out that the threshold speed was 134 kts and the PIC decided to continue with the landing. The PIC continued the approach and advised the SIC that he aimed to fly the aircraft slightly below the normal glide path in order to get more distance available for the landing roll. The aircraft touched down at 0930 UTC and during the landing roll, the PIC had difficulty selecting the thrust reversers. The PIC the applied manual braking. During the subsequent interview, the crew reported that initially they felt a deceleration then afterward a gradual loss of deceleration. The PIC reapplied the brakes and exclaimed to the SIC about the braking condition, then the SIC also applied the brakes to maximum in responding to the situation. The aircraft drifted to the right of the runway centre line about 200 meters prior to departing off the end of the runway, and stopped about 120 meters from the end of the runway 31 in a field about 6 meters below the runway level. Three farmers who were working in that area were hit by the aircraft. One was fatally injured and the other two were seriously injured. The pilots reported that, after the aircraft came to a stop, they executed the Emergency on Ground Procedure. The PIC could not put both start levers to the cut-off position, and also could not pull the engines and APU fire warning levers. The PIC also noticed that the speed brake lever did not extend. The radio communications and the interphone were also not working. The flight attendants noticed a significant impact before the aircraft stopped. They waited for any emergency command from the PIC before ordering the evacuation. However, the passengers started to evacuate the aircraft through the right over-wing exit window before commanded by the flight attendants. The flight attendants subsequently executed the evacuation procedure without command from the PIC. The left aft cabin door was blocked by the left main landing gear that had detached from the aircraft and the flight attendants were unable to open the door. The right main landing gear and both engines were also detached from the aircraft. The Airport Rescue and Fire Fighting (ARFF) come to the crash site and activated the extinguishing agent while the passengers were evacuating the aircraft. The PIC, SIC and FA1 were the last persons to evacuate the aircraft. The APU was still running after all passengers and crew evacuation completed, afterward one company engineer went to the cockpit and switched off the APU. All crew and passengers safely evacuated the aircraft. No significant property damage was reported.

On the Saturday 9 August 2008, a Pilatus Porter PC-6 B2-H4 aircraft, registered PK-RCZ, operated by AMA (Association of Mission Aviation) on a charter flight from Wamena, Papua, to Taive II, Papua departed at 1000 UTC. The aircraft was to pick up a medical patient from Taive II. After landing and unloading cargo at Taive II, the aircraft departed from Taive II for NduNdu, Papua, at 1106 with an estimated time of arrival of 1113. The flight was to be operated in accordance with the visual flight rules (VFR), remaining clear of cloud and navigating visually. When the aircraft had not arrived by 1213, the Wamena authorities decided to search for the aircraft. Three operators assisted the search; Association of Mission Aviation (AMA), Mission Aviation Fellowship (MAF), and Yajasi. They all reported hearing PK-RCZ’s emergency locator transmitter (ELT) signal, but were unable to reach the crash site due to the weather conditions. At 2020 (0520 local time on Sunday 10 August), the aircraft wreckage was found at an elevation of 6,400 feet at the coordinates 03° 26’ 08” S, 138° 21’ 58” E, in the area of NduNdu Pass, on the aircraft’s planned track. The crash site was about 200 feet to the left (east) of the southerly track across the Pass, on the slope of an 11,000 foot mountain. The coordinates and elevation of the lowest point in the NduNdu Pass were
03° 26’ 26” S, 138° 21’ 22” E and 5,700 feet. The pilot, the sole occupant, was fatally injured.

While flying in poor weather conditions, the twin engine aircraft struck the slope of Mt Salak located about 55 km south of Jakarta. All 18 occupants were killed.

On 10 March 2008, a Boeing Company 737-400 aircraft, registered PK-KKT, was being operated by Adam SkyConnection Airlines (Adam Air) as scheduled passenger flight with flight number DHI292. The flight departed Soekarno – Hatta Airport, Jakarta at 01:30 UTC with destination Hang Nadim Airport, Batam and the estimated time of arrival was 03:05 UTC. On board in this flight were 177 people consisted of two pilots, four flight attendants, and 171 passengers. The Pilot in Command (PIC) acted as pilot flying (PF) and the Second in Command (SIC) acted as pilot monitoring (PM). The flight until commencing descend was uneventful. Prior to descend, the flight crew received weather information indicating that the weather was fine. At 0302 UTC the flight crew contacted Hang Nadim tower controller and informed them that the visibility was 1,000 meters and they were sequence number three for landing runway 04. The flight crew of the aircraft on sequence number two informed to Hang Nadim tower controller that the runway was insight at an altitude of about 500 feet. The Hang Nadim tower controller forwarded the information to the flight crew of DHI 292, and followed this by issuing landing clearance, and additional information that the wind velocity was 360 degrees at 8 knots and heavy rain. The DHI 292 flight crew acknowledged the information. The landing configuration used flaps 40 degrees with landing speed of 136 knots. The flight crew were able to see the runway prior to the Decision Altitude (DA), however the PIC was convinced that continuing the approach to landing was unsafe and elected to go around. The Hang Nadim tower controller instructed the flight crew to climb to 3000 feet, maintain runway heading, and contact Singapore Approach. At 0319 UTC, DHI 292 was established on the localizer runway 04, and the Hang Nadim tower controller informed them that the visibility improved to 2,000 meters. While on final approach, the flight crew DHI 292 reported that the runway was in sight and the Hang Nadim tower controller issued a landing clearance. On touchdown, the crew felt that the main wheels barely touch the runway first. During the landing roll, as the ground speed decreased below 30 knots, the aircraft yawed to the right. The flight crew attempted to steer the aircraft back to centerline by applying full left rudder. The aircraft continued yaw to the right and came to stop on the runway shoulder at approximately 40 meters from the right side of the runway edge, and 2,760 meters from the runway 04 threshold. No one was injured in this accident. The aircraft was seriously damaged with the right main landing gear assembly detached and collapsing backward and damaging the right wing and flaps. The right engine was displaced from its attachment point.

On 6 March 2008, a Transall C-160 aircraft, registered PK-VTQ, operated by PT. Manunggal Air, was on an unscheduled freight flight from Sentani Airport, Jayapura, to Wamena Airport, Papua. There were seven people on board; two pilots, two engineers, and three flight officers. The pilots reported that the approach and landing were normal. However, they told the investigators that both Beta lights did not illuminate during the landing roll, so they could not use reverse thrust. They reported that they used maximum brakes to slow the aircraft, and rolled through to the end of runway 15. During the 180-degree right turn at the end of the runway, they felt the left brakes grabbing, and had to use increased thrust on the left engine to assist the turn. After completing the turn, the pilots backtracked the aircraft towards taxiway “E”, about 450 meters from the departure end of runway 15. The air traffic controller informed the Transall crew that heavy smoke was coming from the left main wheels, and that they should proceed to taxiway “E” and stop on the taxiway. Before the aircraft entered taxiway “E”, the controller activated the crash alarm. The pilots stopped the aircraft on taxiway “E”, and the occupants disembarked and attempted to extinguish the wheel-bay fire with a hand held extinguisher. The airport rescue fire fighting service (RFFS) arrived at the aircraft 10 minutes after the aircraft came to a stop on taxiway “E”. It took a further 5 minutes to commence applying foam. The attempts to extinguish the fire were unsuccessful, and the fire destroyed the aircraft and its cargo of fuel in drums. Investigators found molten metal on the runway along the left wheel track for about 16 meters, about 100 meters from taxiway “E”, between taxiway “E” and the departure end of runway 15. There was also molten metal along the left wheel track on taxiway “E”.

On 26 January 2008, a Casa 212-200 aircraft, registered PK-VSE, was being operated by PT. Dirgantara Air Service as a cargo charter flight from Tarakan Airport to Long Apung Airport. There were 3 persons on board; two pilots and one aircraft maintenance engineer/load master. The aircraft was certified as being airworthy prior to departure. The aircraft departed from Tarakan at 0011 UTC (08:11 local time), and the estimated time arrival at Long Apung was 0136. At 0411 the pilot of another aircraft received a distress signal and informed air traffic services at Tarakan. Searchers subsequently found the aircraft wreckage at an elevation of 2,766 feet, about 3.4 NM from Long Apung Airport. The coordinates of the accident site were 01° 39.483′ S and 115° 00.265′ E near Lidung Payau Village, Malinau, East Kalimantan. The accident site was on the left downwind leg of the runway 35 circuit.