Airport (less than 10 km from airport)

The collision was the result of a poor coordination by ATC staff at Jakarta Airport. The following factors were reported:
- Handling of two movements in the same area with different controllers on separate frequencies without proper coordination resulted in the lack of awareness to the controllers, pilots and towing car driver,
- The communication misunderstanding of the instruction to follow ID 7703 most likely contributed the towed aircraft enter the runway,
- The lighting environments in the tower cab and turning pad area of runway 24 might have diminished the capability to the controllers and pilots to recognize the towed aircraft that was installed with insufficient lightings.

Findings as to causes and contributing factors:
1. The pilot’s inability to effectively manage the aircraft’s energy condition led to an unstable approach.
2. The pilot “got behind” the aircraft by allowing events to control his actions, and cognitive biases led him to continue the unstable approach.
3. A loss of control occurred when the pilot rapidly added full power at low airspeed while at low altitude, which caused a power-induced upset and resulted in the aircraft rolling sharply to the right and descending rapidly.
4. It is likely that the pilot was not prepared for the resulting power-induced upset and, although he managed to level the wings, the aircraft was too low to recover before striking the ground.
5. The pilot’s high workload and reduced time available resulted in a task-saturated condition, which decreased his situational awareness and impaired his decision making.
6. It is unlikely that the pilot’s flight skills and procedures were sufficiently practised to ensure his proficiency as the pilot-in-command for single-pilot operation on the MU2B for the conditions experienced during the occurrence flight.

Findings as to risk:
1. If the weight of an aircraft exceeds the certified maximum take-off weight, there is a risk of aircraft performance being degraded, which may jeopardize the safety of the flight.
2. If pilots engage in non-essential communication during critical phases of flight, there is an increased risk that they will be distracted, which reduces the time available to complete cockpit activities and increases their workload.
3. If flight, cockpit, or image/video data recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.
4. If pilots do not recognize that changing circumstances require a new plan, then plan continuation bias may lead them to continue with their original plan even though it may not be safe to do so.
5. If pilots do not apply stable-approach criteria, there is a risk that they will continue an unstable approach to a landing, which can lead to an approach-and-landing accident.
6. If pilots are not prepared to conduct a go-around on every approach, they risk not responding appropriately to situations that require one.
7. If a flight plan does not contain search-and-rescue supplementary information, and if that information is not transmitted or readily available, there is a risk that first responders will not have the information they need to respond adequately.

Other findings:
1. Transport Canada does not monitor or track the number of days foreign-registered aircraft are in Canada during a given 12-month period.
2. Turbulence and icing were not considered factors in this occurrence.
3. Transport Canada considers that the discretionary installation of an angle-of-attack system on normal-category, type-certificated, Canadian-registered aircraft is a major modification that requires a supplemental type certificate approval.
4. Although the aircraft was not in compliance with Airworthiness Directive 2006-17-05 at the time of the occurrence, there was no indication that it was operating outside of the directive’s specifications.
5. Although not required by regulation, the installation and use of a lightweight flight recording system during the occurrence flight, as well as the successful retrieval of its data during the investigation, permitted a greater understanding of this accident.

The right engine caught fire during takeoff for unknown reasons.

The fatal air accident to the Boeing 737-8KN A6-FDN aircraft occurred during the second go around, due to an incorrect aircraft configuration and crew piloting, the subsequent loss of PIC’s situational awareness in nighttime in IMC. This resulted in a loss of control of the aircraft and its impact with the ground. The accident is classified as Loss of Control In-Flight (LOC-I) occurrence.
Most probably, the contributing factors to the accident were:
- The presence of turbulence and gusty wind with the parameters, classified as a moderate to-strong "windshear" that resulted in the need to perform two go-arounds;
- The lack of psychological readiness (not go-around minded) of the PIC to perform the second go-around as he had the dominant mindset on the landing performance exactly at the destination aerodrome, having formed out of the "emotional distress" after the first unsuccessful approach (despite the RWY had been in sight and the aircraft stabilized on the glide path, the PIC had been forced to initiate go-around due to the windshear warning activation), concern on the potential exceedance of the duty time to perform the return flight and the recommendation of the airline on the priority of landing at the destination aerodrome;
- The loss of the PIC’s leadership in the crew after the initiation of go-around and his "confusion" that led to the impossibility of the on-time transition of the flight mental mode from "approach with landing" into "go-around";
- The absence of the instructions of the maneuver type specification at the go-around callout in the aircraft manufacturer documentation and the airline OM;
- The crew’s uncoordinated actions during the second go-around: on the low weight aircraft the crew was performing the standard go-around procedure (with the retraction of landing gear and flaps), but with the maximum available thrust, consistent with the Windshear Escape Maneuver procedure that led to the generation of the substantial excessive nose-up moment and significant (up to 50 lb/23 kg) "pushing" forces on the control column to counteract it;
- The failure of the PIC within a long time to create the pitch, required to perform go around and maintain the required climb profile while piloting aircraft unbalanced in forces;
- The PIC’s insufficient knowledge and skills on the stabilizer manual trim operation, which led to the long-time (for 12 sec) continuous stabilizer nose-down trim with the subsequent substantial imbalance of the aircraft and its upset encounter with the generation of the negative G, which the crew had not been prepared to. The potential impact of the somatogravic "pitch-up illusion" on the PIC might have contributed to the long keeping the stabilizer trim switches pressed;
- The psychological incapacitation of the PIC that resulted in his total spatial disorientation, did not allow him to respond to the correct prompts of the F/O;
- The absence of the criteria of the psychological incapacitation in the airline OM, which prevented the F/O from the in-time recognition of the situation and undertaking more decisive actions;
- The possible operational tiredness of the crew: by the time of the accident the crew had been proceeding the flight for 6 hours, of which 2 hours under intense workload that implied the need to make non-standard decisions; in this context the fatal accident occurred at the worst possible time in terms of the circadian rhythms, when the human performance is severely degraded and is at its lower level along with the increase of the risk of errors.
The lack of the objective information on the HUD operation (there were no flight tests of the unit carried out into the entire range of the operational G, including the negative ones; the impossibility to reproduce the real HUD readings in the progress of the accident flight, that is the image the pilot was watching with the consideration of his posture in the seat trough the stream video or at the FFS) did not allow making conclusion on its possible impact on the flight outcome. At the same time the investigation team is of the opinion that the specific features of the HUD indication and display in conditions existed during final phase of the accident flight (severe turbulence, the aircraft upset encounter with the resulting negative G, the significant difference between the actual and the target flight path) that generally do not occur under conditions of the standard simulator sessions, could have affected the situational awareness of the PIC, having been in the highly stressed state.

Contributing factors:
- Application of commands - undetermined
It is possible that the pilot has not acted properly in the controls after touchdown to avoid a runway excursion.
- Flight indiscipline - contributed
Having landed on a non-approved runway, without justifiable reason, the crew member did not comply with the provisions of civil aviation regulations.
- Influence of the environment - undetermined
The wet and puddled runway may have affected directional control and aircraft braking performances during the landing roll.
- Pilot judgment - contributed
The crew member had not correctly assessed the risks involved in the operation in an unapproved runway, without justifiable reason. In addition, the pilot had no considering that the wet and puddle conditions of the runway could affect the directional control and braking performances of the aircraft.
- Decision-making process - contributed
The decision to land at an unapproved aerodrome, as well as having used a wet runway and the presence of puddles denoted an inadequate assessment of the risks present in the context. Failures related to decisions assumed by the pilot contributed to the occurrence insofar as they resulted in the entry of the aircraft into a critical condition, affecting its control.

The intentional low altitude maneuvering during takeoff in response to a near-miss with an airplane departing from a converging runway, which resulted in an exceedance of the airplane's critical angle of attack and a subsequent aerodynamic stall.

The investigation therefore, concludes that:
- Some internal malfunction of the Propeller Governor Part No. 8210-410 Serial No. 2490719 was the cause of experienced uncommanded auto feather. However, exact cause of the occurrence could not be determined.
- Continuing take off below V1 speed (104kts) after encountering engine malfunction and after takeoff raising flaps below recommended height (400ft AGL) lead to decrease in lift and unsustainability of flight.

The pilots’ failure to use available sources of wind information before landing and recognize cues indicating the presence of the tailwind and conduct a go-around, which resulted in their landing with a significant tailwind and a subsequent runway overrun.