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National Transportation Safety Committee Ministry of Transportation Republic of Indonesia 2012

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National Transportation Safety Committee Ministry of Transportation Republic of Indonesia 2012 FINAL KNKT.11.05.10.04 NNAATTIIOONNAALL TTRRAANNSSPPOORRTTAATTIIOONN SSAAFFEETTYY CCOOMMMMIITTTTEEEE Aircraft Accident Investigation Report PT. Merpati Nusantara Airlines Xi ’An Aircraft Industry MA60; PK-MZK Utarom Airport, Kaimana - Papua Barat Republic of Indonesia 07 May 2011 NATIONAL TRANSPORTATION SAFETY COMMITTEE MINISTRY OF TRANSPORTATION REPUBLIC OF INDONESIA 2012 This Final Report was produced by the National Transportation Safety Committee (NTSC), Transportation Building 3rd Floor, Jalan Medan Merdeka Timur No. 5, Jakarta 10110, INDONESIA. The report is based upon the investigation carried out by the NTSC in accordance with Annex 13 to the Convention on International Civil Aviation Organization, Indonesian Aviation Act (UU No.1/2009), and Government Regulation (PP No. 3/2001). Readers are advised that the NTSC investigates for the sole purpose of enhancing aviation safety. Consequently, NTSC reports are confined to matters of safety significance and may be misleading if used for any other purpose. As NTSC believes that safety information is of greatest value if it is passed on for the use of others, readers are encouraged to copy or reprint for further distribution, acknowledging NTSC as the source. When the NTSC makes recommendations as a result of its investigations or research, safety is its primary consideration. However, the NTSC fully recognizes that the implementation of recommendations arising from its investigations will in some cases incur a cost to the industry. Readers should note that the information in NTSC reports and recommendations is provided to promote aviation safety. In no case is it intended to imply blame or liability TABLE OF CONTENTS TABLE OF CONTENTS.................................................................................................................... i TABLE OF FIGURES .......................................................................................................................iii GLOSSARY OF ABBREVIATIONS ...............................................................................................iv INTRODUCTION.............................................................................................................................. 1 1 FACTUAL INFORMATION..................................................................................................... 3 1.1 HISTORY OF THE FLIGHT ............................................................................................ 3 1.2 INJURIES TO PERSONS.................................................................................................. 7 1.3 DAMAGE TO AIRCRAFT ............................................................................................... 7 1.4 OTHER DAMAGE............................................................................................................ 7 1.5 PERSONNEL INFORMATION........................................................................................ 7 1.5.1 Pilot in command ................................................................................................... 7 1.5.2 Second in Command.............................................................................................. 8 1.6 AIRCRAFT INFORMATION ........................................................................................... 9 1.6.1 General................................................................................................................... 9 1.6.2 Engines................................................................................................................... 9 1.6.3 Weight and Balance ............................................................................................... 9 1.7 METEOROLOGICAL INFORMATION ........................................................................ 10 1.8 AIDS TO NAVIGATION................................................................................................ 10 1.9 COMMUNICATIONS..................................................................................................... 10 1.10 AERODROME INFORMATION.................................................................................... 11 1.11 FLIGHT RECORDERS ................................................................................................... 11 1.11.1 Flight Data Recorder............................................................................................ 11 1.11.2 Cockpit Voice Recorder (CVR)........................................................................... 14 1.12 WRECKAGE AND IMPACT INFORMATION............................................................. 17 1.13 MEDICAL AND PATHOLOGICAL INFORMATION ................................................. 18 1.14 FIRE ................................................................................................................................. 18 1.15 SURVIVAL ASPECTS.................................................................................................... 18 1.16 TESTS AND RESEARCH............................................................................................... 18 1.17 ORGANISATIONAL AND MANAGEMENT INFORMATION .................................. 19 1.18 ADDITIONAL INFORMATION .................................................................................... 20 1.18.1 Aircraft Manuals .................................................................................................. 20 i 1.18.2 Pilot Training ....................................................................................................... 20 1.18.3 Go around procedure............................................................................................ 21 1.18.4 Flight Simulation ................................................................................................. 22 1.18.5 Emergency Locator Transmitter .......................................................................... 22 1.19 USEFUL OR EFFECTIVE INVESTIGATION TECHNIQUES .................................... 22 2 ANALYSIS .............................................................................................................................. 23 2.1 GENERAL INFORMATION .......................................................................................... 23 2.2 SITUATIONS AT THE FINAL SEGMENT OF THE FLIGHT..................................... 23 2.3 COCKPIT DISCIPLINE.................................................................................................. 25 2.4 CREW TRAINING.......................................................................................................... 26 2.5 CREW PAIRING ............................................................................................................. 26 2.6 CREW RESOURCE MANAGEMENT........................................................................... 27 2.7 OPERATOR MANAGEMENT....................................................................................... 27 2.8 EGPWS ............................................................................................................................ 27 2.9 SUMMARY OF ANALYSIS .......................................................................................... 28 3 CONCLUSION ........................................................................................................................ 29 3.1 FINDINGS ....................................................................................................................... 29 3.2 OTHER FINDINGS......................................................................................................... 30 3.3 FACTORS........................................................................................................................ 30 4 SAFETY ACTIONS................................................................................................................. 31 4.1 DIRECTORATE GENERAL OF CIVIL AVIATION .................................................... 31 4.2 PT. MERPATI NUSANTARA AIRLINES..................................................................... 31 4.3 AIRCRAFT MANUFACTURER .................................................................................... 31 5 RECOMMENDATION............................................................................................................ 32 5.1 RECOMMENDATION TO PT. MERPATI NUSANTARA AIRLINES ....................... 32 5.2 RECOMMENDATION TO DIRECTORATE GENERAL OF CIVIL AVIATION....... 32 APPENDIX A .................................................................................................................................. 33 APPENDIX B .................................................................................................................................. 43 ii TABLE OF FIGURES Figure 1: The Xi’An MA60 aircraft registration PK-MZK................................................... 3 Figure 2: Accident Site (red circle is the impact point)......................................................... 5 Figure 3: Events in the final segment of flight ...................................................................... 6 Figure 4: Screenshot of flight animation ............................................................................. 12 Figure 5: Selected FDR flight parameters from final 5 minutes of flight ........................... 13 Figure 6: Wreckage distribution (not to scale) .................................................................... 17 Figure 7: Recovered Pedestal .............................................................................................
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