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Final Report Is Published by the Komite Nasional Keselamatan Transportasi (KNKT), Transportation Building, 3Rd Floor, Jalan Medan Merdeka Timur No

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Final Report Is Published by the Komite Nasional Keselamatan Transportasi (KNKT), Transportation Building, 3Rd Floor, Jalan Medan Merdeka Timur No KOMITE NASIONAL KESELAMATAN TRANSPORTASI REPUBLIC OF INDONESIA FINAL KNKT.18.08.32.04 Aircraft Accident Investigation Report PT. Marta Buana Abadi (Dimonim Air) PAC 750XL; PK-HVQ Menuk Mountain, Oksibil, Papua Republic of Indonesia 11 August 2018 2021 This Final Report is published by the Komite Nasional Keselamatan Transportasi (KNKT), Transportation Building, 3rd Floor, Jalan Medan Merdeka Timur No. 5 Jakarta 10110, Indonesia. The report is based upon the initial investigation carried out by the KNKT in accordance with Annex 13 to the Convention on International Civil Aviation, the Indonesian Aviation Act (UU No. 1/2009) and Government Regulation (PP No. 62/2013). Readers are advised that the KNKT investigates for the sole purpose of enhancing aviation safety. Consequently, the KNKT reports are confined to matters of safety significance and may be misleading if used for any other purpose. As the KNKT believes that safety information is of greaStest value if it is passed on for the use of others, readers are encouraged to copy or reprint for further distribution, acknowledging the KNKT as the source. When the KNKT makes recommendations as a result of its investigations or research, safety is its primary consideration. However, the KNKT fully recognizes that the implementation of recommendations arising from its investigations will in some cases incur a cost to the industry. Readers should note that the information in KNKT reports and recommendations is provided to promote aviation safety. In no case is it intended to imply blame or liability. Jakarta, 19 April 2021 KOMITE NASIONAL KESELAMATAN TRANSPORTASI CHAIRMAN SOERJANTO TJAHJONO TABLE OF CONTENTS TABLE OF CONTENTS ........................................................................................................ i TABLE OF FIGURES .......................................................................................................... iv ABBREVIATIONS AND DEFINITIONS ........................................................................... v SYNOPSIS ............................................................................................................................ vii 1 FACTUAL INFORMATION ......................................................................................... 8 1.1 History of the Flight............................................................................................... 8 1.2 Injuries to Persons................................................................................................ 11 1.3 Damage to Aircraft .............................................................................................. 11 1.4 Other Damage ...................................................................................................... 11 1.5 Personnel Information ......................................................................................... 11 1.5.1 Pilot in Command ................................................................................... 11 1.5.2 Other Pilot 1 ........................................................................................... 12 1.5.3 Other Pilot 2 ........................................................................................... 12 1.5.4 Oksibil Air Traffic Controller ................................................................ 13 1.6 Aircraft Information............................................................................................. 13 1.6.1 General ................................................................................................... 13 1.6.2 Weight and Balance ................................................................................ 14 1.6.3 Stall Warning System ............................................................................. 14 1.6.4 Ground Proximity Warning System/Terrain Awareness and Warning System .................................................................................................... 14 1.6.5 Global Positioning System ..................................................................... 15 1.6.6 Data Acquisition Alarm Monitor ........................................................... 17 1.6.7 Flight Following System ........................................................................ 18 1.7 Meteorological Information ................................................................................. 19 1.7.1 Tower Controller Observation ................................................................ 19 1.7.2 Satellite Image ........................................................................................ 20 1.8 Aids to Navigation ............................................................................................... 22 1.9 Communications .................................................................................................. 24 1.10 Aerodrome Information ....................................................................................... 25 1.11 Flight Recorders................................................................................................... 25 1.12 Wreckage and Impact Information ...................................................................... 26 1.13 Medical and Pathological Information ................................................................ 28 1.14 Fire ....................................................................................................................... 28 i 1.15 Survival Aspects .................................................................................................. 28 1.16 Tests and Research .............................................................................................. 30 1.17 Organizational and Management Information ..................................................... 30 1.17.1 Aircraft Operator .................................................................................... 30 1.17.1.1 Visual Flight Rules Weather Minimum Requirement .......... 31 1.17.1.2 Aerodrome Risk Classification ............................................. 32 1.17.1.3 Route and Airport Familiarization ........................................ 33 1.17.1.4 Operational Control and Supervision .................................... 34 1.17.1.5 Ground Proximity Warning System Requirement ................ 35 1.17.1.6 Pilot Training ........................................................................ 35 1.17.2 Air Traffic Service Provider ................................................................... 35 1.17.2.1 Traffic Circuit Policy ............................................................ 36 1.17.3 Civil Aviation Authority ........................................................................ 36 1.17.3.1 Ground Proximity Warning System Standard Requirement . 36 1.17.3.2 DGCA Oversight on the GPWS/TAWS Requirement Standard ................................................................................ 39 1.17.3.3 DGCA Oversight Activities on TAWS Requirement ........... 41 1.17.3.4 Provision of Aviation Meteorology Standard Requirement . 42 1.17.3.5 DGCA Oversight of the Provision of Aviation Meteorology Standard Requirement ..................................... 42 1.18 Additional Information ........................................................................................ 43 1.18.1 Recorded Electronic Data from Aircraft ................................................ 43 1.18.2 Survived Passenger Recollection ........................................................... 46 1.18.3 Investigation Process .............................................................................. 46 1.19 Useful or Effective Investigation Techniques ..................................................... 47 2 ANALYSIS ..................................................................................................................... 48 2.1 Aircraft Flight Profile .......................................................................................... 48 2.2 Situational Awareness Towards Terrain .............................................................. 49 2.3 Aircraft Operator Operational Control and Supervision ..................................... 51 2.4 Terrain Avoidance Warning System Compliances.............................................. 51 2.5 Provision of Meteorological Information ............................................................ 53 3 CONCLUSION .............................................................................................................. 55 3.1 Findings ............................................................................................................... 55 3.2 Contributing Factors ............................................................................................ 62 ii 4 SAFETY ACTION ........................................................................................................ 63 4.1 Directorate General of Civil Aviation ................................................................. 63 4.2 Dimonim Air ........................................................................................................ 63 5 SAFETY RECOMMENDATIONS ............................................................................. 64 5.1 Dimonim Air ........................................................................................................ 64 5.2 Directorate General of Civil Aviation ................................................................. 65 5.3 Badan Meteorologi Klimatologi dan Geofisika/Bureau of Meteorology, Climatology and Geophysics
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