STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) 2015 - 2019 ( Update s.d 30 Juni 2019)

REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.15.02.04.04 - PT. Garuda Refer to analysis chapter 2.1, 2.2 and 2.3 of this report, the KNKT recommends ATR 72‐600; PK‐GAG Directorate General that DGCA should oversight the implementation of recommendation addressed International PK-GAG 3-Feb-2015 2015 Final Report 9-Dec-2016 of Civil Aviation 04 R 2016 4 1 to the air OPEN NIL PENGAWASAN Airport (DGCA) operator, to ensure the effectiveness ofthe operators safety improvement and Republic of Indonesia to facilitate the recommendation addressed to airport operator. 03 February 2015 KNKT.15.02.04.04 - PT. ATR 72‐600; PK‐GAG The handling of the aircraft was contrary to the wind condition. The KNKT Lombok International PK-GAG 3-Feb-2015 2015 Final Report 9-Dec-2016 Garuda Indonesia 04 O 2016 4 1 OPEN NIL ATURAN recommends that the operator shall emphasized the crosswind handling. Airport Republic of Indonesia 03 February 2015

1 KNKT.15.02.04.04 - PT. In the preliminary report of this investigation, KNKT issued recommendation Garuda Indonesia related to standard call out on final. In addition, investigation identified two ATR 72‐600; PK‐GAG change over control of the flight at critical phase of flight without clear Lombok International PK-GAG 3-Feb-2015 2015 Final Report 9-Dec-2016 Garuda Indonesia 04 O 2016 4 2 OPEN NIL PENGAWASAN statements. This condition may also extend to the other instructors within Airport the company. Therefore, KNKT recommends to review the policy of change over Republic of Indonesia control at critical altitude. 03 February 2015

KNKT.15.02.04.04 - PT. Garuda Indonesia ATR 72‐600; PK‐GAG Angkasa Pura I Refer to analysis chapter 2.3 of this report, the KNKT recommends that the Lombok International PK-GAG 3-Feb-2015 2015 Final Report 9-Dec-2016 Branch Office Lombok 04 B 2016 4 1 airport operator should improve the surfaces runway strip conditionto comply OPEN NIL PRASARANA Airport International Airport with existing regulation. Republic of Indonesia 03 February 2015

KNKT.15.03.06.04 - PT. DERAYA AIR - British The aircraft landed and skid to the right, then re-entered the runway, KNKT Aerospace Bae ATP ; Review & Class Discussion Wet/Slippery Runway Landing 2 PK-DGB 4-Mar-2015 2015 Interim Report 11-Dec-2017 Deraya Air 04 O 2017 6 1 recommends to review the flight crew training related to wet or slippery runway CLOSED 13-Mar-2018 PENGAWASAN PK-DGB; Technique landing technique. , 4 Maret 2015

KNKT.15.03.06.04 - PT. DERAYA AIR - British During the approach, the visibility was reported 2-3 km and continuous heavy Aerospace Bae ATP ; Ensure compliance to Weather Minimum prior to initiate PK-DGB 4-Mar-2015 2015 Interim Report 11-Dec-2017 Deraya Air 04 O 2017 6 2 rain, KNKT recommends to ensure the pilot to comply to the minimum weather CLOSED 13-Mar-2018 PENGAWASAN PK-DGB; the approach. condition prior to initiate the approach. Wamena Airport, Papua 4 Maret 2015

KNKT.15.03.07.04 - PT. Elang Nusantara Air - Agar melakukan evaluasi program Training dan implementasinya bagi instruktur Thrush S2R-T34; PK-ELN pilot yang akan mejalankan fungsinya sesuai kriteria pada approved Agriculture Airstrip Tajur Baras, PK-ELN 13-Mar-2015 2015 Final Report 9-Dec-2016 Elang Nusantara Air O OPEN NIL PENGAWASAN Manual terkait kemampuan teknis sesuai dengan rating atau tipe pesawat yang Waringin Timur, dioperasikan. Kalimantan Tengah 13 Maret 2015

KNKT.15.03.07.04 - PT. Elang Nusantara Air - Thrush S2R-T34; PK-ELN Mengisi posisi Chief Pilot untuk penerbangan agriculture dan tidak melakukan Airstrip Tajur Baras, PK-ELN 13-Mar-2015 2015 Final Report 9-Dec-2016 Elang Nusantara Air O operasi penerbangan agriculture sementara waktu sebelum posisi Chief Pilot OPEN NIL ATURAN Waringin Timur, tersebut terisi. Kalimantan Tengah 13 Maret 2015 3 KNKT.15.03.07.04 - PT. Elang Nusantara Air - Thrush S2R-T34; PK-ELN Directorate General Memonitor dan mengawasi pelaksanaan rekomendasi KNKT pada butir 7.1. (a) Airstrip Tajur Baras, PK-ELN 13-Mar-2015 2015 Final Report 9-Dec-2016 of Civil Aviation R OPEN NIL PENGAWASAN dan (b) bagi PT. Elang Nusantara Air dan operator sejenis lainnya Waringin Timur, (DGCA) Kalimantan Tengah 13 Maret 2015

KNKT.15.03.07.04 - PT. Elang Nusantara Air - Thrush S2R-T34; PK-ELN Directorate General Melakukan review terkait pengoperasian pesawat jenis agriculture dengan Airstrip Tajur Baras, PK-ELN 13-Mar-2015 2015 Final Report 9-Dec-2016 of Civil Aviation R OPEN NIL PENGAWASAN sertifikasi AOC 135. Waringin Timur, (DGCA) Kalimantan Tengah 13 Maret 2015

KNKT.15.03.08.04 - PT. Hevilift Aviation Indonesia Sikorsky S76 C+ Directorate General To ensure the implementation of safety action taken by Hevilift Aviation 4 Helicopter; PK-FUP PK-FUP 21-Mar-2015 2015 Preliminary Report 5-May-2015 of Civil Aviation 04 R 2015 8 1 OPEN NIL PENGAWASAN Indonesia. Delta Mahakam river, (DGCA) East Kalimantan Republic of Indonesia 21 March 2015 REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.15.03.08.04 - PT. Hevilift Aviation Indonesia Sikorsky S76 C+ Directorate General To review the others Sikorsky similar operation’s Operator related to the training Helicopter; PK-FUP PK-FUP 21-Mar-2015 2015 Preliminary Report 5-May-2015 of Civil Aviation 04 R 2015 8 2 OPEN NIL PENGAWASAN and the restriction of automation usage. Delta Mahakam river, (DGCA) East Kalimantan Republic of Indonesia 21 March 2015

KNKT.15.06.13.04 - PT. Garuda Indonesia Boeing 737‐800; PK‐GFA Sultan Hasanuddin To review the pilot training on meteorology training related to cumulonimbus submit Briefing Guides technical TR/PC II year 2015, to International Airport PK-GFA 2-Jun-2015 2015 Final Report 9-Dec-2016 Garuda Indonesia 04 O 2016 7 1 CLOSED 5-Jan-2017 PENGAWASAN development and its effects. include “adverse weather/ windshear” South Republic of Indonesia 2 June 2015

1. Publish Notice to Flight Crew no. 021/15 date 6 June 2015 regarding “Situational awareness during approach and landing”, such as during if there is any runway changes, current weather condition, and if there KNKT.15.06.13.04 - PT. is any doubt, or the approach is not stabilized, or the Garuda Indonesia visibility drops rapidly to below minima, Flight Crew do Boeing 737‐800; PK‐GFA not hesitate to make a go around and/or rejected Sultan Hasanuddin 5 landing. 2. ublish International Airport PK-GFA 2-Jun-2015 2015 Final Report 9-Dec-2016 Garuda Indonesia 04 O 2016 8 2 To emphasis all pilot to perform go around when a safe landing cannot be made. CLOSED 5-Jan-2017 PENGAWASAN Notice to Flight Crew no. 036/15 date 5 October 2015 Makassar regarding “Recommendation for landing RWY13 and 31 South Sulawesi Sultan Hasanudin Airport/ WAAA” in order to strictly Republic of Indonesia follow the stabilized approach criteria and if the criteria 2 June 2015 does not meet, make go around. In this notice, also stated that during moderate and heavy rain, the landing on RWY13 and 31 UPG is strongly not recommended due to braking action is poor.

KNKT.15.06.13.04 - PT. Garuda Indonesia Boeing 737‐800; PK‐GFA Sultan Hasanuddin To provide all controllers with meteorology training that includes the International Airport PK-GFA 2-Jun-2015 2015 Final Report 9-Dec-2016 AirNav Indonesia 04 A 2016 9 1 OPEN NIL ATURAN understanding of cumulonimbus and windshear. Makassar South Sulawesi Republic of Indonesia 2 June 2015

KNKT.15.08.16.04 - PT. Komala Indonesia PAC-750XL; PK-KIG To include Controlled Flight into Terrain (CFIT) and Approach and Landing Ninia Airstrip, Yakuhimo, PK-KIG 12-Aug-2015 2015 Final Report 20-Jun-2016 04 R 2016 43 1 Accident Reduction (ALAR) as a required training component in the CASR Part OPEN NIL ATURAN Papua 135. Republic of Indonesia 12 August 2015

KNKT.15.08.16.04 - PT. Komala Indonesia PAC-750XL; PK-KIG Directorate General The information of runway elevation of Ninia in ALA did not represent the actual DBU akan mengarahkan agar penyelenggara Bandara Ninia Airstrip, Yakuhimo, PK-KIG 12-Aug-2015 2015 Final Report 20-Jun-2016 of Civil Aviation 04 R 2016 44 1 elevation. KNKT recommends reviewing the ALA to ensure the information DKPPU CLOSED 27-Mar-2018 Ninia untuk mengajukan permohonan kepada Direktorat PENGAWASAN Papua (DGCA) contents are valid. Navigasi Penerbangan untuk pengukuran elevasi runway. Republic of Indonesia 12 August 2015

KNKT.15.08.16.04 - PT. Komala Indonesia PAC-750XL; PK-KIG To provide a regulation which requires pilot to be trained for flight with Ninia Airstrip, Yakuhimo, PK-KIG 12-Aug-2015 2015 Final Report 20-Jun-2016 04 R 2016 63 1 DKPPU OPEN NIL ATURAN unreliable airspeed. Papua Republic of Indonesia 12 August 2015 6

KNKT.15.08.16.04 - PT. Komala Indonesia PAC-750XL; PK-KIG Ninia Airstrip, Yakuhimo, PK-KIG 12-Aug-2015 2015 Final Report 20-Jun-2016 04 O 2016 40 1 To ensure pilot familiarization in conducting a flight to airport or airstrip. OPEN NIL PENGAWASAN Papua Republic of Indonesia 12 August 2015

Komala Indonesia 6

REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.15.08.16.04 - PT. Komala Indonesia PAC-750XL; PK-KIG Komala Indonesia Ninia Airstrip, Yakuhimo, PK-KIG 12-Aug-2015 2015 Final Report 20-Jun-2016 04 O 2016 41 1 To provide pilot training in decision making especially in abnormal condition. OPEN NIL PENGAWASAN Papua Republic of Indonesia 12 August 2015

KNKT.15.08.16.04 - PT. Komala Indonesia PAC-750XL; PK-KIG To conduct proper risk assessment including document preparation for Ninia Airstrip, Yakuhimo, PK-KIG 12-Aug-2015 2015 Final Report 20-Jun-2016 04 O 2016 42 1 OPEN NIL PENGAWASAN additional fleet Papua Republic of Indonesia 12 August 2015

KNKT.15.08.17.04 - PT. Service Directorate General ATR 42-300; PK-YRN To ensure that the recommendations addressed to the air operator are well 7 PK-YRN 16-Aug-2015 2015 Preliminary Report 16-Sep-2015 of Civil Aviation 04 R 2015 17 1 OPEN NIL PENGAWASAN Near Oksibil, Papua implemented. (DGCA) Republic of Indonesia 16 August 2015

KNKT.15.08.17.04 - PT. Trigana Air Service The investigation could not find any regulation required for training of any Directorate General ATR 42-300; PK-YRN addition or system modification which affect to the aircraft operation. KNKT PK-YRN 16-Aug-2015 2015 Final Report 27-Dec-2017 of Civil Aviation R DKPPU OPEN NIL PENGAWASAN Near Oksibil, Papua recommends to develop regulation requirement for training of any additional or (DGCA) Republic of Indonesia modification to equipment that affected to safety of aircraft operations. 16 August 2015

KNKT.15.08.17.04 - PT. The information for Oksibil published in AIP volume IV (Aerodrome for Light Ditnavpen akan menawarkan pada Operator Trigana Air Service Directorate General Aircraft/ALA) did not include approach guidance. The operator issued visual penerbangan yang terbang pada rute tersebut dapat ATR 42-300; PK-YRN PK-YRN 16-Aug-2015 2015 Final Report 27-Dec-2017 of Civil Aviation 4 R 2015 17 6 guidance of circling approach runway 11 for internal use. KNKT recommends to CLOSED 27-Mar-2018 menyampaikan draft Visual Guidance kepada ATURAN Near Oksibil, Papua (DGCA) publish the visual route guidance for airport without instrument approach Ditnavpen/Perum LPPNPI unutk pembahasan lebih Republic of Indonesia procedure. lanjut. 16 August 2015

KNKT.15.08.17.04 - PT. PBN offers a number of advantages over the sensor-specific method of Trigana Air Service RNP Approach belum dapat diimplementasikan karena Directorate General developing airspace and obstacle clearance criteria. KNKT recommends to ATR 42-300; PK-YRN Terrain dan area yang sempit. Ditnavpen telah PK-YRN 16-Aug-2015 2015 Final Report 27-Dec-2017 of Civil Aviation 4 R 2015 17 7 consider the application of Performance Based Navigation (PBN) approach for CLOSED 27-Mar-2018 ATURAN Near Oksibil, Papua menawarkan proyek ini pada TAR untuk PBN, namun (DGCA) compatible aircraft to fly in area with ground-based navigation system Republic of Indonesia belum ada informasi lebih lanjut. implementation is limited. 16 August 2015

KNKT.15.08.17.04 - PT. Berdasarkan Notam C1226/16 Kondisi NDB Un- Trigana Air Service There was no information related to the status of ZX NDB published on NOTAM Serviceable mulai 12 Maret 2016 hingga 1 April 2016. Directorate General ATR 42-300; PK-YRN prior to the accident. KNKT recommends to ensure aeronautical information for Berdasarkan Notam C1483/16 Kondisi NDB beroperasi PK-YRN 16-Aug-2015 2015 Final Report 27-Dec-2017 of Civil Aviation 4 R 2015 17 8 CLOSED 27-Mar-2018 PENGAWASAN Near Oksibil, Papua air navigation is updated in accordance with the current condition, including the normal mulai 24 Maret 2016. DNP telah (DGCA) Republic of Indonesia serviceability of the navigation aids. melakukan audit keselamatan penyelenggara navigasi 16 August 2015 penerbangan pada Perum LPPNPI cabang Oksibil.

KNKT.15.08.17.04 - PT. EGPWS has worldwide terrain coverage in low resolution terrain data including Trigana Air Service Directorate General several airports with significant traffic movements. The Oksibil Airport was not ATR 42-300; PK-YRN PK-YRN 16-Aug-2015 2015 Final Report 27-Dec-2017 of Civil Aviation R provided with the high-resolution terrain data in this database version. KNKT OPEN NIL PRASARANA Near Oksibil, Papua (DGCA) recommends to coordinate with the manufacturer to provide several airports in Republic of Indonesia Indonesia with EGPWS high resolution terrain database. 16 August 2015

KNKT.15.08.17.04 - PT. Trigana Air Service Memberikan informasi melalui NOTAM perihal NDB ZX Oksibil sebagai There was no information related to the status of ZX NDB published on NOTAM ATR 42-300; PK-YRN berikut: (C1226/16 NOTAMN Q) PK-YRN 16-Aug-2015 2015 Final Report 27-Dec-2017 Airnav Indonesia 4 A 2015 17 3 prior to the accident. KNKT recommends to ensure the status of the navigation CLOSED 26-Feb-2018 WAFF/QNBAS/IV/BO/AE/000/999/0450S14026E025 A) WAJO PENGAWASAN Near Oksibil, Papua aids disseminates to the air navigation user in timely manner. B)1603120249 C)16049107000 E)NDB ZX 342KHZ Republic of Indonesia U/S DUE TO TECHNICAL REASON 16 August 2015

KNKT.15.08.17.04 - PT. The flight plan form was filed with intended to fly under instrument flight rule Trigana Air Service Melaksanakan perbaikan dalam rangka peningkatan pelayanan navigasi (IFR), at flight level 155, with route from Sentani to MELAM via airways W66 ATR 42-300; PK-YRN penerbangan meliputi : - Pengusulan PK-YRN 16-Aug-2015 2015 Final Report 27-Dec-2017 Airnav Indonesia 4 A 2015 17 4 then to Oksibil. The MORA of W66 between Sentani to Oksibil was 18,500 feet. CLOSED 26-Feb-2018 Penerbitan AIP Indonesia (Vol III) - Mengikuti Indonesia PENGAWASAN Near Oksibil, Papua KNKT recommends to ensure filing the flight plan and flight execution is PBN : ATR/Navblue Coorporation project - Optimalisasi pemberian Republic of Indonesia informasi oleh unit terkait melalui AIP Indonesia (Vol IV) accordance with the regulation. 16 August 2015

KNKT.15.08.17.04 - PT. Trigana Air Service To emphasis the flight crew to comply with the company procedures such as ATR 42-300; PK-YRN PK-YRN 16-Aug-2015 2015 Preliminary Report 16-Sep-2015 Trigana Air Services 04 O 2015 17 1 crew briefing, checklist reading, approach procedure and visual flight rules (VFR) OPEN NIL PENGAWASAN Near Oksibil, Papua minima and provide monitoring system. Republic of Indonesia 16 August 2015 REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.15.08.17.04 - PT. Trigana Air Service ATR 42-300; PK-YRN To ensure the maintenance data record up date includes the installed PK-YRN 16-Aug-2015 2015 Preliminary Report 16-Sep-2015 Trigana Air Services 04 O 2015 17 2 OPEN NIL PENGAWASAN Near Oksibil, Papua component. Republic of Indonesia 16 August 2015

KNKT.15.08.17.04 - PT. Trigana Air Service The visual approach guidance contained incorrect information of terrain (MSA) ATR 42-300; PK-YRN and considered not easy to fly. KNKT recommends that approach guidance shall PK-YRN 16-Aug-2015 2015 Final Report 27-Dec-2017 Trigana Air Services O OPEN NIL PENGAWASAN Near Oksibil, Papua be reviewed to ensure contain correct information and easy to fly to minimise Republic of Indonesia the pilot workload. 16 August 2015

KNKT.15.08.17.04 - PT. The statement in the ATR SB number ATR42-34-0152 required the operator to Trigana Air Service communicate to the manufacture related to the modification. KNKT ATR 42-300; PK-YRN PK-YRN 16-Aug-2015 2015 Final Report 27-Dec-2017 Trigana Air Services O recommends that any modification to the aircraft especially when the OPEN NIL PENGAWASAN Near Oksibil, Papua modification was related to aircraft safety, shall be communicated to the Republic of Indonesia manufacture and/or DGCA. 16 August 2015

KNKT.15.08.18.04 - PT. Garuda Indonesia Directorate General Airbus 330-200; PK-GPO To enforce the development of cabin crew procedures by the operators to 8 PK-GPO 22-Aug-2015 2015 Final Report 5-Dec-2016 of Civil Aviation 04 R 2016 82 1 DKPPU OPEN NIL ATURAN Inflight from Melbourne adequately handle the dry ice on board the aircraft. (DGCA) to 22 August 2015

KNKT.15.08.20.04 - PT. Cardig - Air Boeing 737-300 F; Reg. Directorate General To ensure the establishment and maintenance of flight data analysis program as PK-BBY PK-BBY 28-Aug-2015 2015 Final Report 15-Jun-2016 of Civil Aviation 04 R 2016 50 1 part of aircraft operator safety management system as stated in Civil Aviation DKPPU OPEN NIL ATURAN Wamena Airport (DGCA) Safety Regulation part 121.65 (c). Republic of Indonesia 28 August 2015

KNKT.15.08.20.04 - PT. Cardig - Air Pelaksanaan Windshear Training sesuai surat EVP. Boeing 737-300 F; Reg. Operations & COO PT. kepada Ketua PK-BBY PK-BBY 28-Aug-2015 2015 Final Report 15-Jun-2016 Cardig Air 04 O 2016 45 1 To improve the windshear training to ensure appropriate pilot respond. CLOSED 1-Feb-2018 PENGAWASAN KNKT No. 2096/CADKNKT/ COO/V/16 tanggal 16 Mei Wamena Airport 2016. Republic of Indonesia 28 August 2015

KNKT.15.08.20.04 - PT. - Issued notice number Cardig - Air 13.02.02/00/LPPNPI/05/2016/141 regarding the Boeing 737-300 F; Reg. To improve the knowledge of air traffic controller related to the windshear to be improvement of ATC awareness during extreme bad PK-BBY PK-BBY 28-Aug-2015 2015 Final Report 15-Jun-2016 Airnav Indonesia 04 A 2016 46 1 CLOSED 19-Sep-2016 PENGAWASAN able to provide useful information for flight operation. weather and clear air turbulence. Wamena Airport - Conducted safety awareness workshop and refreshing Republic of Indonesia 9 course. 28 August 2015

KNKT.15.08.20.04 - PT. Cardig - Air Boeing 737-300 F; Reg. PK-BBY PK-BBY 28-Aug-2015 2015 Final Report 15-Jun-2016 Wamena Airport 04 B 2016 47 1 To develop an aerodrome maintenance programme. OPEN NIL PRASARANA Wamena Airport Republic of Indonesia 28 August 2015 KNKT.15.08.20.04 - PT. Cardig - Air Boeing 737-300 F; Reg. PK-BBY PK-BBY 28-Aug-2015 2015 Final Report 15-Jun-2016 Wamena Airport 04 B 2016 48 1 To review and improve the runway inspection system. OPEN NIL PENGAWASAN Wamena Airport Republic of Indonesia 28 August 2015 KNKT.15.08.20.04 - PT. Cardig - Air Boeing 737-300 F; Reg. PK-BBY PK-BBY 28-Aug-2015 2015 Final Report 15-Jun-2016 Wamena Airport 04 B 2016 49 1 To install VASI on the runway 15. OPEN NIL PRASARANA Wamena Airport Republic of Indonesia 28 August 2015 KNKT.15.10.21.04 - PT. Mandiri DHC-6 Twin Otter; PK- BRM at coordinate 3° 25' Directorate General To emphasize the continuity of oversight program to ensure the installed 52.80" S, 120° 4' 12.10" PK-BRM 2-Oct-2015 2015 Final Report 9-Dec-2016 of Civil Aviation 04 R 2016 67 1 DKPPU OPEN NIL PENGAWASAN EGPWS/TAWS functioning properly. E (DGCA) District of Luwu, South Sulawesi Republic of Indonesia 2 October 2015

10 REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.15.10.21.04 - PT. Aviastar Mandiri DHC-6 Twin Otter; PK- BRM at coordinate 3° 25' PT. Aviastar Mandiri has conducted training CRM for all To evaluate the effectiveness of the CRM training and ensuring the correct pilot 52.80" S, 120° 4' 12.10" PK-BRM 2-Oct-2015 2015 Final Report 9-Dec-2016 Aviastar Mandiri 04 O 2016 64 1 CLOSED 28-Feb-2018 Pilots and make Notice to Pilot that pilot must do PENGAWASAN implementation E briefing before flight as implementation. District of Luwu, South Sulawesi Republic of Indonesia 10 2 October 2015 KNKT.15.10.21.04 - PT. Aviastar Mandiri DHC-6 Twin Otter; PK- BRM at coordinate 3° 25' PT. Aviastar Mandiri has conducted Training for the To ensure all pilots are appropriately trained on the operation and testing of the 52.80" S, 120° 4' 12.10" PK-BRM 2-Oct-2015 2015 Final Report 9-Dec-2016 Aviastar Mandiri 04 O 2016 65 2 CLOSED 28-Feb-2018 operation (Pilot) and Technic Division and testing of the PENGAWASAN EGPWS/TAWS systems. E EGPWS/TAWS System. District of Luwu, South Sulawesi Republic of Indonesia 2 October 2015 KNKT.15.10.21.04 - PT. Aviastar Mandiri DHC-6 Twin Otter; PK- BRM at coordinate 3° 25' PT. Aviastar Mandiri make Standard Operating To ensure EGPWS/TAWS operational test procedure is incorporated into the 52.80" S, 120° 4' 12.10" PK-BRM 2-Oct-2015 2015 Final Report 9-Dec-2016 Aviastar Mandiri 04 O 2016 66 3 CLOSED 28-Feb-2018 Procedure (SOP) for Responding to Alert TAWS and has ATURAN Operator’s Standard Operating Procedures (SOP) and pre‐flight checklists. E in state in Pre Flight Checklist (Cockpit Preparation) District of Luwu, South Sulawesi Republic of Indonesia 2 October 2015 KNKT.15.10.22.04 - PT. Penerbangan Angkasa Semesta OM Chapter 8.26 (Flight Overwater), OM Chapter 9.2.6 Eurocopter EC130 B4; PK- Penerbangan Angkasa To ensure the survival equipment is available on the aircraft suitable for area (Passeger Handling), OM Chapter 3.4.3 (Flight Following BKA PK-BKA 11-Oct-2015 2015 Final Report 16-May-2016 04 O 2016 32 1 Provide survival equipment CLOSED 23-Feb-2018 SARANA Semesta operation and properly use and Flight Watch Facilities), Notice to Crew No. Toba Lake, North PAS/NOT/IV/2016 (Emergency Equipment Check) Sumatera Republic of Indonesia 11 October 2015 KNKT.15.10.21.04 - PT. Aviastar Mandiri DHC-6 Twin Otter; PK- BRM at coordinate 3° 25' Penerbangan Angkasa OM Chapter 9.2.2 (Passenger Briefing Procedure), Safety 52.80" S, 120° 4' 12.10" PK-BKA 11-Oct-2015 2015 Final Report 16-May-2016 04 O 2016 58 1 To conduct passenger safety briefing prior to every flight Passenger safety briefing CLOSED 23-Feb-2018 PENGAWASAN Semesta Instruction Card. E District of Luwu, South Sulawesi Republic of Indonesia 2 October 2015 KNKT.15.10.21.04 - PT. Aviastar Mandiri DHC-6 Twin Otter; PK- BRM Consideration to regulate at coordinate 3° 25' Directorate General To consider the regulation of using emergency equipment such as personal or 11 using of personal or portable 52.80" S, 120° 4' 12.10" PK-BKA 11-Oct-2015 2015 Final Report 16-May-2016 of Civil Aviation 04 R 2016 33 1 portable Emergency Locator Transmitter for personal in aircraft operated in OPEN NIL ATURAN emergency locator E (DGCA) inhabitant terrain and offshore. transmitter District of Luwu, South Sulawesi Republic of Indonesia 2 October 2015 KNKT.15.10.21.04 - PT. Aviastar Mandiri DHC-6 Twin Otter; PK- BRM at coordinate 3° 25' 52.80" S, 120° 4' 12.10" PK-BKA 11-Oct-2015 2015 Final Report 16-May-2016 BASARNAS 04 L 2016 34 1 To consider instrument flight training for search and rescue pilots. Instrument Flight Training OPEN NIL ATURAN E District of Luwu, South Sulawesi Republic of Indonesia 2 October 2015 KNKT.15.10.21.04 - PT. Aviastar Mandiri DHC-6 Twin Otter; PK- BRM Unmanned aircraft for at coordinate 3° 25' PK-BKA 11-Oct-2015 2015 Final Report 16-May-2016 BASARNAS 04 L 2016 35 1 To consider using drone or unmanned aerial vehicle for air search operation. OPEN NIL ATURAN search 52.80" S, 120° 4' 12.10" E District of Luwu, South Sulawesi KNKT.15.10.24.04 - PT. Tecnam P2006T Aircraft; PK-LTK To improve the pilot crew resource management that may refer to the FAA Improve quality system - COM replaced by OM (OM part D 1.3.1 "Crew Resouce PK-LTK 20-Oct-2015 2015 Final Report 26-Aug-2016 Asian One Air 04 O 2016 10 1 CLOSED 20-Feb-2018 PENGAWASAN Nusawiru Airport safety bulletin aircraft airworthiness Management") Pangandaran, Jawa Barat 20 October 2015

12 REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.15.10.24.04 - PT. Asian One Air Tecnam P2006T Aircraft; To improve the quality system operation to achieve requirements of Indonesia PK-LTK PK-LTK 20-Oct-2015 2015 Final Report 26-Aug-2016 Asian One Air 04 O 2016 11 1 regulations for the internal and other organization supporting Asian One Air CLOSED 20-Feb-2018 Operation facility inspection and aircraft inspection PENGAWASAN Nusawiru Airport operation refer to CASR 135.85. Pangandaran, Jawa Barat 20 October 2015 KNKT.15.10.24.04 - PT. Asian One Air To improve the quality system of aircraft airworthiness to a achieve Improve quality system - MOU PT. Asian One Air and PT. MS Tech No.AOA Tecnam P2006T Aircraft; PK-LTK 20-Oct-2015 2015 Final Report 26-Aug-2016 Asian One Air 04 O 2016 12 1 requirements of CASR 135.85; CASR 135.363 and CASR 135.373 for the CLOSED 20-Feb-2018 PENGAWASAN operation 061/EDZA1A/N III/2017 PK-LTK internal and other organization supporting Asian One Air. Nusawiru Airport KNKT.15.10.24.04 - PT. Asian One Air 12 Melaksanakan beberapa training kepada para Tecnam P2006T Aircraft; Inspektur/Engineer PT.Mulya Sejahtera, yaitu : Basic PK-LTK Mulya Sejahtera To improve the quality maintenance system to achieve requirements of CASR Improve quality system - PK-LTK 20-Oct-2015 2015 Final Report 26-Aug-2016 04 L 2016 13 1 CLOSED Inspector, Basic Supervisor, Potential Hazard, Human PENGAWASAN Nusawiru Airport Technology 43.15; CASR 145.205 and CASR 145.211 maintenance Factor Recurrent. Dan Melaksanakan improvement Pangandaran, terhadap AMO/QC Manual PT. MSTech. Jawa Barat 20 October 2015 KNKT.15.10.24.04 - PT. Asian One Air Tecnam P2006T Aircraft; Directorate General PK-LTK To develop guideline of single pilot resource management as a reference for the PK-LTK 20-Oct-2015 2015 Final Report 26-Aug-2016 of Civil Aviation 04 R 2016 14 1 DKPPU OPEN NIL PENGAWASAN Nusawiru Airport single pilot operators. (DGCA) Pangandaran, Jawa Barat 20 October 2015 KNKT.15.10.24.04 - PT. Asian One Air Tecnam P2006T Aircraft; Directorate General PK-LTK To improve audit and surveillance system to organisation which have Improve audit and PK-LTK 20-Oct-2015 2015 Final Report 26-Aug-2016 of Civil Aviation 04 R 2016 15 1 OPEN NIL PENGAWASAN Nusawiru Airport authorization to conduct maintenance activity includes assembling of aircraft. surveillance (DGCA) Pangandaran, Jawa Barat 20 October 2015

KNKT.15.10.25.04 - PT. Enggang Air Service Cessna 208B Grand Emergency Training - Engine Has been implementing Recovery Training Post Serious 13 Caravan; PK-RSE PK-RSE 27-Oct-2015 2015 Preliminary Report 20-Jun-2016 Enggang Air Services 04 O 2016 60 1 To emphasize the pilot emergency training related to engine malfunction. CLOSED PENGAWASAN Malfunction Incident on 1st December 2015. Sinak Airport, Papua Republic of Indonesia 27 October 2015

1. has changed Manual of Training, from KNKT.15.11.26.04 - PT. Operation Training Manual (OTM) 02 October 2015 to Batik Air Indonesia Operation Manual D (Training Manual) OMD, 27 January Boeing 737-900 ER; PK- 2016. LBO 2. Chapter Crewmember Emergency Training has To improve the crewmember emergency training to ensure all crewmembers Emergency Training - Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 Batik Air Indonesia 04 O 2016 20 1 CLOSED changed: ATURAN performs the evacuation according to the company procedures Evacuation Airport • curriculum segment Yogyakarta, Republic of • content of module Indonesia • add subchapter record keeping 6 November 2015 3. Training of Crewmember Emergency Training, has been conducting until now with new training manual. KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- Angkasa Pura I LBO Branch Office To perform daily inspection of the movement area as specified in the Aerodrome The daily inspection performed three times a day in Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 04 B 2016 22 1 Movement Area Inspection CLOSED 21-Sep-2016 PENGAWASAN Adisutjipto Manual (AM) and airport Standard Operating Procedure (SOP). accorndance with the AM and SOP. Airport International Airport Yogyakarta, Republic of Indonesia 6 November 2015 KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- Angkasa Pura I LBO To develop procedure for measurement of water depth in runway and taxiway Standing water measurement has not been able to be Branch Office Water Depth Measurement Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 04 B 2016 23 1 as required by chapter 4.5 of Appendix 1 Civil Aviation Safety Regulation (CASR) CLOSED 21-Sep-2016 conducted as the method and equipment have not ATURAN Adisutjipto Procedure Airport Part 139 Volume I. available, it requires further discussion. International Airport Yogyakarta, Republic of Indonesia 6 November 2015 KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- Angkasa Pura I LBO Branch Office To update the AM and SOP, and implement the runway friction measurement Runway Friction Implementation of runway friction test described in the Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 04 B 2016 24 1 CLOSED 21-Sep-2016 ATURAN Adisutjipto according to the specified in the Advisory Circular (AC) CASR Part 139-23. Measurement AM chapter 4.7.7 Airport International Airport Yogyakarta, Republic of Indonesia 6 November 2015 KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- Angkasa Pura I To develop a reporting system to enable disseminate significant information of LBO Branch Office runway condition to Air Traffic Service (ATS) unit and for those units to provide Runway Condition Reporting Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 04 B 2016 25 1 CLOSED 21-Sep-2016 Reporting system has not been established. ATURAN Adisutjipto the necessary information to arriving and departing aircraft without delay as System Airport International Airport required in ICAO Annex 14 Chapter 2.9.1. Yogyakarta, Republic of Indonesia 6 November 2015

14 REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- Angkasa Pura I LBO The airport sent letter to AirNav Indonesia to review the Branch Office Instrument approach Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 04 B 2016 51 1 To review the possibility of development an instrument approach for runway 27. CLOSED 21-Sep-2016 possibility of development an instrument approach for PRASARANA Adisutjipto development Airport runway 27 International Airport Yogyakarta, Republic of Indonesia 6 November 2015

KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- LBO AirNav Indonesia To provide the tower controller with the current weather information by Installation of AWOS display Provided wind and pressure indicator system in the Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 District Office 04 A 2016 26 1 CLOSED 19-Sep-2016 PRASARANA installation of AWOS display monitor in the tower control desk. monitor Tower working space Airport Yogyakarta Yogyakarta, Republic of Indonesia 6 November 2015

KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- LBO AirNav Indonesia development an instrument Conducted review and analysis of RNP approach for Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 District Office 04 A 2016 51 2 To review the possibility of development an instrument approach for runway 27. CLOSED 19-Sep-2016 PRASARANA approach runway 27 with aircraft operators. Airport Yogyakarta Yogyakarta, Republic of Indonesia 6 November 2015

KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- LBO Directorate General Stabilized Approach - Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 of Civil Aviation 04 R 2016 1 2 To emphasize all aircraft operators comply with stabilize approach criteria. OPEN NIL PENGAWASAN General Airport (DGCA) Yogyakarta, Republic of 14 Indonesia 6 November 2015

KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- LBO Directorate General To ensure all aircraft operators calculate the landing distance available is Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 of Civil Aviation 04 R 2016 27 1 Landing Distance Calculation OPEN NIL PENGAWASAN suitable for the landing distance required on existing condition. Airport (DGCA) Yogyakarta, Republic of Indonesia 6 November 2015

KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- LBO Directorate General To emphasize all aircraft operators implement standard callout procedure on Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 of Civil Aviation 04 R 2016 28 1 Standard Callout - Approach OPEN NIL PENGAWASAN approach. Airport (DGCA) Yogyakarta, Republic of Indonesia 6 November 2015

KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- LBO Directorate General To emphasize all aircraft operators conduct emergency training to ensure the Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 of Civil Aviation 04 R 2016 29 1 DKPPU OPEN NIL PENGAWASAN crewmember taking appropriate action during emergency. Airport (DGCA) Yogyakarta, Republic of Indonesia 6 November 2015

KNKT.15.11.26.04 - PT. Direktorat Bandar Udara telah menerbitkan Peraturan Batik Air Indonesia Direktur Jenderal Perhubungan Udara Nomor KP 212 Boeing 737-900 ER; PK- Tahun 2017 tentang LBO Directorate General To ensure that the airport operators manual contain the requirement specified Petunjuk Teknis Peraturan Keselamatan Penerbangan Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 of Civil Aviation 04 R 2016 30 1 in the CASR Past 139, AC CASR Part 139-23 and Manual of Standard CASR Part Airport Operator Manual CLOSED 27-Feb-2018 ATURAN Sipil Bagian 139-11, Prosedur Pengawasan Pavement Airport (DGCA) 139. Management System (PMS) sebagai mekanisme untuk Yogyakarta, Republic of memastikan operator bandar udara telah memenuhi Indonesia persyaratan pelaksanaan PMS 6 November 2015

KNKT.15.11.26.04 - PT. Direktorat Bandar Udara telah menerbitkan Peraturan Batik Air Indonesia Direktur Jenderal Perhubungan Udara Nomor KP 220 Boeing 737-900 ER; PK- Tahun 2017 tentang LBO Directorate General Petunjuk Pelaksanaan Pengawasan Keselamatan Operasi To ensure all airport operators conduct inspection of movement area according Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 of Civil Aviation 04 R 2016 22 2 Movement Area Inspection CLOSED 27-Feb-2018 Bandar Udara dan Tempat Pendaratan dan Lepas Landas PENGAWASAN to the approved manuals. Airport (DGCA) Helikopter SI 139-01 sebagai mekanisme untuk Yogyakarta, Republic of memastikan operator bandar udara telah melaksanakan Indonesia inspeksi area pergerakan dengan frekuensi sebagaimana 6 November 2015 dipersyaratkan dalam MOS Volume) Aerodrome 14

REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.15.11.26.04 - PT. Direktorat Bandar Udara telah menerbitkan Peraturan Batik Air Indonesia Direktur Jenderal Perhubungan Udara Nomor KP 212 Boeing 737-900 ER; PK- Tahun 2017 tentang LBO Directorate General To ensure all airport operators implement the runway friction measurement Runway Friction Petunjuk Teknis Peraturan Keselamatan Penerbangan Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 of Civil Aviation 04 R 2016 24 2 CLOSED 27-Feb-2018 PENGAWASAN according to the specified in the AC CASR Part 139-23. Measurement Sipil Bagian 139-11, Prosedur Pengawasan Pavement Airport (DGCA) Management System (PMS) sebagai mekanisme untuk Yogyakarta, Republic of memastikan operator bandar udara telah Indonesia mengimplementasikan pengukuran kekesatan runway 6 November 2015 KNKT.15.11.26.04 - PT. dalam Peraturan Direktur Jenderal Perhubungan Batik Air Indonesia Udara Nomor : KP 262 Tahun 2017 tentang Manual of Boeing 737-900 ER; PK- Standard (MoS) Part 139 Volume I Aerodrome Bagian To include in the Indonesia regulation, the procedure of reporting system from LBO Directorate General 9.15.11 Operator Bandar Udara wajib the airport operator to the ATS unit to enable disseminate significant Runway Condition Reporting Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 of Civil Aviation 04 R 2016 25 2 CLOSED 27-Feb-2018 menginformasikan keberadaan air di permukaan runway ATURAN information of runway condition to arriving and departing aircraft without delay System Airport (DGCA) kepada Air Traffic Controller untuk dapat disampaikan as required in ICAO Annex 14 Chapter 2.9.1. Yogyakarta, Republic of kepada penerbang sebagaimana bahan Indonesia pertimbangan braking action (good, medium, poor) pada 6 November 2015 saat pendaratan

KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- LBO Directorate General ATS Provider Approval Issued approval certificate for ATS provider for Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 of Civil Aviation 04 R 2016 31 1 To issue approval certificates for the Air Traffic Services providers. CLOSED ATURAN Certificate Yogyakarta Airport (DGCA) Yogyakarta, Republic of Indonesia 6 November 2015

KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- LBO Directorate General IAP runway 27 belum dapat dilakukan karena development an instrument Adisutjipto International PK-LBO 6-Nov-2015 2015 Final Report 9-Jun-2016 of Civil Aviation 04 R 2016 51 2 To review the possibility of development an instrument approach for runway 27 CLOSED 27-Mar-2018 bersinggungan dengan ruang udara Militer dan kondisi PRASARANA approach Airport (DGCA) Terrain yang cukup tingi di area approach. Yogyakarta, Republic of Indonesia 6 November 2015

KNKT.15.12.28.04 - PT. Embraer 190-200LR; PK- KDC Briefed all pilots regarding to the procedures and crew 15 El Tari Airport PK-KDC 21-Dec-2015 2015 Preliminary Report 9-Feb-2015 KalStar Aviation 04 O 2016 16 1 To ensure the flight crew to perform appropriate crew briefing. Crew briefing CLOSED PENGAWASAN briefing for landing , Nusa Tenggara Timur Republic of Indonesia 21 December 2015

KNKT.15.12.28.04 - PT. KalStar Aviation Embraer 190-200LR; PK- KDC Stabilized approach - correct Briefed all pilots regarding to the stabilized approach El Tari Airport PK-KDC 21-Dec-2015 2015 Preliminary Report 9-Feb-2015 KalStar Aviation 04 O 2016 17 1 To emphasize the flight crew to the stabilized approach criteria. flight path, speed, landing CLOSED PENGAWASAN criteria Kupang, Nusa Tenggara configuration, briefing. Timur Republic of Indonesia 21 December 2015

KNKT.15.12.28.04 - PT. KalStar Aviation Embraer 190-200LR; PK- KDC To emphasize the flight crew to response to the aircraft warning system and Response to aircraft warning Briefed all pilots regarding to response to the aircraft El Tari Airport PK-KDC 21-Dec-2015 2015 Preliminary Report 9-Feb-2015 KalStar Aviation 04 O 2016 18 1 CLOSED PENGAWASAN EGPWS warning appropriately. system and EGPWS warning system appropriately. Kupang, Nusa Tenggara Timur Republic of Indonesia 21 December 2015

KNKT.15.12.28.04 - PT. KalStar Aviation Embraer 190-200LR; PK- KDC To ensure pilot performs the operational procedure such as checklist reading, Operational procedure El Tari Airport PK-KDC 21-Dec-2015 2015 Final Report 26-Sep-2016 KalStar Aviation 04 O 2016 73 2 OPEN NIL PENGAWASAN crew briefing properly and consistently. implementation Kupang, Nusa Tenggara Timur Republic of Indonesia 21 December 2015 KNKT.15.12.28.04 - PT. KalStar Aviation Embraer 190-200LR; PK- KDC To develop oversight system that ensure the procedures are implemented Oversight System El Tari Airport PK-KDC 21-Dec-2015 2015 Final Report 26-Sep-2016 KalStar Aviation 04 O 2016 78 1 OPEN NIL ATURAN properly and to monitor pilot performance. Development Kupang, Nusa Tenggara Timur Republic of Indonesia 21 December 2015 KNKT.15.12.28.04 - PT. KalStar Aviation Embraer 190-200LR; PK- KDC To ensure the comprehensive Safety Management System is implemented El Tari Airport PK-KDC 21-Dec-2015 2015 Final Report 26-Sep-2016 KalStar Aviation 04 O 2016 79 1 SMS Implementation OPEN NIL PENGAWASAN correctly. Kupang, Nusa Tenggara Timur Republic of Indonesia 21 December 2015 REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.15.12.28.04 - PT. KalStar Aviation Embraer 190-200LR; PK- AirNav Indonesia district office Kupang updated the KDC Standard operating AirNav Indonesia To include in the Standard Operating Procedure (SOP) of ATC the procedure for Standard Operating Procedure (SOP) for the air traffic El Tari Airport PK-KDC 21-Dec-2015 2015 Preliminary Report 9-Feb-2015 04 A 2016 19 1 procedures - utilized visibilty CLOSED ATURAN District Office Kupang utilizing of visibility chart and determination of the wind information. controller to include the utilization of visibility chart and Kupang, Nusa Tenggara chart, wind information determination of wind information Timur Republic of Indonesia 21 December 2015 KNKT.15.12.28.04 - PT. KalStar Aviation Embraer 190-200LR; PK- To develop a reporting system to enable disseminate significant information of KDC Angkasa Pura I runway condition to Air Traffic Service (ATS) unit and for those units to provide Runway Condition Reporting El Tari Airport PK-KDC 21-Dec-2015 2015 Final Report 26-Sep-2016 Branch Office Eltari 04 B 2016 25 2 OPEN NIL ATURAN the necessary information to arriving and departing aircraft without delay as System Kupang, Nusa Tenggara Airport, Kupang required in ICAO Annex 14 Chapter 2.9.1. Timur Republic of Indonesia 21 December 2015 KNKT.15.12.28.04 - PT. KalStar Aviation Embraer 190-200LR; PK- KDC Directorate General Stabilized Approach - El Tari Airport PK-KDC 21-Dec-2015 2015 Final Report 26-Sep-2016 of Civil Aviation 04 R 2016 1 3 To emphasize all aircraft operator to comply with stabilize approach criteria. OPEN NIL PENGAWASAN General Kupang, Nusa Tenggara (DGCA) Timur Republic of Indonesia 21 December 2015 KNKT.15.12.28.04 - PT. KalStar Aviation Embraer 190-200LR; PK- KDC Directorate General To ensure all aircraft operators implements safety management system as El Tari Airport PK-KDC 21-Dec-2015 2015 Final Report 26-Sep-2016 of Civil Aviation 04 R 2016 81 1 DKPPU OPEN NIL PENGAWASAN required by Indonesia Civil Aviation Safety Regulation. Kupang, Nusa Tenggara (DGCA) Timur Republic of Indonesia 21 December 2015 KNKT.15.12.28.04 - PT. KalStar Aviation Embraer 190-200LR; PK- To include in the Indonesia regulation, the procedure of reporting system from KDC Directorate General Sesuai dengan Peraturan Direktur Jenderal Perhubungan the airport operator to the ATS unit to enable disseminate significant Runway Condition Reporting El Tari Airport PK-KDC 21-Dec-2015 2015 Final Report 26-Sep-2016 of Civil Aviation 04 R 2016 25 3 CLOSED 23-Feb-2018 Udara No. KP 262 Tahun 2017 Tentang Mos Part 139 PENGAWASAN information of runway condition to arriving and departing aircraft without delay System Kupang, Nusa Tenggara (DGCA) Volume I Aerodrome Bagian 9.15.11 as required in ICAO Annex 14 Chapter 2.9.1. Timur Republic of Indonesia 21 December 2015

KNKT.16.02.13.04 The flight to Spot 99 was the first time for the pilot and was not accompanied by PT AMUR AVIATION a qualified pilot and prior to this flight appropriate briefing has not been INDONESIA - Hellicopter PT. Amur Aviation PK-UAG 3-Feb-2016 2016 Final Report 5-Dec-2017 04 O 2017 3 1 conducted therefore KNKT recommend to ensure that the flight to the specific CLOSED TDTL ATURAN Bell 206L-4; PK-UAG Indonesia area shall comply with the requirement of company SOP or conduct risk Siriwo Area - Papua assessment to cover the operation to unfamiliar area. 3 February 2016 16 KNKT.16.02.13.04 Management assigned the pilot to conduct flight to Spot 99 that was the first PT AMUR AVIATION time for the pilot and was not accompanied by a qualified pilot and no INDONESIA - Hellicopter PT. Amur Aviation PK-UAG 3-Feb-2016 2016 Final Report 5-Dec-2017 04 O 2017 3 2 appropriate briefing prior to this flight has not been conducted which contrary to CLOSED TDTL ATURAN Bell 206L-4; PK-UAG Indonesia the company SOP therefore KNKT recommend to emphasize the management to Siriwo Area - Papua improve the safety by conducting safety oversight to the operation. 3 February 2016

KNKT.16.02.05.04 - PT. Lion Mentari Airline Boeing 737-900ER; PK- LFG The deteriorating weather condition and difficulty of the SIC to control the PT. Mentari Juanda International PK-LFG 20-Feb-2016 2016 Final Report 7-Feb-2017 04 O 2017 5 1 aircraft did not trigger a firm decision, therefore KNKT recommends to review OPEN NIL PENGAWASAN Airlines Airport, Sidoarjo, East pilot training program in order to improve pilot decision making. Java Republic of Indonesia 20 February 2016

KNKT.16.02.05.04 - PT. Lion Mentari Airline Boeing 737-900ER; PK- During manual flying, the SIC had difficulty to control the aircraft that was LFG PT. Lion Air Mentari indicated by the activation of EGPWS hard alert ‘GLIDE SLOPE, GLIDE SLOPE’, Juanda International PK-LFG 20-Feb-2016 2016 Final Report 7-Feb-2017 04 O 2017 5 2 OPEN NIL PENGAWASAN Airlines therefore KNKT recommends to review the procedure regarding the use of Airport, Sidoarjo, East autopilot and pilot training program in order to improve manual flying skill. Java Republic of Indonesia 17 20 February 2016 KNKT.16.02.05.04 - PT. Lion Mentari Airline Boeing 737-900ER; PK- LFG Directorate General To emphasize the other aircraft operator to review pilot training program in Juanda International PK-LFG 20-Feb-2016 2016 Final Report 7-Feb-2017 of Civil Aviation 04 R 2017 5 3 DKPPU OPEN NIL PENGAWASAN order to improve pilot decision making. Airport, Sidoarjo, East (DGCA) Java Republic of Indonesia 20 February 2016 KNKT.16.02.05.04 - PT. Lion Mentari Airline Boeing 737-900ER; PK- LFG Directorate General To emphasize the other aircraft operator to develop training specifically address Juanda International PK-LFG 20-Feb-2016 2016 Final Report 7-Feb-2017 of Civil Aviation 04 R 2017 5 4 the pilot recognition of situation in which the speed brakes, thrust reverser and DKPPU OPEN NIL PENGAWASAN Airport, Sidoarjo, East (DGCA) autobrake do not operates as expected after landing. Java Republic of Indonesia 20 February 2016 REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation - Established ground control unit to control ground Boeing 737-800 (PK-LBS) AirNav Indonesia To develop procedure for all aircraft movement on the manoeuvring area movement which have different frequency from tower and ATR 42-600 (PK-TNJ) Communication between 18 PK-LBS & PK-TNJ 4-Apr-2016 2016 Preliminary Report 4-May-2016 District Office Halim 04 A 2016 51 1 including the aircraft movement without aircraft own power, to communicate CLOSED 19-Sep-2016 controller, including its standard operation procedure. ATURAN Halim Perdanakusuma ground movement and ATC Perdanakusuma with air traffic controller on the same frequency. - Established new procedure of ground movement to taxi International Airport, using perimeter service road. Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) AirNav Indonesia and ATR 42-600 (PK-TNJ) To evaluate the current lighting of tower cab to prevent glare that may distract Reduced the lighting on tower cab during low light PK-LBS & PK-TNJ 4-Apr-2016 2016 Preliminary Report 4-May-2016 District Office Halim 04 A 2016 52 1 Working environment CLOSED 19-Sep-2016 PRASARANA Halim Perdanakusuma controller view. condition (night or cloudy situation). Perdanakusuma International Airport, Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and - Issued safety notice number TransNusa Aviation 13.01/00/LPPNPI/04/2016/001 to improve the ATC Boeing 737-800 (PK-LBS) awareness for all movement in manoeuvring area. AirNav Indonesia To remind the ATC controller to maintain continues watch the aircraft and ATR 42-600 (PK-TNJ) Maintain continuously - Put safety campaign poster in working area to improve PK-LBS & PK-TNJ 4-Apr-2016 2016 Preliminary Report 4-May-2016 District Office Halim 04 A 2016 53 1 movement on the manoeuvring area, especially when issued air traffic control CLOSED 19-Sep-2016 PENGAWASAN Halim Perdanakusuma watch safety awareness while providing air navigation services. Perdanakusuma clearance. International Airport, Conducted safety briefing to all ATS personnel regarding Jakarta safety awareness, hazard identification and reporting Republic of Indonesia culture. 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) AirNav Indonesia Published NOTAM number A1268/16 NOTAMN to and ATR 42-600 (PK-TNJ) To inform the aircraft operators to initiate takeoff from the threshold runway 24 PK-LBS & PK-TNJ 4-Apr-2016 2016 Preliminary Report 4-May-2016 District Office Halim 04 A 2016 57 1 Lining up CLOSED 19-Sep-2016 remind all pilot to takeoff (open power) after the ATURAN Halim Perdanakusuma of Halim Perdanakusuma International Airport Perdanakusuma threshold runway 24. International Airport, Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Issued safety notice to all aircraft operator, ground Boeing 737-800 (PK-LBS) AirNav Indonesia handling service and fuel supplier service to include the and ATR 42-600 (PK-TNJ) To develop procedure for vehicle and aircraft on the manoeuvring area shall be SOP development - lighting PK-LBS & PK-TNJ 4-Apr-2016 2016 Preliminary Report 4-May-2016 District Office Halim 04 A 2016 54 1 CLOSED 19-Sep-2016 KNKT recommendation to their standard operating ATURAN Halim Perdanakusuma equipped with serviceable lights visible by air traffic controller. for aircraft manoeuver Perdanakusuma procedure while operating vehicle and/or aircraft on the International Airport, manoeuvring area. Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) AirNav Indonesia It is recommended updating the SOP to accommodate controller coordination to and ATR 42-600 (PK-TNJ) PK-LBS & PK-TNJ 4-Apr-2016 2016 Final Report 10-Apr-2017 District Office Halim 04 A 2017 7 7 warrant the safe operation of aircraft and vehicle movement on maneuvering CLOSED 19-Sep-2016 Responding to KNKT safety recommendation, on 7 April ATURAN Halim Perdanakusuma Perdanakusuma area. 2016, the AirNav Indonesia issued safety notice International Airport, addressed to all air traffic control units as follows: Jakarta a. Required all towing aircraft to switch on the Republic of Indonesia navigation lights. 4 April 2016 b. Required all towing aircraft to communicate in published tower frequency. c. Required all vehicle without radio communication entering maneuvering area shall be guided by “follow me car”. d. Required air traffic controller to record towing movement on the flight progress strip. e. Required to reduce the lights intensity in the tower cab while providing air traffic services at night. On 28 April 2016, issued NOTAM number A1268/16 for all departure aircraft that using runway 24 to initiate the acceleration for takeoff at threshold runway 24. On 1 November 2016, issued NOTAM number A3291/16, informed that the Halim Ground Control services was operated for trial on frequency 118.6 Mhz until 4 January 2017. On 3 January 2017, the Halim Ground Control services trial was extended until 3 April 2017 and on 24 March 2017, the trial re-extended until 9 June 2017. Responding to KNKT safety recommendation, on 7 April 2016, the AirNav Indonesia issued safety notice addressed to all air traffic control units as follows: a. Required all towing aircraft to switch on the navigation lights. REGISTRASI PESAWAT TANGGAL NO TANGGAL b. Required all towing aircraft to communicate in INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS published towerTANGGAPAN frequency. (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED) c. Required all vehicle without radio communication entering maneuvering area shall be guided by “follow me car”. d. Required air traffic controller to record towing movement on the flight progress strip. e. Required to reduce the lights intensity in the tower cab while providing air traffic services at night. On 28 April 2016, issued NOTAM number A1268/16 for all departure aircraft that using runway 24 to initiate the KNKT.16.04.07.04 - Batik acceleration for takeoff at threshold runway 24. Air Indonesia and On 1 November 2016, issued NOTAM number TransNusa Aviation A3291/16, informed that the Halim Ground Control Boeing 737-800 (PK-LBS) AirNav Indonesia services was operated for trial on frequency 118.6 Mhz and ATR 42-600 (PK-TNJ) It is recommended to ensure the taxi or towing clearance issued contains explicit PK-LBS & PK-TNJ 4-Apr-2016 2016 Final Report 10-Apr-2017 District Office Halim 04 A 2017 7 8 CLOSED 19-Sep-2016 until 4 January 2017. On 3 January 2017, the Halim PENGAWASAN Halim Perdanakusuma limit to cross or to hold short of runway as required by AC 170. Perdanakusuma Ground Control services trial was extended until 3 April International Airport, 2017 and on 24 March 2017, the trial re-extended until 9 Jakarta June 2017. Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) It is recommended to reinforce the implementation of the KNKT AirNav Indonesia Published NOTAM number A1844/17 NOTAMN which and ATR 42-600 (PK-TNJ) recommendation (04.B-2016-57.1) which is to inform aircraft operators to PK-LBS & PK-TNJ 4-Apr-2016 2016 Final Report 10-Apr-2017 District Office Halim 04 A 2017 7 9 Lining up CLOSED 29-Nov-2018 instructed all departure aircraft to initiate takeoff (open ATURAN Halim Perdanakusuma initiate takeoff from the threshold runway 24 of Halim Perdanakusuma power) after the threshold runway 24. International Airport, Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) Angkasa Pura II Published NOTAM number A1268/16 NOTAMN to and ATR 42-600 (PK-TNJ) Branch Office Halim To inform the aircraft operators to initiate takeoff from the threshold runway 24 PK-LBS & PK-TNJ 4-Apr-2016 2016 Preliminary Report 4-May-2016 04 B 2016 57 1 Lining up CLOSED remind all pilot to takeoff (open power) after the ATURAN Halim Perdanakusuma Perdanakusuma of Halim Perdanakusuma International Airport threshold runway 24. International Airport, International Airport Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Issued safety notice to all aircraft operator, ground Boeing 737-800 (PK-LBS) Angkasa Pura II handling service and fuel supplier service to include the and ATR 42-600 (PK-TNJ) Branch Office Halim To develop procedure for vehicle and aircraft on the manoeuvring area shall be SOP development - lighting PK-LBS & PK-TNJ 4-Apr-2016 2016 Preliminary Report 4-May-2016 04 B 2016 54 1 CLOSED 16-Sep-2016 KNKT recommendation to their standard operating ATURAN Halim Perdanakusuma Perdanakusuma equipped with serviceable lights visible by air traffic controller. for aircraft manoeuver procedure while operating vehicle and/or aircraft on the International Airport, International Airport manoeuvring area. Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) It is recommended to reinforce the implementation of the KNKT Angkasa Pura II and ATR 42-600 (PK-TNJ) recommendation (04.B-2016-57.1) which is to inform aircraft operators to PK-LBS & PK-TNJ 4-Apr-2016 2016 Final Report 10-Apr-2017 Branch Office Halim 04 B 2017 7 9 OPEN NIL PENGAWASAN Halim Perdanakusuma initiate takeoff from the threshold runway 24 of Halim Perdanakusuma International Airport, Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) Directorate General and ATR 42-600 (PK-TNJ) To develop procedure for vehicle and aircraft on the manoeuvring area shall be PK-LBS & PK-TNJ 4-Apr-2016 2016 Preliminary Report 4-May-2016 of Civil Aviation 04 R 2016 55 1 DKPPU CLOSED 24-Jan-2018 Letter from DGCA 252/DBU/I/2018 ATURAN Halim Perdanakusuma equipped with serviceable lights visible by air traffic controller (DGCA) International Airport, Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) Directorate General To review a requirement for all aircraft movement on the manoeuvring area and ATR 42-600 (PK-TNJ) PK-LBS & PK-TNJ 4-Apr-2016 2016 Preliminary Report 4-May-2016 of Civil Aviation 04 R 2016 56 1 including the aircraft movement without aircraft own power, to communicate DKPPU OPEN NIL PENGAWASAN Halim Perdanakusuma (DGCA) with air traffic controller on the same frequency. International Airport, Jakarta Republic of Indonesia 4 April 2016 REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) Directorate General It is recommended to review the procedure of aircraft movement on and ATR 42-600 (PK-TNJ) PK-LBS & PK-TNJ 4-Apr-2016 2016 Final Report 10-Apr-2017 of Civil Aviation 04 R 2017 7 10 maneuvering area for airport operator and air navigation provider to DKPPU OPEN NIL PENGAWASAN Halim Perdanakusuma (DGCA) accommodate the requirement of CASR 91.209. International Airport, Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) Directorate General and ATR 42-600 (PK-TNJ) It is recommended to review the requirement of personnel licensing for towing PK-LBS & PK-TNJ 4-Apr-2016 2016 Final Report 10-Apr-2017 of Civil Aviation 04 R 2017 7 11 OPEN NIL PENGAWASAN Halim Perdanakusuma car driver as required by the ICAO standard. (DGCA) International Airport, Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) The CASR 170 Air Traffic Rules subpart 170.039 point (4) mentions the Refer to Directorate of Air Navigation Letter No. Directorate General and ATR 42-600 (PK-TNJ) statement “subject to the provisions in 3.8.3” that referred to chapter of ICAO AU.304/4/115/DJPU.DNP.2017 dated 13 June 2017, PK-LBS & PK-TNJ 4-Apr-2016 2016 Final Report 10-Apr-2017 of Civil Aviation 04 R 2017 7 12 CLOSED PENGAWASAN Halim Perdanakusuma Annex 11. they are in the middle of CASR 170 revision in according (DGCA) International Airport, It is recommended to review the contain of CASR to ensure its clarity with ICAO Annex 11 Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Halim has runway length of 3,000 meters and was displaced 200 meters. Boeing 737-800 (PK-LBS) Refer to Directorate of Air Navigation Letter No. Directorate General However, the published Aeronautical Information Publication (AIP) Volume I and ATR 42-600 (PK-TNJ) AU.304/4/115/DJPU.DNP.2017 dated 13 June 2017, the PK-LBS & PK-TNJ 4-Apr-2016 2016 Final Report 10-Apr-2017 of Civil Aviation 04 R 2017 7 13 Amendment 28, did not contain information that the total runway length is CLOSED ATURAN Halim Perdanakusuma AIP of Halim Perdanakusuma Airport declared Landing (DGCA) reduced to 2,800 meters. International Airport, Distance Avaiable (LDA) is 2,800 metres It is recommended to update the current published AIP. Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) It is recommended that the operator enhances the FCTM chapter 3.24 Rejected and ATR 42-600 (PK-TNJ) PT. Batik Air Takeoff Decision which is the PIC should announce the abnormality PK-LBS & PK-TNJ 4-Apr-2016 2016 Final Report 10-Apr-2017 04 O 2017 7 1 OPEN NIL ATURAN Halim Perdanakusuma Indonesia simultaneously. International Airport, Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) It is recommended that the operator to review the evacuation procedure and and ATR 42-600 (PK-TNJ) PT. Batik Air PK-LBS & PK-TNJ 4-Apr-2016 2016 Final Report 10-Apr-2017 04 O 2017 7 2 consider the area can be observed through the viewing windows. OPEN NIL PENGAWASAN Halim Perdanakusuma Indonesia International Airport, Jakarta Republic of Indonesia 4 April 2016 REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) Ensure the aircraft adequately lighted during night operation in accordance with and ATR 42-600 (PK-TNJ) PT. TransNusa Quality Notice No. QN-TAM/018/IV/16 Tanggal 11 April PK-LBS & PK-TNJ 4-Apr-2016 2016 Final Report 10-Apr-2017 04 O 2017 7 3 CASR 91.209. CLOSED ATURAN Halim Perdanakusuma Aviation Mandiri 2016 International Airport, Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) and ATR 42-600 (PK-TNJ) PT. TransNusa Consider risk assessment, compliance to the regulation and specification Quality Notice No. QN-TAM/018/IV/16 Tanggal 11 April PK-LBS & PK-TNJ 4-Apr-2016 2016 Final Report 10-Apr-2017 04 O 2017 7 4 CLOSED PENGAWASAN Halim Perdanakusuma Aviation Mandiri required prior to issue the Engineering Instruction. 2016 International Airport, Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) It is recommended to review the requirement of personnel licensing for towing and ATR 42-600 (PK-TNJ) PT. Jasa Angkasa PK-LBS & PK-TNJ 4-Apr-2016 2016 Final Report 10-Apr-2017 04 L 2017 7 5 car driver as required by the regulation standard, including the language OPEN NIL PENGAWASAN Halim Perdanakusuma Semesta requirement. International Airport, Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) and ATR 42-600 (PK-TNJ) PT. Jasa Angkasa PK-LBS & PK-TNJ 4-Apr-2016 2016 Final Report 10-Apr-2017 04 L 2017 7 6 It is recommended to ensure the SOP of towing procedure is well implemented. OPEN NIL PENGAWASAN Halim Perdanakusuma Semesta International Airport, Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.09.04 - Global Aviation Flying School To introduce the student pilots with Approach and Landing Accident Reduction Cessna 172 G, PK-TGL Global Aviation Flying ALAR & Stabilize approach 19 PK-TGL 28-Apr-2016 2016 Final Report 12-May-2017 04 O 2016 9 1 (ALAR) training and stabilize approach criteria and to emphasized a go around OPEN NIL ATURAN Budiarto Airport, School criteria shall be made when does not meet the criteria. Tangerang Republic of Indonesia 28 April 2016

KNKT.16.05.10.04 - PT.LION MENTARI The aircraft LNI077 was taxi in the narrow area and no ground assistance AIRLINES ; AIRBUS A330 PT.LION MENTARI 20 PK-LEF & PK-LJR 1-Apr-2016 2016 Final 8-Jun-2018 04 O 2018 10 1 provided to the pilot, therefore KNKT recommends to consider to stop or request OPEN NIL ATURAN & B737-800 ; SOEKARNO- AIRLINES ground assistance during taxi in narrow area. HATTA AIRPORT ; 1 MAY 2016

Etihad Airways currently have multiple instances on each KNKT.16.05.13.04 - flight in which the passengers are advised to have their Etihad Airways seat belts fastened even when the seat belt signs are Airbus A330 -243; A6- switched off. The first is through public announcements. To enhance the safety reminder for passenger to fasten the seatbelt while 21 EYN A6-EYN 4-May-2016 2016 Preliminary Report 8-Jun-2016 Etihad Airways 04 O 2016 58 2 Use of seatbelt by passenger CLOSED These are made during the welcome announcement PENGAWASAN seating even though the seatbelt sign is off. Near Bangka Islands made by the captain prior to departure and the second Republic of Indonesia announcement, made by the cabin crew one minute 4 May 2016 after retraction of landing gear after takeoff. These public announcements are made on all passenger flights. REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.16.05.13.04 - Etihad Airways The Etihad Airways issued a Flight Operations Message Airbus A330 -243; A6- To ensure the pilot implementation of the Operations Manual Part-A chapter 12, Declaration of urgency (FOM-218) on 12-July-2016 reminding the entire Etihad EYN A6-EYN 4-May-2016 2016 Preliminary Report 8-Jun-2016 Etihad Airways 04 O 2016 59 1 CLOSED PENGAWASAN subchapter 12.12.1 regarding declaration of urgency message. message Airways flight crew community of the proper Near Bangka Islands phraseology and conditions to declare urgency. Republic of Indonesia 4 May 2016 KNKT.16.05.13.04 - Etihad Airways Airbus A330 -243; A6- The KNKT recommends the Etihad Airways to review the effectiveness of the use EYN A6-EYN 4-May-2016 2016 Final Report Etihad Airways 04 O 2016 13 1 OPEN NIL PENGAWASAN of seatbelt policies to ensure passenger fastened their seatbelt when seated. Near Bangka Islands Republic of Indonesia 4 May 2016 KNKT.16.05.13.04 - Etihad Airways Airbus A330 -243; A6- The KNKT recommends the Etihad Airways to ensure pilot conducts NITS briefing EYN A6-EYN 4-May-2016 2016 Final Report Etihad Airways 04 O 2016 13 2 after abnormal flight event as described in the Safety Emergency & Procedure OPEN NIL PENGAWASAN Near Bangka Islands manual in the subchapter 8.1.2. Republic of Indonesia 4 May 2016 KNKT.16.05.13.04 - Etihad Airways Airbus A330 -243; A6- Directorate General KNKT recommends the DGCA to enforce the Indonesia aircraft operators to EYN A6-EYN 4-May-2016 2016 Final Report of Civil Aviation 04 R 2016 13 3 review the effectiveness of the use of seatbelt policies to ensure passenger DKPPU OPEN NIL PENGAWASAN Near Bangka Islands (DGCA) fastened their seatbelt when seated. Republic of Indonesia 4 May 2016 KNKT.16.06.21.04 - Nusa Flying School Cessna 172P; PK-NIV Demak, Central Java Nusa Flying To review the training syllabus for instructor and student training to ensure Seluruh instruktur memberikan arahan mengenai sistem PK-NIV 20-Jun-2016 2016 Final Report 12-May-2017 04 O 2016 21 1 Training syllabus review CLOSED PENGAWASAN 06°48.094’S, International correct understanding to the aircraft system. bahan bakar sesuai dengan checklist (Training Syllabus). 110°35.011’E Republic of Indonesia 20 June 2016 KNKT.16.06.21.04 - Nusa Flying School Cessna 172P; PK-NIV Demak, Central Java Nusa Flying Mengeluarkan Internal Memo (NFI/IO/01/VI/2016), PK-NIV 20-Jun-2016 2016 Final Report 12-May-2017 04 O 2016 21 2 To use fuel that meet the engine requirement. Fuel Usage CLOSED ATURAN 22 06°48.094’S, International menggunakan 100%avgas. 110°35.011’E Republic of Indonesia 20 June 2016 KNKT.16.06.21.04 - Nusa Flying School Cessna 172P; PK-NIV Directorate General Demak, Central Java PK-NIV 20-Jun-2016 2016 Final Report 12-May-2017 of Civil Aviation 04 R 2016 21 3 To ensure all instructors have adequate knowledge to the aircraft system. DKPPU OPEN NIL ATURAN 06°48.094’S, (DGCA) 110°35.011’E Republic of Indonesia 20 June 2016

KNKT.16.10.32.04 - PT. Asian One Air Cessna 208B EX; PK-LTV To ensure the operation of flights conducted under Visual Flight Rules (VFR) Operation of flight conducted under Visual Flight 23 PK-LTV 13-Oct-2016 2016 Preliminary Report 8-Oct-2016 Asian One Air 04 O 2016 94 1 VFR implementation CLOSED 20-Feb-2018 PENGAWASAN Ilaga Airport, Papua performs according to the VFR limitations. Rules (VFR) are described in the COM part 6.5 Republic of Indonesia 13 October 2016

KNKT.16.11.40.04 - PT. Nusa Flying International Management NFI mengeluarkan Internal Memo Cessna 172P; PK-NIZ Nusa Flying To ensure the maintenance action performed recorded in the Maintenance Log (NFI/011/IOM/KS/III/2018), setiap pekerjaan/inspection 24 Adi Soemarmo PK-NIZ 16-Oct-2016 2016 Preliminary Report 19-Dec-2016 04 O 2016 95 1 Maintenance Record CLOSED 14-Mar-2018 PENGAWASAN International Book. dan pergantian komponen ditulis dan di record di International Airport maintenance Log Book. Republic of Indonesia 16 November 2016

KNKT.16.10.37.04 - Perkumpulan Penerbangan Alfa Indonesia Perkumpulan According to factual information and initial findings, the Komite Nasional 25 DHC – 4 Caribou, PK-SWW 31-Oct-2016 2016 Preliminary Report 29-Nov-2016 Penerbangan Alfa 04 O 2016 38 1 Keselamatan Transportasi (KNKT) recommend to Perkumpulan Penerbangan Alfa OPEN NIL PENGAWASAN PK‐SWW Indonesia Indonesia to comply the DGCA Safety Circular number SE.24 of 2016. Ilaga Pass, Papua Republic of Indonesia 31 October 2016

KNKT.16.12.43.04 - PT. Wings Abadi Airlines The aircraft touched down and bounced twice. After the second bounce, the ATR 72-212A; PK-WGW pilot attempted to go around and the aircraft touched the runway. According to Ahmad Yani PT. Wings Abadi 26 PK-WGW 25-Dec-2016 2016 Preliminary Report 24-Jan-2017 04 O 2016 43 1 the OM Part A and SOP for ATR 72-600 a go around shall be performed if a hard CLOSED PENGAWASAN International Airport, Airlines and/or high bounce occurs. Therefore, KNKT recommends reviewing the bounce recovery training for all pilots. Republic of Indonesia 25 December 2016 REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.16.12.43.04 - PT. After the RFFS personnel arrived near the aircraft to assist the evacuation, the Wings Abadi Airlines tower controller advised the pilot to shut down the engines, thereafter the ATR 72-212A; PK-WGW engines were shutdown. This condition might harm the RFFS personnel and/or Ahmad Yani PT. Wings Abadi PK-WGW 25-Dec-2016 2016 Preliminary Report 24-Jan-2017 04 O 2016 43 2 passenger which evacuated before command by the flight crew members. It also CLOSED PENGAWASAN International Airport, Airlines could prolong the evacuation process. Therefore, KNKT recommends reviewing Semarang the emergency evacuation training including join training of flight crew and flight Republic of Indonesia attendant. 25 December 2016

KNKT.16.12.43.04 - PT. Wings Abadi Airlines ATR 72-212A; PK-WGW Ahmad Yani PK-WGW 25-Dec-2016 2016 FINAL REPORT 8-Jan-2019 International Airport, Semarang Republic of Indonesia 25 December 2016

perpanjangan landas pacu dan pembualan RESA lelah diprogramkan dalam kegialan Tahun Anggaran 2018 sebagai berikul : 1. Konslruksi perpanjangan dan peJebaran runway Bandar Udara lIIaga dari KNKT.16.12.45.04 - PT. 600 x 18 m menjadi 700 x 32 m lermasuk marking dan ASI Pudjiastuti Aviation pengawasan KNKT recommend to the DGCA to review the runway length and consider to Pilatus Porter PC-6, PK- Directorate General (Perpanjangan runway dilaksanakan secara bertahap extend the runway and provide the runway end safety area at the end of runway BVM PK-BVM 31-Dec-2016 2016 Preliminary Report 6-Jan-2017 of Civil Aviation 04 R 2016 45 1 CLOSED 27-Feb-2018 sampai dengan 1150 ATURAN 25 to minimize aircraft overrun and damaged to the aircraft in the case of Ilaga Airport (DGCA) x 30 m sesuai rencana induk); overrun occurred. Republic of Indonesia 2. Penyiapan lahan perpanjangan Bandar Udara Iliaga 31 December 2016 Tahap II lennasuk pengawasan. a) Lahan area perpanjangan Tahap II difungsikan sebagai RESA lerhadap hasil perpanjangan runway Tahap I; b) Panjang lahan yang akan lersedia yailu 210 m.

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation Pilatus Porter PC-6, PK- Directorate General lelah ada pakel pekerjaan pengadaan dan pemasangan KNKT recommend to the DGCA to review the installation navigation aid such as BVM PK-BVM 31-Dec-2016 2016 Preliminary Report 6-Jan-2017 of Civil Aviation 04 R 2016 45 2 DKPPU CLOSED 27-Feb-2018 APAPI dan RTIL 1 ujung 1 sisi volume 1 pakel pada ATURAN PAPI or VASI to prevent the visual illusion. Ilaga Airport (DGCA) runway 25 daJam Tahun Anggaran 2018. Republic of Indonesia 31 December 2016

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation Apron Bandar Udara lIIaga lelah diprogramkan dalam Pilatus Porter PC-6, PK- Directorate General KNKT recommend to the DGCA to consider to expand the apron dimension to kegialan Tahun Anggaran 2017 dan 2018, sehingga pada BVM PK-BVM 31-Dec-2016 2016 Preliminary Report 6-Jan-2017 of Civil Aviation 04 R 2016 45 3 increase the capacity to be able to accommodate more aircraft. CLOSED 27-Feb-2018 akhir Tahun 2018 akan lersedia apron dengan dimensi 60 ATURAN Ilaga Airport (DGCA) x 80 m (semula 30 x 60 m) dan laxiway Republic of Indonesia 75 x 15 m (semula 19 x 18 mi. 31 December 2016

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation KNKT recommend to the DGCA and AirNav Indonesia to establish the Pilatus Porter PC-6, PK- Directorate General standard departure and arrival route guidance to Ilaga and to review the BVM PK-BVM 31-Dec-2016 2016 Preliminary Report 6-Jan-2017 of Civil Aviation 04 R 2016 45 6 OPEN ATURAN possibility of upgrading the air traffic services to aerodrome control area Ilaga Airport (DGCA) (ADC). Republic of Indonesia 31 December 2016

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation Pilatus Porter PC-6, PK- Directorate General KNKT recommend to the DGCA and Airnav Indonesia to review the facility BVM PK-BVM 31-Dec-2016 2016 Preliminary Report 6-Jan-2017 of Civil Aviation 04 R 2016 45 7 OPEN PENGAWASAN to support the performance of duty personnel. Ilaga Airport (DGCA) Republic of Indonesia 31 December 2016

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation Pilatus Porter PC-6, PK- Directorate General BVM PK-BVM 31-Dec-2016 2016 Preliminary Report 6-Jan-2017 of Civil Aviation 04 R 2016 45 8 KNKT recommend to the DGCA to review the aircraft operator SOP. DKPPU OPEN NIL ATURAN Ilaga Airport (DGCA) Republic of Indonesia 31 December 2016

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation 27 There was no direct VFR route from Timika to Ilaga based on the VFR route Pilatus Porter PC-6, PK- Directorate General Ditnavpen akan memprogramkan pembuatan rute which was published on Aeronautical Information Publication (AIP) Indonesia BVM PK-BVM 31-Dec-2016 2016 Preliminary Report 6-Jan-2017 of Civil Aviation 04 R 2016 45 9 CLOSED 27-Mar-2018 Timika-Ilaga dengan mengundang stake holder dan ATURAN Amendment 31 dated 5 April 2012, KNKT recommends to review and update the Ilaga Airport (DGCA) Perum LPPNPI untuk pembahasannya. VFR routes within area of Papua to include Timika - Ilaga. Republic of Indonesia 31 December 2016 27

REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation Pilatus Porter PC-6, PK- Considering the number of flight per day and the availability of meteorological BVM PK-BVM 31-Dec-2016 2016 Preliminary Report 6-Jan-2017 BMKG 04 L 2016 45 10 station, KNKT recommends to the BMKG to consider the installation of OPEN NIL ATURAN Ilaga Airport meteorology observation instrument in Ilaga Republic of Indonesia 31 December 2016

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation Revised visual departure, arrival and approach To establish the standard departure and arrival route Pilatus Porter PC-6, PK- procedure for Illaga Airport and had been inserted to the guidance to Ilaga and to review the possibility of upgrading the air traffic Standard and arrival BVM PK-BVM 31-Dec-2016 2016 Preliminary Report 6-Jan-2017 AirNav Indonesia 04 A 2016 45 11 CLOSED 29-Nov-2018 AIRAC AIP Supplement number 19/17. ATURAN services to aerodrome control area (ADC). guidance Ilaga Airport Conducted safety assessment to upgrade the ATS in Ilaga Republic of Indonesia from AFIS to TWR. 31 December 2016

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation Pilatus Porter PC-6, PK- to review the facility to support the performance of duty AWOS and AFTN had been installed to support the ATS in BVM PK-BVM 31-Dec-2016 2016 Preliminary Report 6-Jan-2017 AirNav Indonesia 04 A 2016 45 12 ATS Facility CLOSED 29-Nov-2018 PRASARANA personnel. Ilaga Ilaga Airport Republic of Indonesia 31 December 2016

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation Pilatus Porter PC-6, PK- PT. ASI Pudjiastuti KNKT recommend to the aircraft operators to support the pilot decision and not BVM PK-BVM 31-Dec-2016 2016 Preliminary Report 6-Jan-2017 04 O 2016 45 13 OPEN NIL ATURAN Airline to apportion blame for pilot conducts RTB or diversion. Ilaga Airport Republic of Indonesia 31 December 2016

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation Pilatus Porter PC-6, PK- PT. ASI Pudjiastuti KNKT recommend to the aircraft operator to consider the BVM PK-BVM 31-Dec-2016 2016 Preliminary Report 6-Jan-2017 04 O 2016 45 14 OPEN NIL ATURAN Airline used of bigger capacity aircraft type to reduce the frequency of flight to Ilaga. Ilaga Airport Republic of Indonesia 31 December 2016

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation Pilatus Porter PC-6, PK- PT. ASI Pudjiastuti KNKT recommend to the aircraft operator to emphasize the EGPWS provider to BVM PK-BVM 31-Dec-2016 2016 Preliminary Report 6-Jan-2017 04 O 2016 45 15 OPEN NIL ATURAN Airline provide the high resolution terrain database in the mountainous area of Papua. Ilaga Airport Republic of Indonesia 31 December 2016

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation Pilatus Porter PC-6, PK- KNKT recommends to review the pilot qualification and requirements to fly to an PT. ASI Pudjiastuti BVM PK-BVM 31-Dec-2016 2016 Preliminary Report 6-Jan-2017 04 O 2016 45 1 airport with special circumstances such as Ilaga. OPEN NIL PENGAWASAN Airline Ilaga Airport Republic of Indonesia 31 December 2016

KNKT.17.01.02.04 ; PT. MANDIRI UTAMA FLIGHT ACADEMY ; PT. MANDIRI UTAMA KNKT recommend to improve the training including demonstration to ensure 28 PK-MUA 16-Jan-2017 2017 Final 8-Jun-2018 4 O 2018 2 1 OPEN NIL ATURAN BLIMBINGSARI AIRPORT, FLIGHT ACADEMY student pilots understanding of correct approach and landing technique. BANYUWANGI ; 16 JANUARI 2017

KNKT.17.01.02.04 ; PT. MANDIRI UTAMA FLIGHT ACADEMY ; BLIMBINGSARI KNKT recommend to improve the rescue and firefighting personnel training to PK-MUA 16-Jan-2017 2017 Final 8-Jun-2018 4 B 2018 2 2 OPEN NIL ATURAN BLIMBINGSARI AIRPORT, AIRPORT OPERATOR ensure the personnel ability to handle the actual emergency. BANYUWANGI ; 16 JANUARI 2017

Direktorat Keamanan Penerbangan akan melaksanakan audit terhadap Bandar Udara KNKT.17.01.02.04 ; PT. Banyuwangi di bidang Rencana Penanggulangan Keadaan MANDIRI UTAMA Darurat Bandar Udara (Airport Emergency Plan] dan Ineffectiveness of fire extinguishing process in Banyuwangi Airport may also FLIGHT ACADEMY ; Pertolongan Kecelakaan PK-MUA 16-Jan-2017 2017 Final 8-Jun-2018 DGCA 4 R 2018 2 3 occur in other airports. KNKT recommend to review oversight process to ensure CLOSED 21-Nov-2018 PENGAWASAN BLIMBINGSARI AIRPORT, Penerbangan dan Pemadam Kebakaran (PKP-PK) sesuai the ARFF ability for extinguishing the fire effectively. BANYUWANGI ; 16 dengan Surat Direktur Jenderal Perhubungan Udara JANUARI 2017 Nomor 1394/DKP/XI/2018 tanggal 06 November 2018 perihal audit AEP dan PKP-PK. REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

Sesuai dengan Surat Perjanjian Pengadaan Barang/Jasa KNKT.17.02.06.04 - PT. Nomor: PBJJOG-16001698 Bandara Internasional Garuda Indonesia Angkasa Pura I Adisutjipto Yoyakarta dalam progress pelaksanaan Boeing 737-800; PK-GNK Branch Office KNKT recommends ensuring that the runway centerline marking is clearly visible pekerjaan overlay sejak tanggal 31 Oktober 2016 s.d 29 29 Adisutjipto International PK-GNK 1-Feb-2017 2017 Preliminary Report 29-Mar-2017 04 B 2017 6 1 CLOSED PRASARANA Adisutjipto during aircraft operation. April 2017. Pekerjaan pengecatan marka sementara dan Airport, Yogyakarta International Airport permanen termasuk Mrka Runway Centreline Marking Republic of Indonesia menjadi satun paket pekerjaan yang termuat dalam 1 February 2017 kontrak tersebut. Bandara Internasional Adisutjipto Yogyakarta saait ini dalam proses pelaksanaan updating Aerodrome Manual yang mana frekuensi inspeksi runway, taxyway dan KNKT.17.02.06.04 - PT. apron sudah disesuaikan dengan SOP menjadi dua kali Garuda Indonesia sehari. Angkasa Pura I Boeing 737-800; PK-GNK Kegiatan inspeksi runway, taxyway dan apron di siang Branch Office reviewing and or amending the inspection schedule to ensure the Adisutjipto International PK-GNK 1-Feb-2017 2017 Preliminary Report 29-Mar-2017 04 B 2017 6 2 CLOSED hari telah dilaksanakan sejak tanggal 22 Maret 2017, PENGAWASAN Adisutjipto implementation is consistent with such manuals, Airport, Yogyakarta sesuai dengan Hasil Kesepakatan Bersama Rapat International Airport Republic of Indonesia Runway Safety Team tanggal 21 Maret 2017 dan sejak 1 February 2017 tanggal 13 April 2017 kegiatan tersebut telah dinotamkan.

PT. Pelita Iar Service issued Flight Safety Alert and conducted Safety Stand Down related to the event and KNKT.17.03.09.04 - PT. the parties issued Safety instruction and Notice To Pilot Service including but not limited to emphasize about syabilized ATR 72-212; PK-PAV approach criteria and do not hesitate to go around if it Halim Perdanakusuma To establish monitoring system in order to monitor the implementation of the has not been met. Furthermore to establish monitoring 30 PK-PAV 19-Mar-2017 2017 Preliminary Report 31-May-2017 PT. Pelita Air Services 04 O 2017 9 1 Monitoring System CLOSED 5-Jun-2018 PENGAWASAN International Airport, procedure for stabilized approach. system for the implementation of stabilized approach Jakarta procedure, PT. Pelita Air Service has reviewed, revised Republic of Indonesia and conduct the SOP of Flight Data Analisys (FDA). The 19 March 2017 flight-data is routinely analysed for safety related events or trends, the causes of those problems are identified and corected as required in all areas of flight operations.

KNKT.17.05.17.04 - PT. During the approach between altitude 500 feet to 200 feet, the EGPWS aural Boeing 737-300; PK-CJC warnings “Sink Rate” and “Pull Up” active, however the pilot elected to land the Rendani Airport, West PK-CJC 31-May-2017 2017 Preliminary Report 20-Sep-2017 PT. Sriwijaya Air 04 O 2017 17 1 aircraft. OPEN NIL PENGAWASAN Papua - Republic of KNKT recommends the aircraft operator to improve the flight crew Indonesia understanding and application of Stabilize Approach Criteria. 31 May 2017

KNKT.17.05.17.04 - The runway observation and CCTV record indicated that standing water present PT.Sriwijaya Air on the runway surface during and after rain and several runway lights were 31 Boeing 737-300; PK-CJC covered by grass. Rendani Airport, West PK-CJC 31-May-2017 2017 Preliminary Report 20-Sep-2017 Rendani Airport 04 B 2017 17 2 OPEN NIL PRASARANA Refer to the aforesaid condition, KNKT recommends the airport operator to Papua - Republic of takes necessary action to minimize the present of standing water and maintain Indonesia the runway lighting system alongside of runway. 31 May 2017

KNKT.17.05.17.04 - PT.Sriwijaya Air Rendani airport has not held Aerodrome Certificate and the Aerodrome Manual Boeing 737-300; PK-CJC Directorate General (AM) has not been approved by DGCA at the time of accident. KNKT recommend Rendani Airport, West PK-CJC 31-May-2017 2017 Preliminary Report 20-Sep-2017 of Civil Aviation 04 R 2017 17 3 OPEN NIL ATURAN DGCA to process the certification of aerodrome certificate for the Rendani Papua - Republic of (DGCA) airport. Indonesia 31 May 2017

KNKT.17.08.25.04 - PT. Lion Airlines dan PT. Wings Abadi Airlines 1. Meng-update dan ammandemend SOP ATS (Tower) Boeing 737-900ER; PK- KNKT recommends to ensure air traffic controller to comply with the dengan refer AC170-02 dan ICAO Doc 9432. 2. LJZ dan ATR 72-500;PK- 32 PK-LJZ dan PK-WFF 3-Aug-2017 2017 Preliminary Report 4-Sep-2017 Airnav Indonesia 04 A 2017 25 1 requirement of the AC170-02 and the ICAO Document 9432 if the conditional CLOSED Mensosialisasikan update dan amandement SOP ATS PENGAWASAN WFF clearance will be used. 9Tower) kepada seluruh personil ATC khususnya Personil Kulanamu International Tower Airport, Medan - Republic of Indonesia 3 August 2017

KNKT.17.08.25.04 - PT. Lion Airlines dan PT. Wings Abadi Airlines 1. Meng-update dan ammandemend SOP ATS (Tower) Boeing 737-900ER; PK- KNKT recommends to ensure air traffic controller to listen to the read-back in dengan refer AC170-02 dan ICAO Doc 9432. 2. LJZ dan ATR 72-500;PK- order to ascertain that the clearance or instruction has been correctly PK-LJZ dan PK-WFF 3-Aug-2017 2017 Preliminary Report 4-Sep-2017 Airnav Indonesia 04 A 2017 25 2 CLOSED Mensosialisasikan update dan amandement SOP ATS PENGAWASAN WFF acknowledged by the pilot and shall take immediate action to correct any 9Tower) kepada seluruh personil ATC khususnya Personil Kulanamu International discrepancies revealed by the read back. Tower Airport, Medan - Republic of Indonesia 3 August 2017 REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.17.08.25.04 - PT. Lion Airlines dan PT. Wings Abadi Airlines Me-refresh kembali kepada seluruh personil ATC Boeing 737-900ER; PK- khususnya personil Tower tentang prosedur Debris / LJZ dan ATR 72-500;PK- KNKT recommends air traffic controller to ensure all hazard on the runway is PK-LJZ dan PK-WFF 3-Aug-2017 2017 Preliminary Report 4-Sep-2017 Airnav Indonesia 04 A 2017 25 3 CLOSED FOD di runway sesuai LOCA antara Perum LPPNPI Kantor PENGAWASAN WFF properly mitigated without delay prior to issue takeoff or landing clearance. Cabang Madya Medan (Tower) dengan PT. Angkasa Pura Kulanamu International 2 Kualanamu (Unit Landasan) Airport, Medan - Republic of Indonesia 3 August 2017

On 3 August 2017, issued notice to pilot number 42/NTP/OMIW/VIII/2017 which contained the following KNKT.17.08.25.04 - PT. instruction: Lion Airlines dan PT.  To keep Airmanship and Situational Awareness at high Wings Abadi Airlines level in all phase of flight. Boeing 737-900ER; PK-  Sterile Cockpit Procedures are implemented to ensure KNKT recommends all pilots to ensure clearances or instructions, including LJZ dan ATR 72-500;PK- PT. Wings Abadi communications to or from the cockpit as well as PK-LJZ dan PK-WFF 3-Aug-2017 2017 Preliminary Report 4-Sep-2017 04 O 2017 25 4 conditional clearances, shall be read back or acknowledged in a manner to CLOSED PENGAWASAN WFF Airlines communications within the cockpit are restricted to clearly indicate that they have been understood and will be complied with. Kulanamu International safety and operational related communications to avoid Airport, Medan - distracting the flight crew from full attention to aircraft Republic of Indonesia maneuver and performance. 3 August 2017  All ATC clearance must be fully understood by both pilots before read back. If any doubt must be reconfirmed to ATC. KNKT.17.08.25.04 - PT. On 5 August 2017, issued notice to pilot number Lion Airlines dan PT. 44/NTP/OMIW/VIII/2017 which contained the following Wings Abadi Airlines instruction: Boeing 737-900ER; PK- KNKT recommends to ensure all pilots shall understand and comply the air LJZ dan ATR 72-500;PK- PT. Wings Abadi departure runways. Always avoid (whenever possible) PK-LJZ dan PK-WFF 3-Aug-2017 2017 Preliminary Report 4-Sep-2017 04 O 2017 25 5 traffic controller instruction or clearance and to clarify when there is uncertain CLOSED PENGAWASAN WFF Airlines depart from intersections. instruction or clearance. Kulanamu International Airport, Medan - crossing runways. Republic of Indonesia 3 August 2017 good monitoring to ATC instructions.

KNKT.17.08.25.04 - PT. Lion Airlines dan PT. Wings Abadi Airlines Boeing 737-900ER; PK- The AirNav Indonesia Branch Office Medan issued LJZ dan ATR 72-500;PK- The KNKT recommends to ensure air traffic controllers consider the possible PK-LJZ dan PK-WFF 3-Aug-2017 2017 Final 9-Apr-2018 AirNav Indonesia 04 A 2017 25 6 Use of RET for departure OPEN 27-Nov-2018 circular letter which is prohibit ATCo to use RET for PENGAWASAN WFF hazard when using RET for departure aircraft. departure aircraft. Kulanamu International Airport, Medan - Republic of Indonesia 3 August 2017

KNKT.17.08.25.04 - PT. Lion Airlines dan PT. Wings Abadi Airlines Boeing 737-900ER; PK- Deleted the phraseology of "after traffic on final landing LJZ dan ATR 72-500;PK- The KNKT recommends to review the ATS SOP to include detail procedure or PK-LJZ dan PK-WFF 3-Aug-2017 2017 Final 9-Apr-2018 AirNav Indonesia 04 A 2017 25 7 SOP review OPEN 27-Nov-2018 passing, line up behind" ATURAN WFF guideline for air traffic controller. Inserted prohibition to line up aircraft from RET. Kulanamu International Airport, Medan - Republic of Indonesia 3 August 2017

KNKT.17.08.25.04 - PT. Lion Airlines dan PT. Wings Abadi Airlines Boeing 737-900ER; PK- The AirNav Indonesia branch office Medan developed The KNKT recommends to review the performance check or other methods of LJZ dan ATR 72-500;PK- Unusual Condition procedure and included the Unusual PK-LJZ dan PK-WFF 3-Aug-2017 2017 Final 9-Apr-2018 AirNav Indonesia 04 A 2017 25 8 maintaining air traffic controller competency to ensure the air traffic controller Performance check review OPEN 27-Nov-2018 ATURAN WFF Condition procesure as briefing material during ability to handle unusual condition of aircraft operation. Kulanamu International performance check. Airport, Medan - Republic of Indonesia 3 August 2017

The KNKT recommend the FlyingSAS to increase pilot awareness of their medical condition and emphasize pilot who acquaint or experienced any decrease in 33 2017 26-May-2019 FlyingSAS 04 O 2018 10 1 OPEN PENGAWASAN medical fitness which could cause incapacitation to report to FlyingSAS management and the Director General of Civil Aviation.

The KNKT recommend the FlyingSAS to review and improve the hazard reporting 2017 26-May-2019 FlyingSAS 04 O 2018 10 2 OPEN ATURAN system including identification of operational safety issue.

The KNKT recommend the Aviation Medical Center to conduct the required Balai Kesehatan 2017 26-May-2019 04 R 2018 10 3 examination including ECG resting or ECG exercise in accordance with the CASR OPEN ATURAN Penerbangan part 67.

KNKT.17.04.10.04 - PT. The KNKT recommend the Aviation Medical Center to conduct examiner Spirit Avia Sentosa Balai Kesehatan 2017 26-May-2019 04 R 2018 10 4 workload analysis to adjust the ration of examiner and applicant so that the OPEN ATURAN (FlyingSAS); Cessna PK-FSO 12-Apr-2017 Final Penerbangan 2018; PK-FSO; Anem examination can be performed thoroughly. Mountain, Oksibil Papua KNKT.17.04.10.04 - PT. REGISTRASI PESAWAT TANGGAL NO TANGGAL SpiritINVESTIGASI Avia Sentosa INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (FlyingSAS);(INVESTIGATION) Cessna PK-FSO 12-Apr-2017 Final (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED) 2018; PK-FSO; Anem Mountain, Oksibil Papua The KNKT recommend the DGCA providing method and address to report any 2017 26-May-2019 04 R 2018 5 decrease in medical fitness which causes incapacitation by holder of medical OPEN ATURAN certificate.

The KNKT recommend the DGCA to review the implementation of Safety 2017 26-May-2019 04 R 2018 6 Management System including hazard reporting system by aircraft operator in OPEN PENGAWASAN regards to be able identifying operational safety issue.

KNKT.17.11.33.04 - PT. Wings Abadi Airlines & BP3 Banyuwangi - ATR Reminded all ATS personel of AirNav Indonesia branch The KNKT recommend to AirNav Indonesia to ensure air traffic controller Information transfer to 72-212A & CESSNA 172S PK-WHS & PK-BYK 21-Nov-2017 2017 Preliminary Report 29-Dec-2017 Airnav Indonesia 04 A 2017 33 1 OPEN 29-Nov-2018 Denpasar and Lombok to provides all necessary PENGAWASAN provides all necessary information to the accepting unit as stated in the SOP. adjacent unit Near point NAMP information to the accepting unit (no evidence) ISLAND, NTB 21 November 2017

KNKT.17.11.33.04 - PT. Wings Abadi Airlines & BP3 Banyuwangi - ATR Reminded all ATS personel of AirNav Indonesia branch The KNKT recommend to AirNav Indonesia to ensure air traffic controller 72-212A & CESSNA 172S PK-WHS & PK-BYK 21-Nov-2017 2017 Preliminary Report 29-Dec-2017 Airnav Indonesia 04 A 2017 33 2 Maintain listening watch OPEN 29-Nov-2018 Denpasar and Lombok to improve awareness during PENGAWASAN maintain listening watch to all communication. Near point NAMP duty (no evidence) ISLAND, NTB 21 November 2017

KNKT.17.11.33.04 - PT. Wings Abadi Airlines & BP3 Banyuwangi - ATR The KNKT recommends the BP3B to ensure all student pilots to comply with ATC 72-212A & CESSNA 172S PK-WHS & PK-BYK 21-Nov-2017 2017 Preliminary Report 29-Dec-2017 BP3 Banyuwangi 04 O 2017 33 3 OPEN NIL PENGAWASAN clearance including assigned altitude and aware of the right of way. 34 Near point NAMP ISLAND, NTB 21 November 2017

KNKT.17.11.33.04 - PT. Wings Abadi Airlines & BP3 Banyuwangi - ATR The KNKT recommends the BP3B to ensure all student pilots maintain listening 72-212A & CESSNA 172S PK-WHS & PK-BYK 21-Nov-2017 2017 Preliminary Report 29-Dec-2017 BP3 Banyuwangi 04 O 2017 33 4 OPEN NIL PENGAWASAN watch to air traffic controller communication. Near point NAMP ISLAND, NTB 21 November 2017

KNKT.17.11.33.04 - PT. Wings Abadi Airlines & BP3 Banyuwangi - ATR The KNKT recommends the BP3B to ensure SD data card for data logging is 72-212A & CESSNA 172S PK-WHS & PK-BYK 21-Nov-2017 2017 Preliminary Report 29-Dec-2017 BP3 Banyuwangi 04 O 2017 33 5 inserted in all aircraft that installed with Garmin G1000 for the purpose of OPEN NIL PENGAWASAN Near point NAMP enhancing safety. ISLAND, NTB 21 November 2017

The duty and flight hour of both pilot did not exceed the requirement of the OM KNKT.18.01.01.04; PT. – Part A however, the slip of altitude clearance between the pilot mind and the Batik Air Indonesia dan readback, the ability to monitor the other traffic communication and feeling PT. Lion Mentari Airlines; sleepy were indications of pilot fatigue. The fatigue might be caused by Airbus A320-200 dan PK-LUI & PK-LFP 6-Jan-2018 2018 Draft Final 24-Jul-2018 Batik Air Indonesia 04 O 2018 1 1 overnight flight which increasing of potential fatigue was not fully recovered, OPEN ATURAN Boeing 737-900ER; Near and the condition of the pilots woke up in early morning might reduce the time Waypoint Tirus for recovery sleep Surabaya, East of Java Therefore, KNKT recommends the Batik Air to establish fatigue risk management which may refer to ICAO Annex 6 and ICAO Document 9966.

35

KNKT.18.01.01.04; PT. Batik Air Indonesia dan The Indonesia regulation of fatigue management is described in the Civil Aviation PT. Lion Mentari Airlines; Safety Regulation (CASR) Part 91. However, the regulation did not contain detail Airbus A320-200 dan PK-LUI & PK-LFP 6-Jan-2018 2018 Draft Final 24-Jul-2018 Batik Air Indonesia 04 R 2018 1 2 guideline to establish fatigue risk management. OPEN ATURAN Boeing 737-900ER; Near Therefore, KNKT recommends the DGCA to review the regulation for fatigue risk Waypoint Tirus management. Surabaya, East of Java REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT,18,04,09,04 ; PT.LION MENTARI PT. Lion Air Mentari Improve the pilot training to ensure pilot understanding to the aircraft system 36 AIRLINES ; B737-900ER ; PK-LFK 1-Apr-2018 2018 Preliminary Report 8-Jun-2018 04 O 2018 9 1 OPEN ATURAN Airlines and performs procedure properly. ON ROUTE JAKARTA TO JAMBI

KNKT.18.04.10.04 - The operator utilized the company quick reference handbook (QRH) that was PT.WHITESKY AVIATION - PT.WHITESKY derived from the manufacture manual where the significant part was missing 37 HELIKOPTER BELL 429 - PK-WSX 20-Apr-2018 2018 Preliminary Report 30-May-2018 04 O 2018 10 1 OPEN NIL ATURAN AVIATION from the QRH, KNKT recommend to the operator to review and revised the MOROWALI, SULAWESI checklist to refer to the manufacture checklist. TENGAH

KNKT.18.04.12.04 - PT. Lion Mentari Airlines; The crash bell had not been connected to the Airport Rescue and Fire Fighting 38 Boeing 737-800; PK-LOO 29-Apr-2018 2018 Preliminary Report 30-Jun-2018 Djalaluddin Airport 04 B 2018 12 1 (ARFF) station. KNKT recommend Djalaluddin Airport Operator to establish all OPEN PRASARANA Djalaluddin Airport, equipment required for the standard airport services. Gorontalo

The stored GPS flight plan route on PK-FSP aircraft and the Route Information published by FlyingSAS on OM – Part C contained checkpoint TOPO for route Bilorai to Nabire while the stored GPS flight plan route on the PK-FSL aircraft and PK-FSL 18-Jun-2018 2018 FlyingSAS 04 O 2018 24 1 OPEN PENGAWASAN VFR Route Chart published on OM – Part C was not containing checkpoint TOPO. KNKT recommends the FlyingSAS to ensure the route guidance for pilot contains same information.

The AIP Volume IV of Nabire published by the DGCA contained different Conducted location check to the actual location of the coordinate of the NBR VOR/DME location. NBR VOR/DME and published NOTAM to disseminate PK-FSL 18-Jun-2018 2018 AirNav Indonesia 04 A 2018 24 2 KNKT recommends the AirNav Indonesia to provide correct information of the AIP information OPEN 29-Nov-2018 the correct coordinate of the NBR VOR/DME. Planned to PRASARANA NBR VOR/DME location to the DGCA and also review the possibility of other revise the AIP Volume IV of the NBR VOR/DME incorrect coordinate of navigation aid prior to publish in the AIP. coordinate.

KNKT.18.06.24.04 - In 2017, KNKT issued safety recommendation number 04.R-2015-17.6 which FlyingSAS; Cessna 208B; 39 Preliminary Report 11-Jul-2018 was recommend the Directorate General of Civil Aviation (DGCA) to publish the Nabire, Papua; 18 Juni visual route guidance for airport without instrument approach procedure and 2018 responded that the DGCA offered aircraft operator to submit draft visual guidance to DGCA and AirNav Indonesia for further discussion. During this occurrence, the AIP Volume IV did not include approach guidance for PK-FSL 18-Jun-2018 2018 DGCA 04 R 2018 24 3 OPEN ATURAN Nabire. The FlyingSAS issued route information of Nabire and Visual Flight Rules (VFR) chart for route Nabire – Sugapa (Bilorai) and return, this guidance was used for internal purpose. KNKT recommends the DGCA to ensure that the safety recommendation number 04.R-2015-17.6 which published in 2017 is performed for all Indonesian airports without instrument approach procedure.

The AIP Volume IV of Nabire published by the DGCA contained different coordinate of the NBR VOR/DME location. PK-FSL 18-Jun-2018 2018 DGCA 04 R 2018 24 4 KNKT recommends the DGCA to determine the correct coordinate of NBR OPEN ATURAN VOR/DME and also review the possibility of other incorrect coordinate of navigation aid in the AIP.

Short Term :

On June 25, 2018 - SSQ published Safety Notice 008 Date 25/06/2018 Landing or Attepted Landing on a closed runway or taxi way

On June 28, 2018 - Operation published Notice to All Crews, NTA/001/VI/2018 Upstream Defenses to prevent landing or Attepted Landing on a Closed Runway KNKT.18.06.25.04; PT. or Taxi Way. The flight was the first flight for the PIC and SIC to Tebelian Airport and there Wings Abadi Airlines; PT. Wings Abadi was no briefing related to the operation of new airport, therefore KNKT ATR 72-212; Sintang, PK-WHF 19-Jun-2018 2018 04 O 2018 25 1 CLOSED 21-Aug-2018 On June 22, 2018 – Flight Standard input AVG Tebelian, PENGAWASAN Airlines recommends to ensure the pilot provide with the current information before West Kalimantan; 19 Sintang on File Management System conducting flight. June 2018 Long Term :

On August 3, 2018 – Operation made Training Review Board (CRM), modules review of serious incident Sintang - (Done)

On August 15, 2018 – Evaluation for Material CRM between Training Departement Wings Air and ATC (Angkasa Training Centre) – (Done)

40 Preliminary Report REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

The flight Standard Depatement is responsible for ensuring that any revision to this manual are in the on line version. This OM will be controlled and current only in this webside and available on line in File Management System.

The aircraft had document library which contained several documents including (OAM – Operation Administration Manual, Preamble KNKT.18.06.25.04; PT. Airport Visual Guidance (AVG). The aircraft document library was updated on page 4/18, Electronic (Soft Copy). Wings Abadi Airlines; January 2018, while the AVG revision status was number 5 dated 25 August 40 Preliminary Report PT. Wings Abadi ATR 72-212; Sintang, PK-WHF 19-Jun-2018 2018 04 O 2018 25 2 2017. The AVG of the Sintang Airport available on the aircraft library and utilized CLOSED 21-Aug-2018 Short term : PENGAWASAN Airlines West Kalimantan; 19 by the pilot was published on 2 March 2018 and effective since 9 March 2018, June 2018 therefore KNKT recommends to ensure all the document provided for the flight The Flight Standard Departement already input AVG operation up to date and properly documented. SINTANG on June 22, 2018 – 10:23:40 wib.

Long Term :

All change in Airport Visual Guidance wil rised on Management of Change – and sure process distribute AVG to all controlled library.

KNKT.18.06.25.04; PT. On the AIP, the coordinate of TB NDB position was written 000230.07 S and Wings Abadi Airlines; 1112713.13 E, this format is not clearly describe decimal degrees format or ATR 72-212; Sintang, PK-WHF 19-Jun-2018 2018 DGCA 04 R 2018 25 3 OPEN PENGAWASAN degrees-minutes-second format, therefore KNKT recommends to ensure the West Kalimantan; 19 standard coordinate format in the AIP. June 2018

On the day of the occurrence, the Sintang Aiport information available on the KNKT.18.06.25.04; PT. website on page link AIP Volume IV contained information of Susilo Airport Wings Abadi Airlines; which had been closed for operation. The information of the Tebelian Airport ATR 72-212; Sintang, PK-WHF 19-Jun-2018 2018 DGCA 04 R 2018 25 4 OPEN PENGAWASAN available in the website on page link AIP Supplement, therefore KNKT West Kalimantan; 19 recommends to ensure only the current information available in the publication June 2018 and to remove the overdue information.

KNKT.18.06.25.04; PT. The un-serviceability mark of white cross on runway of Susilo Airport had not Wings Abadi Airlines; been completed at that time of occurrence, therefore KNKT recommends to ATR 72-212; Sintang, PK-WHF 19-Jun-2018 2018 DGCA 04 R 2018 25 5 OPEN PENGAWASAN ensure the process of airport certification are properly conducted before release West Kalimantan; 19 amendment of aerodrome certificate. June 2018

KNKT recommends the to ensure all flights are conducted at or 41 PK-HVQ 11-Aug-2018 2018 Dimonim Air 04 O 2018 32 1 OPEN PENGAWASAN above the required weather minima. KNKT.18.08.32.04; PT. Marta Buana Abadi (Dimonim Air); PAC Preliminary Report.pdf 750XL; Menuk Mountain Oksibil Papua; 11 August 2018 KNKT recommends the DGCA to ensure that the safety recommendation number PK-HVQ 11-Aug-2018 2018 DGCA 04 R 2018 32 2 04.R-2015-17.6 which published in 2017 and 04.R-2018-24.3 in 2018 to publish OPEN ATURAN the visual route guidance for airport without instrument approach procedure.

Refer to the CASR Part 91.7 Civil Aircraft Airworthiness and the Operation Manual part A subchapter 1.4.2, the pilot in command shall discontinue the flight when un-airworthy mechanical, electrical, or structural conditions occur. The flight from Denpasar to Jakarta experienced stick shaker activation during 42 29-Oct-2018 2018 Lion Air 04 O 2018 35 1 the takeoff rotation and remained active throughout the flight. This condition is OPEN PENGAWASAN considered as un-airworthy condition and the flight shall not be continued. KNKT recommend ensuring the implementation of the Operation Manual part A KNKT.18.10.35.04 PT. subchapter 1.4.2 in order to improve the safety culture and to enable the pilot to Lion Mentari Airlines; make proper decision to continue the flight. Boeing 737-8 MAX; PK-LQP Preliminary Report 28-Nov-2018 Tanjung Karawang, West Java; 29 October 2018 According to the weight and balance sheet, on board the aircraft were two pilots, five flight attendants and 181 passengers consisted of 178 adult, one child and two infants. The voyage report showed that the number of flight attendant 30-Oct-2018 2018 Lion Air 04 O 2018 35 2 on board was six flight attendants. This indicated that the weight and balance OPEN PENGAWASAN sheet did not contain actual information. KNKT recommend ensuring all the operation documents are properly filled and documented.

The PK-ASE aircraft was equipped with Global Positioning System (GPS) manufactured by Garmin with type/model G1000 which has capability of flight KNKT.18.12.41.04 PT. data logging that can be used as Flight Data Analysis for the safety management Alfa Trans Dirgantara; system and support the investigation process to enhance safety. During the PT. Alfa Trans 43 Cessna 208; Kasonaweja PK-ASE 12-Dec-2018 2018 Preliminary Report 29-Jan-2019 04 O 2019 41 1 occurrence, the GPS was not inserted with a Secure Digital (SD) data card to OPEN PENGAWASAN Dirgantara Airstrip, Papua; 12 record the flight data. Desember 2018 The KNKT recommends the Alfa Aviation to ensure SD data card for data logging is inserted in all aircraft that installed with Garmin G1000 for the purpose of enhancing safety. REGISTRASI PESAWAT TANGGAL NO TANGGAL INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA (RESPONSE NO (AIRCRAFT KEJADIAN (DATE SUMBER (SOURCE) DIKELUARKAN NO RECOMMENDATION REKOMENDASI (RECOMMENDATION) KEYWORD STATUS TANGGAPAN (RESPONSE) KATEGORI (CLASSIFICATION) (INVESTIGATION) (ADDRESS TO) DATE) REGISTRATION) OF OCCURRENCE) (DATE OF ISSUED)

KNKT.19.03.08.04 - PT. ..\..\..\00 Investigation Data\2019\008 PK-EAH Air Transport Services - 16032019\Correspondence Helikopter Bolkow BO \OUT\rekomendasi PT. Air Transport Meyakinkan management dan system perawatan dilaksanakan dengan benar 44 PK-EAH 16-Mar-2019 2019 29-Mar-2019 04 O 2019 8 1 OPEN PENGAWASAN 105 - Desa Jayaratu, segera\IK.203-1-8 KNKT Services sesuai prosedur yang berlaku Tasikmalaya, Jawa Barat - 2019 (Kecelakaan Helikopter Bolkow BO 105 16 Maret 2019 PK-EAH).pdf

Melaksanakan pemeriksaan ganda (double inspection atau required inspection 2019 04 O 2019 8 2 OPEN PENGAWASAN item) pada pekerjaan yang melibatkan flight control atau engine control.

JUMLAH 192