Merpati audit recommends ban of MA-60 aircraft from three airports

May 25, 2011

A special audit  of Merpati Nusantara Airlines following a recent fatal accident resulted in the ban of MA-60 aircraft from three Indonesian airports.

On May 7, 2011 a Xian MA-60 turboprop plane, opertated by Merpati Nusantara Airlines, crashed into the sea while on approach to Kaimana, Indonesia. All 25 on board were killed. Four days later, the Indonesian Ministry of Transportation announced that they would conduct a special audit of the airline.

Following the audit, it was concluded that the MA-60 meets airworthiness standards and is safe to be operated. Also, the  aircraft were maintained in accordance with the maintenance programme.
However, the Ministry of Transportation recommended to no longer operate the MA-60 to Ende (ENE/WATE), Waingapu (WGP/WADW) and Ruteng (RTG/WATG). Approaches into these airports are considered difficult.

The audit further revealed a certain level of indiscipline in cases were pilots for instance carried out approaches and landings in below-minima weather conditions. The Ministry  recommended additional training for 77 MA-60 flight crew members.

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Indonesia: Investigators issue interim safety recommendations after Merpati crash

May 21, 2011

The Indonesian National Transportation Safety Committee (NTSC) issued three interim recommendations in the light of the May 7, 2011 fatal accident involving a Merpati passenger plane.

A Xian MA60 airplane crashed during a visual approach to Kaimana  Airport (KNG), Indonesia in weather conditions below VFR minima. All 25 on board were killed in the accident.

The investigation is still on-going, but the NTSC published three immediate safety recommendations based on their findings so far:

A. to Merpati Nusantara Airlines:
Ensure that visual flight is being conducted in accordance with VFR conditions, and conduct training on the MA60 Crew Simulator with an emphasis on CRM in the face of the bad weather.

B. to the Director General of Civil Aviation:
Monitor the implementation of the recommendations in point A , to be carried out  by Merpati Nusantara Airlines.

C. to Directorate General of Civil Aviation and Directorate of Airports:
Review the provisions of the use of facilities / equipment, especially the airport runway lights to enhance the safety of flight operations, especially in low visibility conditions.

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Indonesia conducts special audit of Merpati following accident

May 11, 2011

The Indonesian Ministry of Transportation decided to conduct a special audit of Merpati Nusantara Airlines following a recent fatal accident.

On May 7, 2011 a Xian MA-60 turboprop plane crashed into the sea while on approach to Kaimana, Indonesia. All 27 on board were killed.

The Indonesian Ministry of Transportation announced that they would conduct a special audit  involving three things:

  • the condition of aircraft maintenance;
  • management audit of safety standards according to Air Operation Certificate (AOC); and
  • an audit of Defect Reports.
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Report: misaligned VOR track factor in Indonesian taxiway landing

May 9, 2011

Touch down marks on the parallel taxiway at Palembang

A Garuda Boeing 737-400 landed on a taxiway at Palembang in October 2008. NTSC investigators from Indonesia  concluded that the captain under training and instructor captain were focussed on instrument scanning when they were following the misaligned track, leading them to the parallel taxiway.

On 2 October 2008, a Boeing 737-4K5 aircraft, registered PK-GWT was being operated on an Instrument Flight Rules (IFR) scheduled passenger service from Jakarta Soekarno-Hatta Airport to Sultan Mahmud Badarudin II Airport, Palembang. There were two pilots, 4 flight attendants, and 49 passengers on board.

The co-pilot who occupied the left seat was a candidate captain under training and the Pilot in Command (PIC) occupying the right seat was a training captain (instructor). The co-pilot acted as the Pilot Flying (PF) during the flight, and the PIC acted as Pilot Monitoring (PM).

Prior to the departure from Jakarta, the pilots received a departure briefing consisting of weather, flight plan, and notams. The notams contained significant information for Palembang Airport that the parallel taxiway from intersection Alpha to taxiway Bravo was closed due to work in progress. The runway 29 Instrument Landing System (ILS) was not in service due to replacement of its localizer antenna.

The aircraft departed from Jakarta at 23:51 UTC. When it entered Palembang’s Controlled Airspace at 00:13, the crew was instructed by the Palembang Approach controller to track direct to the initial approaches point BANJAR and descends to 2,500 feet for the VOR/DME approach to runway 29. During the approach, the PIC reported that they were conducting the VOR/DME instrument approach procedure for runway 29.

At 00:28 the PIC reported that the aircraft was on final approach for runway 29.
At 00:30 the PIC reported that he had the runway insight after assuring the co-pilot that they both had seen the runway. The Aerodrome Controller gave the crew the clearance to land.
The co-pilot was concentrating on instrument scanning during the approach by following the VOR radial. He wanted to improve his ability to fly manual (without auto pilot) during an instrument approach. The PIC then rechecked if there was any item missed prior to land.

The ATC saw that the aircraft was not on the approach path properly and came close to the parallel taxiway.
At 00:32 the aircraft landed on the parallel taxiway, touching down 500 meters from the eastern end. Both pilot then realized that they were on the taxiway and also saw the barrier on the taxiway indicated that some part of the taxiway was closed. The PIC immediately applied manual brake and the aircraft stopped at the intersection of taxiway Charlie. The landing roll distance was about 700 meters.

The aircraft was then instructed to taxi via runway and taxiway Echo to the apron. No one was injured in this serious incident.
The investigators concluded that the Pilot monitoring was not sufficiently looking outside to cross-check the flight path to the runway. Also, there was a misalignment of the VOR approach path. There had been 10 pilot reports of misalignment of the final track for the runway 29 VOR/DME approach since May 2008. The VOR/DME runway 29 approach track to the runway 29 VOR was 291 degrees while the runway direction was 293 degrees. The 2 degrees differences between VOR approach path and runway direction has an off track to the right of approximately 200 meters off the runway centreline at the threshold runway 29.
The parallel taxiway used to be a temporary runway in 2003 when a new terminal was built.  The runway markings on the parallel taxi way reappeared after some time. These markings were visible to the aircraft on final approach.


Indonesia grounds airline SMAC over safety concerns

February 19, 2011

The Indonesian Directorate General of Civil Aviation suspended the AOC of Sabang Merauke Raya Air Charter (SMAC) following the fatal accident of a CASA C-212 Aviocar operated by SMAC on February 12, 2011.

The CASA Aviocar operated on a test flight from Batam Airport (BTH), Indonesia to Tanjung Pinang (TNJ) after the replacement of an engine. Preliminary investigation results indicated that:

  1. The pilot in command was not qualified for this kind of flight;
  2. No permission was obtain to carry out this test flight; and
  3. A spare engine was carried on board during the test flight.

These findings led the DGCA to suspend the airline’s AOC as a “preventive action”, according to the official statement. The DGCA will conduct a special safety audit of the airline and the airline will remain grounded until further notice.

The airline was added to EU list of banned air carriers on July 4, 2007.

 


Airport safety recommendations after Indonesian B737 runway excursion accident

May 18, 2010

Wreckage of the Boeing 737 after it came to rest in an area of shallow muddy water surrounded by mangrove vegetation. Photo: NTSC

The Indonesian National Transportation Safety Committee (NTSC) issued their preliminary report regarding the runway excursion accident involving a Boeing 737. Seven safety recommendations were issued addressing various aspects of airport safety.

On April 13, 2010 a Boeing 737-322 passenger plane, registered PK-MDE, sustained substantial damage in a runway excursion accident at Manokwari-Rendani Airport (MKW/WASR), Indonesia. All 103 passengers and seven crew members survived but ten sustained serious injuries.
Merpati Flight MNA836 operated on a scheduled flight from Sorong-Dominique Edward Osok Airport (SOQ/WAXX). Departure was delayed for almost three hours due to heavy rain over Manokwari.
On approach Rendani Radio informed the crew that the weather was continuous slight rain, visibility 3 kilometers, cloud overcast with cumulus-stratocumulus at 1,400 feet, temperature 24 degrees Celsius, QNH 1012 hectopascals.
At 10:54 the crew reported that they were on final for runway 35. The controller informed them that the wind was calm, runway condition was wet and clear.
The crew read back the wind condition and that the runway was clear, but did not mention the wet runway condition.
The aircraft was observed to make a normal touchdown on the runway, about 120 meters from the approach end of runway 35. Witnesses on the ground and on board reported that engine reverser sound was not heard during landing roll.
During the landing roll, the aircraft veered to the left about 140 meters from the end of runway 35, then overran the departure end of runway 35. It came to a stop 205 meters beyond the end of the runway in a narrow river; the Rendani River.
The airport rescue and fire fighting unit was immediately deployed to assist the post-crash evacuation. Due to the steep terrain 155 meters from the end of runway 35, the rescuers had to turn back and use the airport’s main road to reach the aircraft. The accident site was in an area of shallow muddy water surrounded by mangrove vegetation.

Seven safety recommendations were issued:

1) The Directorate General Civil of Aviation (DGCA) should ensure that Merpati Nusantara Airlines Operational Specifications and other technical and operational safety requirements are met.

2) DGCA should urgently review the Rendani Airport, Manokwari runway complex, to ensure that the runway end safety areas (RESA) meet the dimension Standards prescribed in ICAO Annex 14.

3) DGCA should urgently review all airports involving Part 121 and 135 operations, to ensure that the runway end safety areas (RESA) meet the dimension Standards prescribed in ICAO Annex 14.

4) DGCA should urgently ensure that Indonesian airports equipped with visual approach slope guidance systems, maintain the equipment to a serviceable standard.

5) DGCA should review the procedures and equipment used by airport Rescue and Fire Fighting Services to ensure that they a) meet the minimum requirements, including timeliness, specified in ICAO Annex 14; and b) meet the requirements to cover the area up to 5 NM (8 Km) from the airport perimeter.

6) Merpati should review its technical and operational safety requirements to ensure they are implemented.

7) Merpati should review equipment used by airport Rescue and Fire Fighting Services at airports in its network, to ensure that they meet the minimum requirements for Boeing 737 aircraft.


VFR flight into cloud caused Indonesian DHC-6 Twin Otter CFIT accident

April 22, 2010

Indonesian accident investigators of the National Transportation Safety Committee (NTSC) have concluded that a fatal accident involving a DHC-6 Twin Otter in August 2009 has been caused by VFR flight into cloud. The airplane flew into the side of a mountain, killing all 15 on board.

Wreckage of Twin Otter PK-NVC on the mountainside

The Merpati Nusantara Airlines DHC-6 Twin Otter passenger plane flew into the side of a mountain during a domestic flight from Jayapura (DJJ) to Oksibil Airport (OKL). Merpati Flight MZ9760D took off at 10:15 with an estimated time of arrival at Oksibil of 11:05. The pilots were operating under visual flight rules (VFR) procedures. This required them to remain clear of cloud. Ten minutes before impact the pilot in command mentioned climbing to 10,000 feet, and stated “if we cannot go visual I will turn left”. The cockpit conversations did not exhibit any signs of stress or concern until two minutes before the impact, when the copilot mentioned haze and asked the captain if he could see. Fifty seconds before impact, the copilot expressed further concern and asked about the captain’s intentions, and the captain said “climb, to the left”. Forty-two seconds before impact the copilot asked if it was safe on the left.
The copilot became increasingly uncertain about the safety of the flight, specifically mentioning visibility and speed. From the recorded sounds, it is apparent that 13 seconds before impact, engine power was increased symmetrically to a high power setting. The Twin Otter struck the side of a mountain at an elevation of 9300 feet.
The wreckage was located August 4 with some difficulty because the ELT was unserviceable.

As a result of this investigation, the National Transportation Safety Committee
issued recommendations to address safety issues, specifically with respect to: maintenance procedures and maintenance inspection programs, to ensure that Emergency Locator Transmitters are serviceable; and the provision of weather information services for all civilian aircraft operations throughout Papua.


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