Knkt 2021 / 04

STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE) KNKT.15.02.04.04 - PT. Directorate General Refer to analysis chapter 2.1, 2.2 and 2.3 of this report, the KNKT recommends PK-GAG 3-Feb 2015 Final Report 9-Dec 2016 04 R 2016 4 1 OPEN 9-Mar-2017 PENGAWASAN Garuda Indonesia of Civil Aviation that DGCA should oversight the implementation of recommendation KNKT.15.02.04.04 - PT. The handling of the aircraft was contrary to the wind condition. The KNKT Chief Pilot ATR has issued notice no. 03/15 and 04/15 PK-GAG 3-Feb 2015 Final Report 9-Dec 2016 Garuda Indonesia 04 O 2016 4 1 OPEN 27-Jan 2020 9-Mar-2017 ATURAN Garuda Indonesia recommends that the operator shall emphasized the crosswind handling. date 11 February 2015 to all ATR VP Flight Operations has issued notice no. 04/15 date on 9 February 2015 to all Flight Crew. 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 Chief Pilot ATR has issued notice no. 04/15 date 11 1 ATR 72‐600; PK‐GAG change over control of the flight at critical phase of flight without clear February 2015 to all ATR Flight Crew Lombok International PK-GAG 3-Feb 2015 Final Report 9-Dec 2016 Garuda Indonesia 04 O 2016 4 2 OPEN 27-Jan 2020 9-Mar-2017 PENGAWASAN statements. This condition may also extend to the other instructors within regarding “Safety Alertness Regarding Critical Phase of Airport the company. Therefore, KNKT recommends to review the policy of change Flight” which instructed all PiC to Republic of Indonesia over control at critical altitude. keep maintain situational awareness in all phase of 03 February 2015 flight (Approach and Landing) with follow procedures consistently at 500’ Agl PiC as Pilot KNKT.15.02.04.04 - PT. Angkasa Pura I Refer to analysis chapter 2.3 of this report, the KNKT recommends that the PK-GAG 3-Feb 2015 Final Report 9-Dec 2016 04 B 2016 4 1 OPEN 9-Mar-2017 NIL PRASARANA Garuda Indonesia Branch Office airport operator should improve the surfaces runway strip conditionto comply 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 PK-DGB 4-Mar 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 CLOSED 13-Mar 2018 11-Mar-2018 PENGAWASAN PK-DGB; Landing Technique 2 runway landing technique. Wamena Airport, Papua 4 Maret 2015 KNKT.15.03.06.04 - PT. During the approach, the visibility was reported 2-3 km and continuous heavy Ensure compliance to Weather Minimum prior to PK-DGB 4-Mar 2015 Interim Report 11-Dec 2017 Deraya Air 04 O 2017 6 2 CLOSED 13-Mar 2018 11-Mar-2018 PENGAWASAN DERAYA AIR - British rain, KNKT recommends to ensure the pilot to comply to the minimum initiate the approach. KNKT.15.03.07.04 - PT. Elang Nusantara Air - Agar melakukan evaluasi program Training dan implementasinya bagi Thrush S2R-T34; PK-ELN Immediate instruktur pilot yang akan mejalankan fungsinya sesuai kriteria pada approved Airstrip Tajur Baras, PK-ELN 13-Mar 2015 9-Dec 2016 Elang Nusantara Air 04 O OPEN 9-Mar-2017 NIL PENGAWASAN Recommendation Agriculture Manual terkait kemampuan teknis sesuai dengan rating atau tipe Waringin Timur, pesawat yang 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 Immediate 2016 Airstrip Tajur Baras, PK-ELN 13-Mar 2015 Recommendation 9-Dec Elang Nusantara Air 04 O operasi penerbangan agriculture sementara waktu sebelum posisi Chief Pilot OPEN 9-Mar-2017 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 Immediate Directorate General Memonitor dan mengawasi pelaksanaan rekomendasi KNKT pada butir 7.1. (a) Airstrip Tajur Baras, PK-ELN 13-Mar 2015 9-Dec 2016 04 R OPEN 9-Mar-2017 PENGAWASAN Recommendation of Civil Aviation dan (b) bagi PT. Elang Nusantara Air dan operator sejenis lainnya Waringin Timur, Kalimantan Tengah 13 Maret 2015

KNKT.15.03.07.04 - PT. Elang Nusantara Air - Thrush S2R-T34; PK-ELN Immediate Directorate General Melakukan review terkait pengoperasian pesawat jenis agriculture dengan Airstrip Tajur Baras, PK-ELN 13-Mar 2015 9-Dec 2016 04 R OPEN 9-Mar-2017 PENGAWASAN Recommendation of Civil Aviation sertifikasi AOC 135. Waringin Timur, Kalimantan Tengah 13 Maret 2015 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE) KNKT.15.03.08.04 - PT. Directorate General To ensure the implementation of safety action taken by Hevilift Aviation PK-FUP 21-Mar 2015 Preliminary Report 5-May 2015 04 R 2015 8 1 OPEN 3-Aug-2015 PENGAWASAN Hevilift Aviation of Civil Aviation Indonesia.

KNKT.15.03.08.04 - PT. Hevilift Aviation Indonesia 4 Sikorsky S76 C+ Directorate General To review the others Sikorsky similar operation’s Operator related to the Helicopter; PK-FUP PK-FUP 21-Mar 2015 Preliminary Report 5-May 2015 04 R 2015 8 2 OPEN 3-Aug-2015 PENGAWASAN of Civil Aviation training and the restriction of automation usage. Delta Mahakam river, 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 Final Report 9-Dec 2016 Garuda Indonesia 04 O 2016 7 1 CLOSED 5-Jan 2017 9-Mar-2017 PENGAWASAN development and its effects. include “adverse weather/ windshear” Makassar South Sulawesi Republic of Indonesia 2 June 2015

5 KNKT.15.06.13.04 - PT. To emphasis all pilot to perform go around when a safe landing cannot be 1. Publish Notice to Flight Crew no. 021/15 date 6 PK-GFA 2-Jun 2015 Final Report 9-Dec 2016 Garuda Indonesia 04 O 2016 8 2 CLOSED 5-Jan 2017 9-Mar-2017 PENGAWASAN Garuda Indonesia made. June 2015 regarding “Situational awareness during

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 Final Report 9-Dec 2016 AirNav Indonesia 04 A 2016 9 1 OPEN 9-Mar-2017 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 Directorate General Ninia Airstrip, PK-KIG 12-Aug 2015 Final Report 20-Jun 2016 04 R 2016 43 1 Accident Reduction (ALAR) as a required training component in the CASR Part OPEN 18-Sep-2016 ATURAN of Civil Aviation Yakuhimo, Papua 135. Republic of Indonesia 12 August 2015

KNKT.15.08.16.04 - PT. Komala Indonesia DBU akan mengarahkan agar penyelenggara Bandara PAC-750XL; PK-KIG The information of runway elevation of Ninia in ALA did not represent the Directorate General Ninia untuk mengajukan permohonan kepada Ninia Airstrip, PK-KIG 12-Aug 2015 Final Report 20-Jun 2016 04 R 2016 44 1 actual elevation. KNKT recommends reviewing the ALA to ensure the CLOSED 27-Mar 2018 18-Sep-2016 PENGAWASAN of Civil Aviation Direktorat Navigasi Penerbangan untuk pengukuran Yakuhimo, Papua information contents are valid. elevasi runway. Republic of Indonesia 12 August 2015

KNKT.15.08.16.04 - PT. Komala Indonesia PAC-750XL; PK-KIG Directorate General To provide a regulation which requires pilot to be trained for flight with Ninia Airstrip, PK-KIG 12-Aug 2015 Final Report 20-Jun 2016 04 R 2016 63 1 OPEN 18-Sep-2016 ATURAN of Civil Aviation unreliable airspeed. Yakuhimo, Papua Republic of Indonesia 12 August 2015 6

KNKT.15.08.16.04 - PT. Komala Indonesia PAC-750XL; PK-KIG Ninia Airstrip, PK-KIG 12-Aug 2015 Final Report 20-Jun 2016 Komala Indonesia 04 O 2016 40 1 To ensure pilot familiarization in conducting a flight to airport or airstrip. OPEN 18-Sep-2016 NIL PENGAWASAN Yakuhimo, Papua Republic of Indonesia 12 August 2015 6

KNKT.15.08.16.04 - PT. Komala Indonesia PAC-750XL; PK-KIG Ninia Airstrip, PK-KIG 12-Aug 2015 Final Report 20-Jun 2016 Komala Indonesia 04 O 2016 41 1 To provide pilot training in decision making especially in abnormal condition. OPEN 18-Sep-2016 NIL PENGAWASAN Yakuhimo, 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, PK-KIG 12-Aug 2015 Final Report 20-Jun 2016 Komala Indonesia 04 O 2016 42 1 OPEN 18-Sep-2016 NIL PENGAWASAN additional fleet Yakuhimo, Papua Republic of Indonesia 12 August 2015

KNKT.15.08.17.04 - PT. Trigana Air Service ATR 42-300; PK-YRN Directorate General To ensure that the recommendations addressed to the air operator are well PK-YRN 16-Aug 2015 Preliminary Report 16-Sep 2015 04 R 2015 17 1 OPEN 15-Dec-2015 PENGAWASAN Near Oksibil, Papua of Civil Aviation implemented. 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 ATR 42-300; PK-YRN Directorate General addition or system modification which affect to the aircraft operation. KNKT PK-YRN 16-Aug 2015 Final Report 27-Dec 2017 R OPEN 27-Mar-2018 PENGAWASAN Near Oksibil, Papua of Civil Aviation recommends to develop regulation requirement for training of any additional Republic of Indonesia or 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 Aircraft/ALA) did not include approach guidance. The operator issued visual penerbangan yang terbang pada rute tersebut dapat ATR 42-300; PK-YRN Directorate General PK-YRN 16-Aug 2015 Final Report 27-Dec 2017 4 R 2015 17 6 guidance of circling approach runway 11 for internal use. KNKT recommends CLOSED 27-Mar 2018 27-Mar-2018 menyampaikan draft Visual Guidance kepada ATURAN Near Oksibil, Papua of Civil Aviation to 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 developing airspace and obstacle clearance criteria. KNKT recommends to ATR 42-300; PK-YRN Directorate General Terrain dan area yang sempit. Ditnavpen telah PK-YRN 16-Aug 2015 Final Report 27-Dec 2017 4 R 2015 17 7 consider the application of Performance Based Navigation (PBN) approach for CLOSED 27-Mar 2018 27-Mar-2018 ATURAN Near Oksibil, Papua of Civil Aviation menawarkan proyek ini pada TAR untuk PBN, namun 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. Directorate General There was no information related to the status of ZX NDB published on Berdasarkan Notam C1226/16 Kondisi NDB Un- PK-YRN 16-Aug 2015 Final Report 27-Dec 2017 4 R 2015 17 8 CLOSED 27-Mar 2018 27-Mar-2018 PENGAWASAN Trigana Air Service of Civil Aviation NOTAM prior to the accident. KNKT recommends to ensure aeronautical Serviceable mulai 12 Maret 2016 hingga 1 April 2016. KNKT.15.08.17.04 - PT. Directorate General EGPWS has worldwide terrain coverage in low resolution terrain data including PK-YRN 16-Aug 2015 Final Report 27-Dec 2017 R OPEN 27-Mar-2018 PRASARANA Trigana Air Service of Civil Aviation several airports with significant traffic movements. The Oksibil Airport was not

KNKT.15.08.17.04 - PT. Trigana Air Service Memberikan informasi melalui NOTAM perihal NDB ZX Oksibil There was no information related to the status of ZX NDB published on ATR 42-300; PK-YRN sebagai berikut: (C1226/16 NOTAMN Q) PK-YRN 16-Aug 2015 Final Report 27-Dec 2017 Airnav Indonesia 4 A 2015 17 3 NOTAM prior to the accident. KNKT recommends to ensure the status of the CLOSED 26-Feb 2018 27-Mar-2018 WAFF/QNBAS/IV/BO/AE/000/999/0450S14026E025 A) WAJO PENGAWASAN Near Oksibil, Papua navigation aids disseminates to the air navigation user in timely manner. B)1603120249 C)16049107000 E)NDB ZX 342KHZ 7 Republic of Indonesia U/S DUE TO TECHNICAL REASON 16 August 2015 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS 7 INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE)

KNKT.15.08.17.04 - PT. The flight plan form was filed with intended to fly under instrument flight rule Melaksanakan perbaikan dalam rangka peningkatan pelayanan Trigana Air Service (IFR), at flight level 155, with route from Sentani to MELAM via airways W66 navigasi penerbangan meliputi : - ATR 42-300; PK-YRN Pengusulan Penerbitan AIP Indonesia (Vol III) - PK-YRN 16-Aug 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 CLOSED 26-Feb 2018 27-Mar-2018 PENGAWASAN Near Oksibil, Papua Mengikuti Indonesia PBN : ATR/Navblue Coorporation project - feet. KNKT recommends to ensure filing the flight plan and flight execution is Republic of Indonesia Optimalisasi pemberian informasi oleh unit terkait melalui AIP accordance with the regulation. Indonesia (Vol IV) 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 Final Report 16-Sep 2015 Trigana Air Services 04 O 2015 17 1 crew briefing, checklist reading, approach procedure and visual flight rules OPEN 15-Dec-2015 NIL PENGAWASAN Near Oksibil, Papua (VFR) minima and provide monitoring system. Republic of Indonesia 16 August 2015

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 Final Report 16-Sep 2015 Trigana Air Services 04 O 2015 17 2 OPEN 15-Dec-2015 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 PK-YRN 16-Aug 2015 Final Report 27-Dec 2017 Trigana Air Services O OPEN 27-Mar-2018 NIL PENGAWASAN Near Oksibil, Papua shall be reviewed to ensure contain correct information and easy to fly to Republic of Indonesia minimise 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 Final Report 27-Dec 2017 Trigana Air Services O recommends that any modification to the aircraft especially when the OPEN 27-Mar-2018 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 Airbus 330-200; PK-GPO Directorate General To enforce the development of cabin crew procedures by the operators to 8 PK-GPO 22-Aug 2015 Final Report 5-Dec 2016 04 R 2016 82 1 OPEN 5-Mar-2017 ATURAN Inflight from Melbourne of Civil Aviation adequately handle the dry ice on board the aircraft. to Jakarta 22 August 2015

KNKT.15.08.20.04 - PT. Cardig - Air Boeing 737-300 F; Reg. To ensure the establishment and maintenance of flight data analysis program Directorate General PK-BBY PK-BBY 28-Aug 2015 Final Report 15-Jun 2016 04 R 2016 50 1 as part of aircraft operator safety management system as stated in Civil OPEN 13-Sep-2016 ATURAN of Civil Aviation Wamena Airport Aviation 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. Cardig Air kepada Ketua PK-BBY PK-BBY 28-Aug 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 13-Sep-2016 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 improvement of ATC awareness during extreme bad PK-BBY PK-BBY 28-Aug 2015 Final Report 15-Jun 2016 Airnav Indonesia 04 A 2016 46 1 CLOSED 19-Sep 2016 13-Sep-2016 PENGAWASAN be 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 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS 9 INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE) KNKT.15.08.20.04 - PT. Cardig - Air Boeing 737-300 F; Reg. PK-BBY PK-BBY 28-Aug 2015 Final Report 15-Jun 2016 Wamena Airport 04 B 2016 47 1 To develop an aerodrome maintenance programme. OPEN 13-Sep-2016 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 Final Report 15-Jun 2016 Wamena Airport 04 B 2016 48 1 To review and improve the runway inspection system. OPEN 13-Sep-2016 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 Final Report 15-Jun 2016 Wamena Airport 04 B 2016 49 1 To install VASI on the runway 15. OPEN 13-Sep-2016 NIL PRASARANA Wamena Airport Republic of Indonesia 28 August 2015 KNKT.15.10.21.04 - PT. Aviastar 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 Final Report 9-Dec 2016 04 R 2016 67 1 OPEN 9-Mar-2017 PENGAWASAN of Civil Aviation EGPWS/TAWS functioning properly. E District of Luwu, South 10 Sulawesi Republic of Indonesia 2 October 2015 KNKT.15.10.21.04 - PT. To evaluate the effectiveness of the CRM training and ensuring the correct PT. Aviastar Mandiri has conducted training CRM for all PK-BRM 2-Oct 2015 Final Report 9-Dec 2016 Aviastar Mandiri 04 O 2016 64 1 CLOSED 28-Feb 2018 9-Mar-2017 PENGAWASAN Aviastar Mandiri pilot implementation Pilots and make Notice to Pilot that pilot must do KNKT.15.10.21.04 - PT. To ensure all pilots are appropriately trained on the operation and testing of PT. Aviastar Mandiri has conducted Training for the PK-BRM 2-Oct 2015 Final Report 9-Dec 2016 Aviastar Mandiri 04 O 2016 65 2 CLOSED 28-Feb 2018 9-Mar-2017 PENGAWASAN Aviastar Mandiri the EGPWS/TAWS systems. operation (Pilot) and Technic Division and testing of KNKT.15.10.21.04 - PT. To ensure EGPWS/TAWS operational test procedure is incorporated into the PT. Aviastar Mandiri make Standard Operating PK-BRM 2-Oct 2015 Final Report 9-Dec 2016 Aviastar Mandiri 04 O 2016 66 3 CLOSED 28-Feb 2018 9-Mar-2017 ATURAN Aviastar Mandiri Operator’s Standard Operating Procedures (SOP) and pre‐flight checklists. Procedure (SOP) for Responding to Alert TAWS and has KNKT.15.10.22.04 - PT. Penerbangan Angkasa Semesta OM Chapter 8.26 (Flight Overwater), OM Chapter 9.2.6 Eurocopter EC130 B4; Penerbangan To ensure the survival equipment is available on the aircraft suitable for area (Passeger Handling), OM Chapter 3.4.3 (Flight PK-BKA PK-BKA 11-Oct 2015 Final Report 16-May 2016 04 O 2016 32 1 CLOSED 23-Feb 2018 14-Aug-2016 SARANA Angkasa Semesta operation and properly use Following and Flight Watch Facilities), Notice to Crew Toba Lake, North No. PAS/NOT/IV/2016 (Emergency Equipment Check) Sumatera Republic of Indonesia 11 October 2015 KNKT.15.10.22.04 PT. Penerbangan OM Chapter 9.2.2 (Passenger Briefing Procedure), PK-BKA 11-Oct 2015 Final Report 16-May 2016 04 O 2016 58 1 To conduct passenger safety briefing prior to every flight CLOSED 23-Feb 2018 14-Aug-2016 PENGAWASAN Penerbangan Angkasa Angkasa Semesta Safety Instruction Card. KNKT.15.10.22.04 PT. Penerbangan Angkasa To consider the regulation of using emergency equipment such as personal or 11 Directorate General Semesta PK-BKA 11-Oct 2015 Final Report 16-May 2016 04 R 2016 33 1 portable Emergency Locator Transmitter for personal in aircraft operated in OPEN 14-Aug-2016 ATURAN of Civil Aviation Eurocopter EC130 B4; inhabitant terrain and offshore. PK-BKA STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) 11 REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE) KNKT.15.10.21.04 - PT. PK-BKA 11-Oct 2015 Final Report 16-May 2016 BASARNAS 04 L 2016 34 1 To consider instrument flight training for search and rescue pilots. CLOSED 2-Mar 2020 14-Aug-2016 NIL ATURAN Aviastar Mandiri KNKT.15.10.21.04 - PT. Aviastar Mandiri DHC-6 Twin Otter; PK- BRM at coordinate 3° 25' PK-BKA 11-Oct 2015 Final Report 16-May 2016 BASARNAS 04 L 2016 35 1 To consider using drone or unmanned aerial vehicle for air search operation. CLOSED 2-Mar 2020 14-Aug-2016 NIL ATURAN 52.80" S, 120° 4' 12.10" E District of Luwu, South Sulawesi KNKT.15.10.24.04 - PT. Asian One Air Tecnam P2006T Aircraft; PK-LTK To improve the pilot crew resource management that may refer to the FAA COM replaced by OM (OM part D 1.3.1 "Crew Resouce PK-LTK 20-Oct 2015 Final Report 26-Aug 2016 Asian One Air 04 O 2016 10 1 CLOSED 20-Feb 2018 24-Nov-2016 PENGAWASAN Nusawiru Airport safety bulletin Management") Pangandaran, Jawa Barat 20 October 2015 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 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 24-Nov-2016 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 MOU PT. Asian One Air and PT. MS Tech No.AOA Tecnam P2006T Aircraft; PK-LTK 20-Oct 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 24-Nov-2016 PENGAWASAN 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 PK-LTK 20-Oct 2015 Final Report 26-Aug 2016 04 MO 2016 13 1 CLOSED 24-Nov-2016 Inspector, Basic Supervisor, Potential Hazard, Human PENGAWASAN Nusawiru Airport Technology 43.15; CASR 145.205 and CASR 145.211 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; PK-LTK Directorate General To develop guideline of single pilot resource management as a reference for PK-LTK 20-Oct 2015 Final Report 26-Aug 2016 04 R 2016 14 1 OPEN 24-Nov-2016 PENGAWASAN Nusawiru Airport of Civil Aviation the single pilot operators. Pangandaran, Jawa Barat 20 October 2015

KNKT.15.10.24.04 - PT. Asian One Air Tecnam P2006T Aircraft; PK-LTK Directorate General To improve audit and surveillance system to organisation which have PK-LTK 20-Oct 2015 Final Report 26-Aug 2016 04 R 2016 15 1 OPEN 24-Nov-2016 PENGAWASAN Nusawiru Airport of Civil Aviation authorization to conduct maintenance activity includes assembling of aircraft. Pangandaran, Jawa Barat 20 October 2015

KNKT.15.10.25.04 - PT. Enggang Air Service Cessna 208B Grand Has been implementing Recovery Training Post Serious 13 Caravan; PK-RSE PK-RSE 27-Oct 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 18-Sep-2016 PENGAWASAN Incident on 1st December 2015. Sinak Airport, Papua Republic of Indonesia 27 October 2015 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE) KNKT.15.11.26.04 - PT. 1. Batik Air has changed Manual of Training, from To improve the crewmember emergency training to ensure all crewmembers Batik Air Indonesia PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 Batik Air 04 O 2016 20 1 CLOSED 7-Sep-2016 Operation Training Manual (OTM) 02 October 2015 to ATURAN performs the evacuation according to the company procedures KNKT.15.11.26.04Boeing 737-900 ER; - PT.PK- Angkasa Pura I Operation Manual D (Training Manual) OMD, 27 To perform daily inspection of the movement area as specified in the The daily inspection performed three times a day in Batik Air Indonesia PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 Branch Office 04 B 2016 22 1 CLOSED 21-Sep 2016 7-Sep-2016 PENGAWASAN Aerodrome Manual (AM) and airport Standard Operating Procedure (SOP). accorndance with the AM and SOP. KNKT.15.11.26.04Boeing 737-900 ER; - PT.PK- AngkasaAdisutjipto Pura I To develop procedure for measurement of water depth in runway and taxiway Standing water measurement has not been able to be Batik Air Indonesia PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 Branch Office 04 B 2016 23 1 as required by chapter 4.5 of Appendix 1 Civil Aviation Safety Regulation CLOSED 21-Sep 2016 7-Sep-2016 conducted as the method and equipment have not ATURAN KNKT.15.11.26.04Boeing 737-900 ER; - PT.PK- AngkasaAdisutjipto Pura I (CASR) Part 139 Volume I. available, it requires further discussion. To update the AM and SOP, and implement the runway friction measurement Implementation of runway friction test described in Batik Air Indonesia PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 Branch Office 04 B 2016 24 1 CLOSED 21-Sep 2016 7-Sep-2016 ATURAN according to the specified in the Advisory Circular (AC) CASR Part 139-23. the AM chapter 4.7.7 KNKT.15.11.26.04Boeing 737-900 ER; - PT.PK- AngkasaAdisutjipto Pura I To develop a reporting system to enable disseminate significant information Batik Air Indonesia PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 Branch Office 04 B 2016 25 1 of runway condition to Air Traffic Service (ATS) unit and for those units to CLOSED 21-Sep 2016 7-Sep-2016 Reporting system has not been established. ATURAN Boeing 737-900 ER; PK- Adisutjipto provide the necessary information to arriving and departing aircraft without 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 Branch Office To review the possibility of development an instrument approach for runway Adisutjipto International PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 04 B 2016 51 1 CLOSED 21-Sep 2016 7-Sep-2016 the possibility of development an instrument approach PRASARANA Adisutjipto 27. Airport for 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 Provided wind and pressure indicator system in the Adisutjipto International PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 District Office 04 A 2016 26 1 CLOSED 19-Sep 2016 7-Sep-2016 PRASARANA installation of AWOS display monitor in the tower control desk. 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 To review the possibility of development an instrument approach for runway Conducted review and analysis of RNP approach for Adisutjipto International PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 District Office 04 A 2016 51 2 CLOSED 19-Sep 2016 7-Sep-2016 PRASARANA 27. 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 Adisutjipto International PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 04 R 2016 1 2 To emphasize all aircraft operators comply with stabilize approach criteria. OPEN 7-Sep-2016 PENGAWASAN of Civil Aviation Airport Yogyakarta, Republic of Indonesia 6 November 2015

14 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE)

KNKT.15.11.26.04 - PT. 14 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 Final Report 9-Jun 2016 04 R 2016 27 1 OPEN 7-Sep-2016 PENGAWASAN of Civil Aviation suitable for the landing distance required on existing condition. Airport 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 Final Report 9-Jun 2016 04 R 2016 28 1 OPEN 7-Sep-2016 PENGAWASAN of Civil Aviation approach. Airport 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 Final Report 9-Jun 2016 04 R 2016 29 1 OPEN 7-Sep-2016 PENGAWASAN of Civil Aviation crewmember taking appropriate action during emergency. Airport Yogyakarta, Republic of Indonesia 6 November 2015 KNKT.15.11.26.04 - PT. Directorate General To ensure that the airport operators manual contain the requirement specified Direktorat Bandar Udara telah menerbitkan Peraturan PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 04 R 2016 30 1 CLOSED 27-Feb 2018 7-Sep-2016 ATURAN Batik Air Indonesia of Civil Aviation in the CASR Past 139, AC CASR Part 139-23 and Manual of Standard CASR Part Direktur Jenderal Perhubungan Udara Nomor KP 212 KNKT.15.11.26.04 - PT. Direktorat Bandar Udara telah menerbitkan Peraturan Directorate General To ensure all airport operators conduct inspection of movement area Batik Air Indonesia PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 04 R 2016 22 2 CLOSED 27-Feb 2018 7-Sep-2016 Direktur Jenderal Perhubungan Udara Nomor KP 220 PENGAWASAN of Civil Aviation according to the approved manuals. KNKT.15.11.26.04Boeing 737-900 ER; - PT.PK- DirektoratTahun 2017 Bandar tentang Udara telah menerbitkan Peraturan Directorate General To ensure all airport operators implement the runway friction measurement Batik Air Indonesia PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 04 R 2016 24 2 CLOSED 27-Feb 2018 7-Sep-2016 Direktur Jenderal Perhubungan Udara Nomor KP 212 PENGAWASAN of Civil Aviation according to the specified in the AC CASR Part 139-23. KNKT.15.11.26.04Boeing 737-900 ER; - PT.PK- To include in the Indonesia regulation, the procedure of reporting system dalamTahun Peraturan2017 tentang Direktur Jenderal Perhubungan Directorate General Batik Air Indonesia PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 04 R 2016 25 2 from the airport operator to the ATS unit to enable disseminate significant CLOSED 27-Feb 2018 7-Sep-2016 Udara Nomor : KP 262 Tahun 2017 tentang Manual of ATURAN of Civil Aviation Boeing 737-900 ER; PK- information of runway condition to arriving and departing aircraft without Standard (MoS) Part 139 Volume I Aerodrome Bagian KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- LBO Directorate General Issued approval certificate for ATS provider for Adisutjipto International PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 04 R 2016 31 1 To issue approval certificates for the Air Traffic Services providers. CLOSED 7-Sep-2016 ATURAN of Civil Aviation Yogyakarta Airport Yogyakarta, Republic of Indonesia 6 November 2015

KNKT.15.11.26.04 - PT. Batik Air Indonesia Boeing 737-900 ER; PK- LBO IAP runway 27 belum dapat dilakukan karena Directorate General To review the possibility of development an instrument approach for runway Adisutjipto International PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 04 R 2016 51 2 CLOSED 27-Mar 2018 7-Sep-2016 bersinggungan dengan ruang udara Militer dan kondisi PRASARANA of Civil Aviation 27 Airport Terrain yang cukup tingi di area approach. Yogyakarta, Republic of Indonesia 6 November 2015 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE) KNKT.15.12.28.04 - PT. Briefed all pilots regarding to the procedures and crew PK-KDC 21-Dec 2015 Preliminary Report 9-Feb 2015 KalStar Aviation 04 O 2016 16 1 To ensure the flight crew to perform appropriate crew briefing. CLOSED 10-May-2015 PENGAWASAN KalStar Aviation briefing for landing KNKT.15.12.28.04 - PT. KalStar Aviation Embraer 190-200LR; PK- KDC Briefed all pilots regarding to the stabilized approach El Tari Airport PK-KDC 21-Dec 2015 Preliminary Report 9-Feb 2015 KalStar Aviation 04 O 2016 17 1 To emphasize the flight crew to the stabilized approach criteria. CLOSED 10-May-2015 PENGAWASAN criteria Kupang, Nusa Tenggara 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 Briefed all pilots regarding to response to the aircraft El Tari Airport PK-KDC 21-Dec 2015 Preliminary Report 9-Feb 2015 KalStar Aviation 04 O 2016 18 1 CLOSED 10-May-2015 PENGAWASAN EGPWS warning appropriately. and EGPWS warning system appropriately. Kupang, Nusa Tenggara Timur Republic of Indonesia 21 December 2015 KNKT.15.12.28.04 - PT. To ensure pilot performs the operational procedure such as checklist reading, KalStar Aviation PK-KDC 21-Dec 2015 Final Report 26-Sep 2016 KalStar Aviation 04 O 2016 73 2 TDTL 25-Dec-2016 NIL PENGAWASAN crew briefing properly and consistently. Embraer 190-200LR; PK- KNKT.15.12.28.04 - PT. KalStar Aviation Embraer 190-200LR; PK- 15 KDC To develop oversight system that ensure the procedures are implemented El Tari Airport PK-KDC 21-Dec 2015 Final Report 26-Sep 2016 KalStar Aviation 04 O 2016 78 1 TDTL 25-Dec-2016 NIL ATURAN properly and to monitor pilot performance. Kupang, Nusa Tenggara Timur Republic of Indonesia 21 December 2015 KNKT.15.12.28.04 - PT. To ensure the comprehensive Safety Management System is implemented PK-KDC 21-Dec 2015 Final Report 26-Sep 2016 KalStar Aviation 04 O 2016 79 1 TDTL 25-Dec-2016 NIL PENGAWASAN KalStar Aviation correctly. KNKT.15.12.28.04 - PT. AirNav Indonesia district office Kupang updated the KalStar Aviation AirNav Indonesia To include in the Standard Operating Procedure (SOP) of ATC the procedure Standard Operating Procedure (SOP) for the air traffic Embraer 190-200LR; PK- PK-KDC 21-Dec 2015 Preliminary Report 9-Feb 2015 District Office 04 A 2016 19 1 CLOSED 10-May-2015 ATURAN for utilizing of visibility chart and determination of the wind information. controller to include the utilization of visibility chart KDC Kupang and determination of wind information KNKT.15.12.28.04El Tari Airport - PT. Angkasa Pura I To develop a reporting system to enable disseminate significant information KalStar Aviation PK-KDC 21-Dec 2015 Final Report 26-Sep 2016 Branch Office Eltari 04 B 2016 25 2 of runway condition to Air Traffic Service (ATS) unit and for those units to OPEN 25-Dec-2016 NIL ATURAN KNKT.15.12.28.04Embraer 190-200LR; - PT. PK- Airport, Kupang provide the necessary information to arriving and departing aircraft without Directorate General KalStar Aviation PK-KDC 21-Dec 2015 Final Report 26-Sep 2016 04 R 2016 1 3 To emphasize all aircraft operator to comply with stabilize approach criteria. OPEN 25-Dec-2016 PENGAWASAN of Civil Aviation Embraer 190-200LR; PK- KNKT.15.12.28.04 - PT. Directorate General To ensure all aircraft operators implements safety management system as PK-KDC 21-Dec 2015 Final Report 26-Sep 2016 04 R 2016 81 1 OPEN 25-Dec-2016 PENGAWASAN KalStar Aviation of Civil Aviation required by Indonesia Civil Aviation Safety Regulation. 15

KNKT.16.02.13.04 The flight to Spot 99 was the first time for the pilot and was not accompanied PT AMUR AVIATION by a qualified pilot and prior to this flight appropriate briefing has not been INDONESIA - Hellicopter Amur Aviation PK-UAG 3-Feb 2016 Final Report 5-Dec 2017 04 O 2017 3 1 conducted therefore KNKT recommend to ensure that the flight to the specific TDTL 5-Mar-2018 The aircraft operator had been stopped the operation 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 Amur Aviation appropriate briefing prior to this flight has not been conducted which contrary PK-UAG 3-Feb 2016 Final Report 5-Dec 2017 04 O 2017 3 2 TDTL 5-Mar-2018 The aircraft operator had been stopped the operation ATURAN Bell 206L-4; PK-UAG Indonesia to the company SOP therefore KNKT recommend to emphasize the Siriwo Area - Papua management to improve the safety by conducting safety oversight to the 3 February 2016 operation.

1. The PIC may change over the control at any time to KNKT.16.02.05.04 - PT. ensure that the Lion Mentari Airline highest level of safety is maintained. (OM-A8.3.1.5.3) Boeing 737-900ER; PK- 2. Pilot Decision Making Concept is part of CRM LFG The deteriorating weather condition and difficulty of the SIC to control the training Syllabus on Juanda International PK-LFG 20-Feb 2016 Final Report 7-Feb 2017 Lion Air 04 O 2017 5 1 aircraft did not trigger a firm decision, therefore KNKT recommends to review OPEN 4-Feb 2020 8-May-2017 Pilot program training in Operation Training Manual PENGAWASAN Airport, Sidoarjo, East pilot training program in order to improve pilot decision making. (OM D 5.3.8) Java 17 3. Initial Training/Mandatory Training (OM-D 5.2.2) Republic of Indonesia 4. Upgrading Training/Command Training (OM-D 5.2.6) 20 February 2016 5. Re-Qualification Training (OM-D 5.2.7) 6. Recurrent Training, included on Recurrent/LOFT (OM- KNKT.16.02.05.04 - PT. During manual flying, the SIC had difficulty to control the aircraft that was 1. Initial Training Lesson Plan PK-LFG 20-Feb 2016 Final Report 7-Feb 2017 Lion Air 04 O 2017 5 2 OPEN 4-Feb 2020 8-May-2017 PENGAWASAN Lion Mentari Airline indicated by the activation of EGPWS hard alert ‘GLIDE SLOPE, GLIDE SLOPE’, 2. Line Training Lesson Plan (OTM 5.5.17) KNKT.16.02.05.04 - PT. Directorate General To emphasize the other aircraft operator to review pilot training program in PK-LFG 20-Feb 2016 Final Report 7-Feb 2017 04 R 2017 5 3 OPEN 8-May-2017 PENGAWASAN Lion Mentari Airline of Civil Aviation order to improve pilot decision making. KNKT.16.02.05.04 - PT. Directorate General To emphasize the other aircraft operator to develop training specifically PK-LFG 20-Feb 2016 Final Report 7-Feb 2017 04 R 2017 5 4 OPEN 8-May-2017 PENGAWASAN Lion Mentari Airline of Civil Aviation address the pilot recognition of situation in which the speed brakes, thrust

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) - Established ground control unit to control ground and ATR 42-600 (PK- AirNav Indonesia To develop procedure for all aircraft movement on the manoeuvring area movement which have different frequency from tower TNJ) PK-LBS & PK-TNJ 4-Apr 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 2-Aug-2016 controller, including its standard operation procedure. ATURAN Halim Perdanakusuma Perdanakusuma with air traffic controller on the same frequency. - Established new procedure of ground movement to International Airport, taxi using perimeter service road. Jakarta Republic of Indonesia 4 April 2016

18 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE)

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) and ATR 42-600 (PK- AirNav Indonesia To evaluate the current lighting of tower cab to prevent glare that may distract Reduced the lighting on tower cab during low light TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Preliminary Report 4-May 2016 District Office Halim 04 A 2016 52 1 CLOSED 19-Sep 2016 2-Aug-2016 PRASARANA controller view. condition (night or cloudy situation). Halim Perdanakusuma 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. and ATR 42-600 (PK- AirNav Indonesia To remind the ATC controller to maintain continues watch the aircraft - Put safety campaign poster in working area to TNJ) PK-LBS & PK-TNJ 4-Apr 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 2-Aug-2016 improve safety awareness while providing air PENGAWASAN Halim Perdanakusuma Perdanakusuma clearance. navigation services. International Airport, Conducted safety briefing to all ATS personnel Jakarta regarding safety awareness, hazard identification and Republic of Indonesia reporting culture. 4 April 2016

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) and ATR 42-600 (PK- AirNav Indonesia Published NOTAM number A1268/16 NOTAMN to To inform the aircraft operators to initiate takeoff from the threshold runway TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Preliminary Report 4-May 2016 District Office Halim 04 A 2016 57 1 CLOSED 19-Sep 2016 2-Aug-2016 remind all pilot to takeoff (open power) after the ATURAN 24 of Halim Perdanakusuma International Airport Halim Perdanakusuma Perdanakusuma 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) Issued safety notice to all aircraft operator, ground and ATR 42-600 (PK- AirNav Indonesia handling service and fuel supplier service to include To develop procedure for vehicle and aircraft on the manoeuvring area shall TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Preliminary Report 4-May 2016 District Office Halim 04 A 2016 54 1 CLOSED 19-Sep 2016 2-Aug-2016 the KNKT recommendation to their standard operating ATURAN be equipped with serviceable lights visible by air traffic controller. Halim Perdanakusuma Perdanakusuma procedure while operating vehicle and/or aircraft on International Airport, the 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) and ATR 42-600 (PK- AirNav Indonesia It is recommended updating the SOP to accommodate controller coordination Responding to KNKT safety recommendation, on 7 TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 District Office Halim 04 A 2017 7 7 to warrant the safe operation of aircraft and vehicle movement on CLOSED 19-Sep 2016 9-Jul-2017 ATURAN April 2016, the AirNav Indonesia issued safety notice Halim Perdanakusuma Perdanakusuma maneuvering area. addressed to all air traffic control units as follows: International Airport, a. Required all towing aircraft to switch on the Jakarta navigation lights. Republic of Indonesia b. Required all towing aircraft to communicate in 4 April 2016 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.

18 Responding to KNKT safety recommendation, on 7 April 2016, the AirNav Indonesia issued safety notice STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) addressed to all air traffic control units as follows: a. Required all towing aircraft to switch on the navigation lights. TAHUN 2007 - 2021 (Data s.d Agustus 2021) b. Required all towing aircraft to communicate in REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS published tower frequency. INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE c. Required all TANGGAPANvehicle without (RESPONSE) radio communication (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE) 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 KNKT.16.04.07.04 - all departure aircraft that using runway 24 to initiate Batik Air Indonesia and the acceleration for takeoff at threshold runway 24. TransNusa Aviation On 1 November 2016, issued NOTAM number Boeing 737-800 (PK-LBS) A3291/16, informed that the Halim Ground Control and ATR 42-600 (PK- AirNav Indonesia services was operated for trial on frequency 118.6 Mhz It is recommended to ensure the taxi or towing clearance issued contains TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 District Office Halim 04 A 2017 7 8 CLOSED 19-Sep 2016 9-Jul-2017 until 4 January 2017. On 3 January 2017, the Halim PENGAWASAN explicit limit to cross or to hold short of runway as required by AC 170. Halim Perdanakusuma Perdanakusuma Ground Control services trial was extended until 3 April International Airport, 2017 and on 24 March 2017, the trial re-extended until Jakarta 9 June 2017. Republic of Indonesia 4 April 2016

KNKT.16.04.07.04 - AirNav Indonesia It is recommended to reinforce the implementation of the KNKT Published NOTAM number A1844/17 NOTAMN which PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 04 A 2017 7 9 CLOSED 29-Nov 2018 9-Jul-2017 ATURAN Batik Air Indonesia and District Office Halim recommendation (04.B-2016-57.1) which is to inform aircraft operators to instructed all departure aircraft to initiate takeoff KNKT.16.04.07.04 - Angkasa Pura II To inform the aircraft operators to initiate takeoff from the threshold runway Published NOTAM number A1268/16 NOTAMN to PK-LBS & PK-TNJ 4-Apr 2016 Preliminary Report 4-May 2016 04 B 2016 57 1 CLOSED 2-Aug-2016 PENGAWASAN Batik Air Indonesia and Branch Office Halim 24 of Halim Perdanakusuma International Airport remind all pilot to takeoff (open power) after the

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) Issued safety notice to all aircraft operator, ground Angkasa Pura II and ATR 42-600 (PK- handling service and fuel supplier service to include Branch Office Halim To develop procedure for vehicle and aircraft on the manoeuvring area shall TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Preliminary Report 4-May 2016 04 B 2016 54 1 CLOSED 16-Sep 2016 2-Aug-2016 the KNKT recommendation to their standard operating ATURAN Perdanakusuma be equipped with serviceable lights visible by air traffic controller. Halim Perdanakusuma procedure while operating vehicle and/or aircraft on International Airport International Airport, the 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) Angkasa Pura II It is recommended to reinforce the implementation of the KNKT and ATR 42-600 (PK- Branch Office Halim recommendation (04.B-2016-57.1) which is to inform aircraft operators to TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 04 B 2017 7 9 OPEN 9-Jul-2017 NIL PENGAWASAN Perdanakusuma initiate takeoff from the threshold runway 24 of Halim Halim Perdanakusuma International Airport International Airport, Jakarta Republic of Indonesia 18 4 April 2016

KNKT.16.04.07.04 - Directorate General To develop procedure for vehicle and aircraft on the manoeuvring area shall PK-LBS & PK-TNJ 4-Apr 2016 Preliminary Report 4-May 2016 04 R 2016 55 1 CLOSED 24-Jan 2018 2-Aug-2016 Letter from DGCA 252/DBU/I/2018 ATURAN Batik Air Indonesia and of Civil Aviation be equipped with serviceable lights visible by air traffic controller KNKT.16.04.07.04 - Directorate General To review a requirement for all aircraft movement on the manoeuvring area PK-LBS & PK-TNJ 4-Apr 2016 Preliminary Report 4-May 2016 04 R 2016 56 1 OPEN 2-Aug-2016 PENGAWASAN Batik Air Indonesia and of Civil Aviation including the aircraft movement without aircraft own power, to communicate STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) 18 TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE)

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) and ATR 42-600 (PK- It is recommended to review the procedure of aircraft movement on Directorate General TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 04 R 2017 7 10 maneuvering area for airport operator and air navigation provider to OPEN 9-Jul-2017 PENGAWASAN of Civil Aviation Halim Perdanakusuma 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) and ATR 42-600 (PK- Directorate General It is recommended to review the requirement of personnel licensing for TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 04 R 2017 7 11 OPEN 9-Jul-2017 PENGAWASAN of Civil Aviation towing car driver as required by the ICAO standard. 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) The CASR 170 Air Traffic Rules subpart 170.039 point (4) mentions the Refer to Directorate of Air Navigation Letter No. and ATR 42-600 (PK- Directorate General 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, TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 04 R 2017 7 12 CLOSED 9-Jul-2017 PENGAWASAN of Civil Aviation Annex 11. they are in the middle of CASR 170 revision in Halim Perdanakusuma It is recommended to review the contain of CASR to ensure its clarity according with ICAO Annex 11 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) Halim has runway length of 3,000 meters and was displaced 200 meters. Refer to Directorate of Air Navigation Letter No. and ATR 42-600 (PK- However, the published Aeronautical Information Publication (AIP) Volume I Directorate General AU.304/4/115/DJPU.DNP.2017 dated 13 June 2017, the TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 04 R 2017 7 13 Amendment 28, did not contain information that the total runway length is CLOSED 9-Jul-2017 ATURAN of Civil Aviation AIP of Halim Perdanakusuma Airport declared Landing Halim Perdanakusuma reduced to 2,800 meters. Distance Avaiable (LDA) is 2,800 metres International Airport, 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 and ATR 42-600 (PK- Rejected Takeoff Decision which is the PIC should announce the abnormality Operation Directorate revised the Operation Manual A TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 Batik Air 04 O 2017 7 1 OPEN 4-Feb 2020 9-Jul-2017 ATURAN simultaneously. 8.3.2.2.4 Rejection of Take-Off. (Appendix B) 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) Operation Directorate revised SEP 1.4.5. Manual and ATR 42-600 (PK- It is recommended that the operator to review the evacuation procedure and regarding principles before opening exit(s) and warning TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 Batik Air 04 O 2017 7 2 consider the area can be observed through the viewing windows. OPEN 4-Feb 2020 9-Jul-2017 PENGAWASAN signals fligh crew to flight attendants on SEP 1.4.3.1 Halim Perdanakusuma (Appendix C) 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- Ensure the aircraft adequately lighted during night operation in accordance TransNusa Aviation Quality Notice No. QN-TAM/018/IV/16 Tanggal 11 TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 04 O 2017 7 3 with CASR 91.209. CLOSED 9-Jul-2017 ATURAN Mandiri April 2016 Halim Perdanakusuma International Airport, Jakarta Republic of Indonesia 4 April 2016 18

KNKT.16.04.07.04 - Batik Air Indonesia and TransNusa Aviation Boeing 737-800 (PK-LBS) and ATR 42-600 (PK- TransNusa Aviation Consider risk assessment, compliance to the regulation and specification Quality Notice No. QN-TAM/018/IV/16 Tanggal 11 TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 04 O 2017 7 4 CLOSED 9-Jul-2017 PENGAWASAN Mandiri required prior to issue the Engineering Instruction. April 2016 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) and ATR 42-600 (PK- It is recommended to review the requirement of personnel licensing for Jasa Angkasa TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 04 L 2017 7 5 towing car driver as required by the regulation standard, including the OPEN 9-Jul-2017 NIL PENGAWASAN Semesta Halim Perdanakusuma language 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- Jasa Angkasa It is recommended to ensure the SOP of towing procedure is well TNJ) PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 04 G 2017 7 6 OPEN 9-Jul-2017 NIL PENGAWASAN Semesta implemented. Halim Perdanakusuma International Airport, Jakarta Republic of Indonesia 4 April 2016

KNKT.16.04.09.04 - Global Aviation Flying School The Global Aviation Flying School conducted safety To introduce the student pilots with Approach and Landing Accident Cessna 172 G, PK-TGL Global Aviation briefing to all pilot about Approach and Landing 19 PK-TGL 28-Apr 2016 Final Report 12-May 2017 04 O 2016 9 1 Reduction (ALAR) training and stabilize approach criteria and to emphasized a CLOSED 18-Feb 2020 10-Aug-2017 ATURAN Budiarto Airport, Flying School Accident Reduction (ALAR) using ALAR toolkit from go around shall be made when does not meet the criteria. Tangerang Flight Safety Foundation. Republic of Indonesia 28 April 2016

1. Conduct re-training to flight crew with summary 2. Operation published company Internal Notam KNKT.16.05.10.04 - (INTAM) PT.LION MENTARI The aircraft LNI077 was taxi in the narrow area and no ground assistance 3. Safety & Security Directorate has been conducted AIRLINES ; AIRBUS A330 20 PK-LEF & PK-LJR 1-Apr 2016 Final 8-Jun 2018 Lion Air 04 O 2018 10 1 provided to the pilot, therefore KNKT recommends to consider to stop or OPEN 4-Feb 2020 6-Sep-2018 Risk Management ATURAN & B737-800 ; request ground assistance during taxi in narrow area. (14/RMR/VI/2016) SOEKARNO-HATTA 4. Safety & Security Directorate has been published AIRPORT ; 1 MAY 2016 Safety Information to All pilot (07/SS/SINF/V/2016)

Etihad Airways currently have multiple instances on each flight in which the passengers are advised to have KNKT.16.05.13.04 - their seat belts fastened even when the seat belt signs Etihad Airways are switched off. The first is through public Airbus A330 -243; A6- To enhance the safety reminder for passenger to fasten the seatbelt while announcements. These are made during the welcome EYN A6-EYN 4-May 2016 Preliminary Report 8-Jun 2016 Etihad Airways 04 O 2016 58 2 CLOSED 6-Sep-2016 PENGAWASAN seating even though the seatbelt sign is off. announcement made by the captain prior to departure Near Bangka Islands and the second announcement, made by the cabin Republic of Indonesia crew one minute after retraction of landing gear after 4 May 2016 21 takeoff. These public announcements are made on all passenger flights. KNKT.16.05.13.04 - The Etihad Airways issued a Flight Operations Message To ensure the pilot implementation of the Operations Manual Part-A chapter Etihad Airways A6-EYN 4-May 2016 Preliminary Report 8-Jun 2016 Etihad Airways 04 O 2016 59 1 CLOSED 6-Sep-2016 (FOM-218) on 12-July-2016 reminding the entire Etihad PENGAWASAN 12, subchapter 12.12.1 regarding declaration of urgency message. Airbus A330 -243; A6- Airways flight crew community of the proper KNKT.16.05.13.04 - The KNKT recommends the Etihad Airways to review the effectiveness of the A6-EYN 4-May 2016 Final Report 27-Dec 2017 Etihad Airways 04 O 2016 13 1 OPEN 27-Mar-2018 NIL PENGAWASAN Etihad Airways use of seatbelt policies to ensure passenger fastened their seatbelt when KNKT.16.05.13.04 - The KNKT recommends the Etihad Airways to ensure pilot conducts NITS A6-EYN 4-May 2016 Final Report 27-Dec 2017 Etihad Airways 04 O 2016 13 2 OPEN 27-Mar-2018 NIL PENGAWASAN Etihad Airways briefing after abnormal flight event as described in the Safety Emergency & KNKT.16.05.13.04 - Directorate General KNKT recommends the DGCA to enforce the Indonesia aircraft operators to A6-EYN 4-May 2016 Final Report 27-Dec 2017 04 R 2016 13 3 OPEN 27-Mar-2018 NIL PENGAWASAN Etihad Airways of Civil Aviation review the effectiveness of the use of seatbelt policies to ensure passenger STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE) KNKT.16.06.21.04 - Nusa Flying School Cessna 172P; PK-NIV Seluruh instruktur memberikan arahan mengenai Demak, Central Java Nusa Flying To review the training syllabus for instructor and student training to ensure PK-NIV 20-Jun 2016 Final Report 12-May 2017 04 O 2016 21 1 CLOSED 10-Aug-2017 sistem bahan bakar sesuai dengan checklist (Training PENGAWASAN 06°48.094’S, International correct understanding to the aircraft system. 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 Final Report 12-May 2017 04 O 2016 21 2 To use fuel that meet the engine requirement. CLOSED 10-Aug-2017 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 Demak, Central Java Directorate General PK-NIV 20-Jun 2016 Final Report 12-May 2017 04 R 2016 21 3 To ensure all instructors have adequate knowledge to the aircraft system. OPEN 10-Aug-2017 NIL ATURAN 06°48.094’S, of Civil Aviation 110°35.011’E Republic of Indonesia 20 June 2016

KNKT.16.09.27.04 - PT. KNKT recommend during approach descend about 400 feet AGL and the pilot Trigana Air Services did not see the runway, the PM reminded to the PF that they were too far and Boeing 737-300F; PK- suggested to go around. The reminder and suggestion of the PM were not YSY PK-YSY 13-Sep 2016 Final Report 9-Jul 2020 Trigana Air Services 04 O 2020 27 1 taken by the PF indicated lack of crew coordination and resulted in the flight OPEN 7-Oct-2020 Wamena Airport, Papua continued the approach landing under the un-stabilized approach condition Republic of Indonesia and the weather that was not suitable for landing. KNKT recommends to 13 September 2016 provide training for pilots to improve crew coordination. 23 KNKT.16.09.27.04 - PT. Trigana Air Services The data download of the FDR installed on PK-YSY aircraft retrieved 20 Boeing 737-300F; PK- parameters recorded on the FDR. The limited parameters recorded on the FDR YSY PK-YSY 13-Sep 2016 Final Report 9-Jul 2020 Trigana Air Services 04 O 2020 27 2 contributed to FDA analysis and investigation purposes. KNKT recommends to OPEN 7-Oct-2020 Wamena Airport, Papua ensure that all FDR installed are capable to record sufficient data as required Republic of Indonesia by the regulation 13 September 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 24 PK-LTV 13-Oct 2016 Preliminary Report 8-Oct 2016 Asian One Air 04 O 2016 94 1 CLOSED 20-Feb 2018 6-Jan-2017 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 (NFI/011/IOM/KS/III/2018), setiap 25 PK-NIZ 16-Oct 2016 Preliminary Report 19-Dec 2016 04 O 2016 95 1 CLOSED 14-Mar 2018 19-Mar-2017 PENGAWASAN Adi Soemarmo International Log Book. pekerjaan/inspection dan pergantian komponen ditulis International Airport dan di record di 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 26 DHC – 4 Caribou, PK-SWW 31-Oct 2016 Preliminary Report 29-Nov 2016 Penerbangan Alfa 04 O 2016 38 1 Keselamatan Transportasi (KNKT) recommend to Perkumpulan Penerbangan OPEN 27-Feb-2017 NIL PENGAWASAN PK‐SWW Indonesia Alfa Indonesia to comply the DGCA Safety Circular number SE.24 of 2016. Ilaga Pass, Papua Republic of Indonesia 31 October 2016

Wings Air issued notice to pilot which contained instruction to review and adhere procedures as described in the Operation Manual Part A and Quick KNKT.16.12.43.04 - PT. Reference Handbook as follows: Wings Abadi Airlines - OM-A 8.3.12 ADVERSE AND POTENTIALLY The aircraft touched down and bounced twice. After the second bounce, the ATR 72-212A; PK-WGW HAZARDOUS ATMOSPHERIC CONDITIONS pilot attempted to go around and the aircraft touched the runway. According Ahmad Yani - OM-A 8.1.1.2 PRE-FLIGHT INFORMATION PK-WGW 25-Dec 2016 Preliminary Report 24-Jan 2017 Wings Air 04 O 2016 43 1 to the OM Part A and SOP for ATR 72-600 a go around shall be performed if a CLOSED 6-Jan 2017 24-Apr-2017 PENGAWASAN International Airport, - OM-A 8.3.2.5.5 REQUIREMENT FOR STABILIZED FINAL hard and/or high bounce occurs. Therefore, KNKT recommends reviewing the Semarang APPROACH bounce recovery training for all pilots. Republic of Indonesia - OM-A 8.3.2.9.4 BOUNCED LANDING / LONG FLARE 25 December 2016 - OM-A 8.3.2.10 GO-AROUND AND MISSED APPROACH - OM-A 8.3.20.14 EVACUATION DIRECTIVES 27 - QRH 1.02 EMER EVACUATION ON GROUND

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 Wings Air issued notice to pilot which encourage all ATR 72-212A; PK-WGW engines were shutdown. This condition might harm the RFFS personnel and/or simulator instructors to conduct additional training of Ahmad Yani PK-WGW 25-Dec 2016 Preliminary Report 24-Jan 2017 Wings Air 04 O 2016 43 2 passenger which evacuated before command by the flight crew members. It CLOSED 10-Jan 2017 24-Apr-2017 Bounce Landing Technique during pilot recurrent PENGAWASAN International Airport, also could prolong the evacuation process. Therefore, KNKT recommends session and review the Bounce Landing Technique Semarang reviewing the emergency evacuation training including join training of flight during pilot Line Training. Republic of Indonesia crew and flight attendant. 25 December 2016 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE) 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- (Perpanjangan runway dilaksanakan secara bertahap Directorate General extend the runway and provide the runway end safety area at the end of BVM PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 04 R 2016 45 1 CLOSED 27-Feb 2018 6-Apr-2017 sampai dengan 1150 ATURAN of Civil Aviation runway 25 to minimize aircraft overrun and damaged to the aircraft in the case Ilaga Airport x 30 m sesuai rencana induk); of 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- lelah ada pakel pekerjaan pengadaan dan pemasangan Directorate General KNKT recommend to the DGCA to review the installation navigation aid such BVM PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 04 R 2016 45 2 CLOSED 27-Feb 2018 6-Apr-2017 APAPI dan RTIL 1 ujung 1 sisi volume 1 pakel pada ATURAN of Civil Aviation as PAPI or VASI to prevent the visual illusion. Ilaga Airport 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- KNKT recommend to the DGCA to consider to expand the apron dimension to kegialan Tahun Anggaran 2017 dan 2018, sehingga Directorate General BVM PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 04 R 2016 45 3 increase the capacity to be able to accommodate more aircraft. CLOSED 27-Feb 2018 6-Apr-2017 pada akhir Tahun 2018 akan lersedia apron dengan ATURAN of Civil Aviation Ilaga Airport dimensi 60 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 Preliminary Report 6-Jan 2017 04 R 2016 45 6 OPEN 6-Apr-2017 ATURAN of Civil Aviation possibility of upgrading the air traffic services to aerodrome control area Ilaga Airport (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 Preliminary Report 6-Jan 2017 04 R 2016 45 7 OPEN 6-Apr-2017 PENGAWASAN of Civil Aviation to support the performance of duty personnel. Ilaga Airport 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 Preliminary Report 6-Jan 2017 04 R 2016 45 8 KNKT recommend to the DGCA to review the aircraft operator SOP. OPEN 6-Apr-2017 ATURAN of Civil Aviation Ilaga Airport Republic of Indonesia 31 December 2016

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation 28 There was no direct VFR route from Timika to Ilaga based on the VFR route Pilatus Porter PC-6, PK- Ditnavpen akan memprogramkan pembuatan rute Directorate General which was published on Aeronautical Information Publication (AIP) Indonesia BVM PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 04 R 2016 45 9 CLOSED 27-Mar 2018 6-Apr-2017 Timika-Ilaga dengan mengundang stake holder dan ATURAN of Civil Aviation Amendment 31 dated 5 April 2012, KNKT recommends to review and update Ilaga Airport Perum LPPNPI untuk pembahasannya. the VFR routes within area of Papua to include Timika - Ilaga. Republic of Indonesia 31 December 2016

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation Pilatus Porter PC-6, PK- Badan Meteorologi Considering the number of flight per day and the availability of meteorological BVM PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 Klimatologi dan 04 L 2016 45 10 station, KNKT recommends to the BMKG to consider the installation of OPEN 6-Apr-2017 NIL ATURAN Ilaga Airport Geofisika 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 guidance to Ilaga and to review the possibility of upgrading the air traffic BVM PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 AirNav Indonesia 04 A 2016 45 11 CLOSED 29-Nov 2018 6-Apr-2017 the AIRAC AIP Supplement number 19/17. ATURAN services to aerodrome control area (ADC). Ilaga Airport Conducted safety assessment to upgrade the ATS in Republic of Indonesia Ilaga 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 BVM PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 AirNav Indonesia 04 A 2016 45 12 CLOSED 29-Nov 2018 6-Apr-2017 PRASARANA personnel. in Ilaga Ilaga Airport Republic of Indonesia 31 December 2016

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation Pilatus Porter PC-6, PK- KNKT recommend to the aircraft operators to support the pilot decision and BVM PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 Susi Air 04 O 2016 45 13 OPEN 6-Apr-2017 NIL ATURAN not to apportion blame for pilot conducts RTB or diversion. Ilaga Airport Republic of Indonesia 31 December 2016 28

KNKT.16.12.45.04 - PT. ASI Pudjiastuti Aviation Pilatus Porter PC-6, PK- KNKT recommend to the aircraft operator to consider the BVM PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 Susi Air 04 O 2016 45 14 OPEN 6-Apr-2017 NIL ATURAN 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- KNKT recommend to the aircraft operator to emphasize the EGPWS provider BVM PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 Susi Air 04 O 2016 45 15 to provide the high resolution terrain database in the mountainous area of OPEN 6-Apr-2017 NIL ATURAN Ilaga Airport Papua. 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 BVM PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 Susi Air 04 O 2016 45 1 an airport with special circumstances such as Ilaga. OPEN 6-Apr-2017 NIL PENGAWASAN Ilaga Airport Republic of Indonesia 31 December 2016

KNKT.17.01.02.04 ; PT. MANDIRI UTAMA FLIGHT ACADEMY ; Mandiri Utama Flight KNKT recommend to improve the training including demonstration to ensure Follow up recommendation could not be confirmed. PK-MUA 16-Jan 2017 Final 8-Jun 2018 4 O 2018 2 1 TDTL 6-Sep-2018 ATURAN BLIMBINGSARI Academy student pilots understanding of correct approach and landing technique. The aircraft operator is no longer operation. AIRPORT, BANYUWANGI ; 16 JANUARI 2017

KNKT.17.01.02.04 ; PT. MANDIRI UTAMA FLIGHT ACADEMY ; Blimbingsari Airport KNKT recommend to improve the rescue and firefighting personnel training to PK-MUA 16-Jan 2017 Final 8-Jun 2018 4 B 2018 2 2 OPEN 6-Sep-2018 NIL ATURAN BLIMBINGSARI Operator ensure the personnel ability to handle the actual emergency. AIRPORT, BANYUWANGI ; 16 JANUARI 2017 29

Direktorat Keamanan Penerbangan akan melaksanakan audit terhadap Bandar Udara KNKT.17.01.02.04 ; PT. Banyuwangi di bidang Rencana Penanggulangan MANDIRI UTAMA Keadaan Darurat Bandar Udara (Airport Emergency Ineffectiveness of fire extinguishing process in Banyuwangi Airport may also FLIGHT ACADEMY ; Directorate General Plan] dan Pertolongan Kecelakaan PK-MUA 16-Jan 2017 Final 8-Jun 2018 4 R 2018 2 3 occur in other airports. KNKT recommend to review oversight process to CLOSED 21-Nov 2018 6-Sep-2018 PENGAWASAN BLIMBINGSARI of Civil Aviation Penerbangan dan Pemadam Kebakaran (PKP-PK) sesuai ensure the ARFF ability for extinguishing the fire effectively. AIRPORT, BANYUWANGI dengan Surat Direktur Jenderal Perhubungan Udara ; 16 JANUARI 2017 Nomor 1394/DKP/XI/2018 tanggal 06 November 2018 perihal audit AEP dan PKP-PK.

KNKT.17.02.06.04 - PT. Angkasa Pura I KNKT recommends ensuring that the runway centerline marking is clearly Sesuai dengan Surat Perjanjian Pengadaan Barang/Jasa PK-GNK 1-Feb 2017 Preliminary Report 29-Mar 2017 04 B 2017 6 1 CLOSED 27-Jun-2017 PRASARANA Garuda Indonesia Branch Office visible during aircraft operation. Nomor: PBJJOG-16001698 Bandara Internasional Bandara Internasional Adisutjipto Yogyakarta saait ini dalam proses pelaksanaan updating Aerodrome Manual yang mana frekuensi inspeksi runway, taxyway KNKT.17.02.06.04 - PT. dan apron sudah disesuaikan dengan SOP menjadi dua Garuda Indonesia kali sehari. Angkasa Pura I 30 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 Preliminary Report 29-Mar 2017 04 B 2017 6 2 CLOSED 27-Jun-2017 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.

KNKT.17.03.09.04 - PT. To establish monitoring system in order to monitor the implementation of the PT. Pelita Iar Service issued Flight Safety Alert and 31 PK-PAV 19-Mar 2017 Preliminary Report 31-May 2017 Pelita Air Services 04 O 2017 9 1 CLOSED 5-Jun 2018 29-Aug-2017 PENGAWASAN Pelita Air Service procedure for stabilized approach. conducted Safety Stand Down related to the event and STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE)

KNKT.17.05.17.04 - PT.Sriwijaya Air 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 Rendani Airport, West PK-CJC 31-May 2017 Preliminary Report 20-Sep 2017 Sriwijaya Air 04 O 2017 17 1 the aircraft. OPEN 19-Dec-2017 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 PT.Sriwijaya Air present on the runway surface during and after rain and several runway lights 32 Boeing 737-300; PK-CJC were covered by grass. Rendani Airport, West PK-CJC 31-May 2017 Preliminary Report 20-Sep 2017 Rendani Airport 04 B 2017 17 2 OPEN 19-Dec-2017 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 Boeing 737-300; PK-CJC Directorate General Manual (AM) has not been approved by DGCA at the time of accident. KNKT PK-CJC 31-May 2017 Preliminary Report 20-Sep 2017 04 R 2017 17 3 OPEN 19-Dec-2017 ATURAN Rendani Airport, West of Civil Aviation recommend DGCA to process the certification of aerodrome certificate for the Papua - Republic of Rendani 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. LJZ dan ATR 72-500;PK- PK-LJZ dan PK-WFF 3-Aug 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 3-Dec-2017 2. Mensosialisasikan update dan amandement SOP ATS PENGAWASAN WFF clearance will be used. 9Tower) kepada seluruh personil ATC khususnya Kulanamu International Personil 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 Preliminary Report 4-Sep 2017 Airnav Indonesia 04 A 2017 25 2 CLOSED 3-Dec-2017 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 Kulanamu International discrepancies revealed by the read back. Personil Tower Airport, Medan - Republic of Indonesia 3 August 2017

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 Preliminary Report 4-Sep 2017 Airnav Indonesia 04 A 2017 25 3 CLOSED 3-Dec-2017 FOD di runway sesuai LOCA antara Perum LPPNPI PENGAWASAN WFF properly mitigated without delay prior to issue takeoff or landing clearance. Kantor Cabang Madya Medan (Tower) dengan PT. Kulanamu International Angkasa Pura 2 Kualanamu (Unit Landasan) Airport, Medan - Republic of Indonesia 3 August 2017

KNKT.17.08.25.04 - KNKT recommends all pilots to ensure clearances or instructions, including On 3 August 2017, issued notice to pilot number PK-LJZ dan PK-WFF 3-Aug 2017 Preliminary Report 4-Sep 2017 Wings Air 04 O 2017 25 4 CLOSED 3-Dec-2017 PENGAWASAN PT. Lion Airlines dan conditional clearances, shall be read back or acknowledged in a manner to 42/NTP/OMIW/VIII/2017 which contained the KNKT.17.08.25.04 - KNKT recommends to ensure all pilots shall understand and comply the air On 5 August 2017, issued notice to pilot number PK-LJZ dan PK-WFF 3-Aug 2017 Preliminary Report 4-Sep 2017 Wings Air 04 O 2017 25 5 CLOSED 3-Dec-2017 PENGAWASAN PT. Lion Airlines dan traffic controller instruction or clearance and to clarify when there is uncertain 44/NTP/OMIW/VIII/2017 which contained the

33 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE)

The AirNav Indonesia amended the ATS SOP for 33 Aerodrome Control Tower to include detail procedure to use of Rapid Exit Taxiway (RET) as follows:

If controller will use RET for departure traffic, the controller must consider: KNKT.17.08.25.04 - - The use of RET will expedite and avoid delay, or to PT. Lion Airlines dan optimize the use of runway; PT. Wings Abadi Airlines - The remaining runway is sufficient for aircraft to Boeing 737-900ER; PK- takeoff; 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 Final 9-Apr 2018 AirNav Indonesia 04 A 2017 25 6 CLOSED 7-Feb 2020 - No aircraft conducts landing approach on long PENGAWASAN WFF hazard when using RET for departure aircraft. final/final/inbound heading; and Kulanamu International - No objection from pilot to use RET for takeoff. Airport, Medan - Republic of Indonesia The procedure for using RET for departure is as follows: 3 August 2017 - Controller must advise the remain runway length to the pilot; - The use RET on opposite runway condition is prohibited; and - The use of conditional phrase/clearance is prohibited.

KNKT.17.08.25.04 - PT. Lion Airlines dan PT. Wings Abadi Airlines Boeing 737-900ER; PK- The AirNav Indonesia issued instruction to all branch LJZ dan ATR 72-500;PK- The KNKT recommends to review the ATS SOP to include detail procedure or offices to review their ATS SOP ensuring that detail PK-LJZ dan PK-WFF 3-Aug 2017 Final 9-Apr 2018 AirNav Indonesia 04 A 2017 25 7 CLOSED 1-Apr 2020 ATURAN WFF guideline for air traffic controller. procedure or guideline for air traffic controller is Kulanamu International described Airport, Medan - Republic of Indonesia 3 August 2017

KNKT.17.08.25.04 - The KNKT recommends to review the performance check or other methods of The AirNav Indonesia branch office Medan developed PK-LJZ dan PK-WFF 3-Aug 2017 Final 9-Apr 2018 AirNav Indonesia 04 A 2017 25 8 OPEN 27-Nov 2018 8-Jul-2018 ATURAN PT. Lion Airlines dan maintaining air traffic controller competency to ensure the air traffic controller Unusual Condition procedure and included the

KNKT.17.04.10.04 - PT. Spirit Avia Sentosa The KNKT recommend the FlyingSAS to increase pilot awareness of their Issued notice for all pilot to be more aware of their (FlyingSAS); Cessna medical condition and emphasize pilot who acquaint or experienced any medical condition and to report to the management PK-FSO 12-Apr 2017 Final 26-May 2019 FlyingSAS 04 O 2018 10 1 CLOSED 1-Aug 2019 24-Aug-2019 PENGAWASAN 2018; PK-FSO; Anem decrease in medical fitness which could cause incapacitation to report to when suspected decrease in medical fitness thatc can Mountain, Oksibil FlyingSAS management and the Director General of Civil Aviation. cause incapacitation. Papua

KNKT.17.04.10.04 - PT. Spirit Avia Sentosa (FlyingSAS); Cessna The KNKT recommend the FlyingSAS to review and improve the hazard Issued notice to all FlyingSAS personnel which PK-FSO 12-Apr 2017 Final 26-May 2019 FlyingSAS 04 O 2018 10 2 CLOSED 1-Aug 2019 24-Aug-2019 ATURAN 2018; PK-FSO; Anem reporting system including identification of operational safety issue. reminded to report hazard. Mountain, Oksibil Papua

The Aviation Medical Center had developed an KNKT.17.04.10.04 - PT. integrated online medical record application which Spirit Avia Sentosa included the exercises need to be completed based on The KNKT recommend the Aviation Medical Center to conduct the required (FlyingSAS); Cessna Balai Kesehatan CASR part 67 as a default step to be completed in the PK-FSO 12-Apr 2017 Final 26-May 2019 04 L 2017 10 3 examination including ECG resting or ECG exercise in accordance with the CLOSED 29-Jan 2020 24-Aug-2019 ATURAN 2018; PK-FSO; Anem Penerbangan application. Special issuance for pilots who could not CASR part 67. Mountain, Oksibil performed or does not meet the requirement and Papua standard for ECG resting or exercise, shall be discussed 34 in Medical Review Board for further evaluation

KNKT.17.04.10.04 - PT. The Aviation Medical Center (AMC) had reviewed the Spirit Avia Sentosa ratio between examiner and their workload, and The KNKT recommend the Aviation Medical Center to conduct examiner (FlyingSAS); Cessna Balai Kesehatan conducted workload analysis. The result of the analysis PK-FSO 12-Apr 2017 Final 26-May 2019 04 L 2018 10 4 workload analysis to adjust the ration of examiner and applicant so that the CLOSED 29-Jan 2020 24-Aug-2019 ATURAN 2018; PK-FSO; Anem Penerbangan was the AMC need 11 examiners. After the accident, examination can be performed thoroughly. Mountain, Oksibil the AMC had added 5 examiners and currently had 15 Papua examiners in total.

KNKT.17.04.10.04 - PT. Directorate General The KNKT recommend the DGCA providing method and address to report any The Directorate General of Civil Aviation has issued PK-FSO 12-Apr 2017 Final 26-May 2019 04 R 2018 10 5 CLOSED 30-Dec 2020 24-Aug-2019 ATURAN Spirit Avia Sentosa of Civil Aviation decrease in medical fitness which causes incapacitation by holder of medical safety Circular No. SE 25 year 2020 concerning 34

The AirNav Indonesia developed Rating Examination Guidelines for Air Traffic Controller which included: - 8 hours classroom briefing session to rehears KNKT.17.11.33.04 - PT. technical knowledge of air traffic control, including the Wings Abadi Airlines & requirement to maintain the listening watch; BP3 Banyuwangi - ATR The KNKT recommend to AirNav Indonesia to ensure air traffic controller - theoretical check based on the classroom session 72-212A & CESSNA 172S PK-WHS & PK-BYK 21-Nov 2017 Preliminary Report 29-Dec 2017 Airnav Indonesia 04 A 2017 33 2 CLOSED 7-Feb 2020 PENGAWASAN maintain listening watch to all communication. material; Near point NAMP - practical check during daily duty which included the ISLAND, NTB requirement to maintain the listening watch. 21 November 2017 The AirNav Indonesia conducted technical briefing for all personnel before their duty which included the

The BP3B issued notice to flight instructor and student KNKT.17.11.33.04 - PT. pilots which contained reminder: Wings Abadi Airlines & - to maintain listening watch on the designated ATC BP3 Banyuwangi - ATR The KNKT recommends the BP3B to ensure all student pilots to comply with frequencies; 72-212A & CESSNA 172S PK-WHS & PK-BYK 21-Nov 2017 Preliminary Report 29-Dec 2017 BP3 Banyuwangi 04 O 2017 33 3 CLOSED 4-Mar 2019 29-Mar-2018 PENGAWASAN ATC clearance including assigned altitude and aware of the right of way. - to comply with ATC clearance including assigned 35 Near point NAMP altitude, heading or sequence of traffic; and ISLAND, NTB - to follow right of way rules as stated on the Training 21 November 2017 Procedure Manual.

The BP3B issued notice to flight instructor and student KNKT.17.11.33.04 - PT. pilots which contained reminder: Wings Abadi Airlines & - to maintain listening watch on the designated ATC BP3 Banyuwangi - ATR The KNKT recommends the BP3B to ensure all student pilots maintain frequencies; 72-212A & CESSNA 172S PK-WHS & PK-BYK 21-Nov 2017 Preliminary Report 29-Dec 2017 BP3 Banyuwangi 04 O 2017 33 4 CLOSED 4-Mar 2019 29-Mar-2018 PENGAWASAN listening watch to air traffic controller communication. - to comply with ATC clearance including assigned Near point NAMP altitude, heading or sequence of traffic; and ISLAND, NTB - to follow right of way rules as stated on the Training 21 November 2017 Procedure Manual.

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 The BP3B inserted SD card for data logging to all 72-212A & CESSNA 172S PK-WHS & PK-BYK 21-Nov 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 CLOSED 4-Dec 2017 29-Mar-2018 Cessna 172 aircraft that was equipped with Garmin PENGAWASAN Near point NAMP enhancing safety. G1000. ISLAND, NTB 21 November 2017

The duty and flight hour of both pilot did not exceed the requirement of the KNKT.18.01.01.04; PT. Operation Directorate revised the operation OM – Part A however, the slip of altitude clearance between the pilot mind Batik Air Indonesia dan administrative manual regarding operational planning and the readback, the ability to monitor the other traffic communication and PT. Lion Mentari process to include the acclimatization. feeling sleepy were indications of pilot fatigue. The fatigue might be caused by Airlines; Airbus A320- PK-LUI & PK-LFP 6-Jan 2018 Final 24-Jul 2018 Batik Air 04 O 2018 1 1 overnight flight which increasing of potential fatigue was not fully recovered, OPEN 4-Feb 2020 22-Oct-2018 ATURAN 200 dan Boeing 737- The Safety Security and Quality Directorate published and the condition of the pilots woke up in early morning might reduce the 900ER; Near Waypoint the Quality Assurance Recommendation regarding time for recovery sleep Tirus Surabaya, East of fatigue Risk Management Plan addressing Batik Air Therefore, KNKT recommends the Batik Air to establish fatigue risk Java Management. management which may refer to ICAO Annex 6 and ICAO Document 9966.

36 KNKT.18.01.01.04; PT. Batik Air Indonesia dan The Indonesia regulation of fatigue management is described in the Civil PT. Lion Mentari Aviation Safety Regulation (CASR) Part 91. However, the regulation did not Airlines; Airbus A320- Directorate General PK-LUI & PK-LFP 6-Jan 2018 Final 24-Jul 2018 04 R 2018 1 2 contain detail guideline to establish fatigue risk management. OPEN 22-Oct-2018 ATURAN 200 dan Boeing 737- of Civil Aviation Therefore, KNKT recommends the DGCA to review the regulation for fatigue 900ER; Near Waypoint risk management. Tirus Surabaya, East of Java

KNKT.18.03.08.04 - Based on the video footage, during the last maneuver, the aircraft initiated the Genesa Flying School roll earlier and at lower altitude which not accordance to the requirement to Super Decathlon 8KCAB; start roll is when the pitch 45° for the Cuban Eight or Cloverleaf maneuver. PK-RTZ The early roll resulted in the aircraft altitude too low during inverted which Tunggul Wulung was the initial altitude when the aircraft flying down and resulted in the Genesa Flight Academy PSC 141D-016 did not operate 37 PK-RTZ 20-Mar 2018 Final Report 24-Aug 2020 Genesa Dirgantara 04 O 2018 8 1 CLOSED 22-Jun 2021 22-Nov-2020 Airport, Cilacap Central aircraft bounced to the apron during leveling off. the aerobatic aircraft since the accident Java KNKT recommend the performance of aerobatic maneuver should follow the Republic of Indonesia minimum requirement of the aerobatic flight technique and the aircraft 20 March 2018 performance. STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE) 1. Lion Operational Training Department has been revised syllabus KNKT,18,04,09,04 ; B737NG Recurrent (LOFT) 4, Issued 01 revision 01, 25 PT.LION MENTARI Improve the pilot training to ensure pilot understanding to the aircraft system July 2018 38 AIRLINES ; B737-900ER ; PK-LFK 1-Apr 2018 Preliminary Report 8-Jun 2018 Lion Air 04 O 2018 9 1 OPEN 4-Feb 2020 6-Sep-2018 ATURAN and performs procedure properly. ‐page 9: MEL Discussion 21 – 01 ‐1c Air‐condition Packs ON ROUTE JAKARTA TO (-900/- JAMBI 900ER) objective: trainee understand how to read and when to set

KNKT.18.04.10.04 - The operator utilized the company quick reference handbook (QRH) that was PT.WHITESKY AVIATION Officially QRH declared withdrawn from all PT. derived from the manufacture manual where the significant part was missing 39 - HELIKOPTER BELL 429 - PK-WSX 20-Apr 2018 Preliminary Report 30-May 2018 Whitesky Aviation 04 O 2018 10 1 CLOSED 22-Sep 2019 28-Aug-2018 Whitesky Aviation, and stated only using Checklist ATURAN from the QRH, KNKT recommend to the operator to review and revised the MOROWALI, SULAWESI which refers to Manufacturing checklist to refer to the manufacture checklist. TENGAH STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE)

KNKT.18.04.12.04 - PT. Lion Mentari Airlines; The crash bell had not been connected to the Airport Rescue and Fire Fighting 40 Boeing 737-800; PK-LOO 29-Apr 2018 Preliminary Report 30-Jun 2018 Djalaluddin Airport 04 B 2018 12 1 (ARFF) station. KNKT recommend Djalaluddin Airport Operator to establish all OPEN 28-Sep-2018 PRASARANA Djalaluddin Airport, equipment required for the standard airport services. Gorontalo

KNKT.18.05.18.04 - The Air Traffic Services (ATS) provided in Tambolaka Aerodrome Flight Garuda Indonesia Information Zone (AFIZ) were flight information, alerting, and, if required, air CRJ 1000; PK-GRJ and traffic advisory services. The Tambolaka ATS provider did not provide air traffic Wings Air Airnav Indonesia control services that contain clearance and/or instructions, as the airspace of PK-GRJ & PK-WFW 11-May 2018 Final Report 10-Jul 2020 04 A 2018 18 1 OPEN 8-Oct-2020 ATR 72-500; PK-WFW District Tambolaka the Tambolaka was Class G airspace. Left Downwind Runway Some advice from the ACO given to the pilot used instruction phraseology, 10, Tambolaka Airport and the pilot sometimes requested a clearance to the ACO. These mixed-up KNKT.18.05.18.04Republic of Indonesia - Onecommunications day before the indicated day of theunclear occurrence, determination the GIA460 of service PF was status felt unfit between and onair Garuda Indonesia the following day after the occurrence, the PIC was hospitalized. The CRJ 1000; PK-GRJ and investigation considered that on the day of the occurrence the PIC medical Prior the occurrence, Garuda Indonesia had revised the Wings Air condition might reduce his performance. Flight Crew Guidance by adding procedure for pilot to PK-GRJ & PK-WFW 11-May 2018 Final Report 10-Jul 2020 Garuda Indonesia 04 O 2018 18 2 OPEN 23-Jun 2021 8-Oct-2020 ATR 72-500; PK-WFW The OM-Part A of Garuda Indonesia described that pilot must maintain their consider their physical and mental health condition Left Downwind Runway performance in physical fitness and pilot is prohibited to fly when unfit. The prior duty. 10, Tambolaka Airport pilot may refuse their duty if unfit by submitting an unfit statement letter KNKT.18.05.18.04Republic of Indonesia - Theaccording readback to the from Pedoman GIA460 AwakPM that Pesawat the WON1921 (Flight Crew would Guidance). join left downwind In 2020, Garuda Indonesia published Human Factors Garuda Indonesia runway 10 indicated that the PM had acknowledged the WON1921 pilot Bulletin for all pilot which included a reminder to CRJ 1000; PK-GRJ and intention. However, when the GIA460 PF advised the PM that WON1921 create an effective working climate by communicate, Wings Air would join right downwind runway 10, made the PM followed the PF cooperative, coordinative and contributive. 41 PK-GRJ & PK-WFW 11-May 2018 Final Report 10-Jul 2020 Garuda Indonesia 04 O 2018 18 3 CLOSED 23-Jun 2021 8-Oct-2020 ATR 72-500; PK-WFW assumption and disregarded the WON1921 information. The absence of pilot’s Left Downwind Runway discussion to assess of WON1921 flight properly indicated that Crew Resource In 2021, Garuda Indonesia conducted CRM recurrent 10, Tambolaka Airport Management was not implemented properly. training that highlighted verbal intervention as useful KNKT.18.05.18.04Republic of Indonesia - The AirOM-Part Traffic A Services subchapter (ATS) 11.11.1 provided described in Tambolaka that Crew Aerodrome Resource Flight method to prevent incident or accident. The recurrent Garuda Indonesia Information Zone (AFIZ) were flight information, alerting, and, if required, air In 2019, Garuda Indonesia revised the OM-Part A to CRJ 1000; PK-GRJ and traffic advisory services. The Tambolaka ATS provider did not provide air traffic include description of Class G airspace requirement. Wings Air control services that contain clearance and/or instructions, as the airspace of PK-GRJ & PK-WFW 11-May 2018 Final Report 10-Jul 2020 Garuda Indonesia 04 O 2018 18 4 OPEN 13-Jun 2021 8-Oct-2020 The description highlighted that IFR and VFR flights in ATR 72-500; PK-WFW the Tambolaka was Class G airspace. Class G airspace would receive flight information Left Downwind Runway However, some advice from the ACO given to the pilot used instruction service if requested. 10, Tambolaka Airport phraseology, and the pilot sometimes requested a clearance to the ACO. KNKT.18.05.18.04Republic of Indonesia - TheThese Air mixed-up Traffic Services communications (ATS) provided indicated in Tambolaka unclear determination Aerodrome Flight of service Garuda Indonesia Information Zone (AFIZ) were flight information, alerting, and, if required, air On 16 June 2021, Wings Air published Notice to Pilot CRJ 1000; PK-GRJ and traffic advisory services. The Tambolaka ATS provider did not provide air traffic which reminded the requirement when flying in Class Wings Air control services that contain clearance and/or instructions, as the airspace of PK-GRJ & PK-WFW 11-May 2018 Final Report 10-Jul 2020 Wings Air 04 O 2018 18 5 CLOSED 16-Jun 2021 8-Oct-2020 G airspace. The notice also highlighted that in the Class ATR 72-500; PK-WFW the Tambolaka was Class G airspace. G airspace, pilot would only receive flight information Left Downwind Runway However, some advice from the ACO given to the pilot used instruction service without having air traffic control clearance. 10, Tambolaka Airport phraseology, and the pilot sometimes requested a clearance to the ACO. Republic of Indonesia These mixed-up communications indicated unclear determination of service 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 KNKT.18.06.24.04 - The FlyingSAS had revised the VFR Route Chart in the Bilorai to Nabire while the stored GPS flight plan route on the PK-FSL aircraft FlyingSAS; Cessna 208B; PT. Spirit Avia OM – Part C to include the checkpoint TOPO for arrival PK-FSL 18-Jun 2018 Preliminary Report 11-Jul 2018 04 O 2018 24 1 and VFR Route Chart published on OM – Part C was not containing checkpoint CLOSED 10-Oct 2018 9-Oct-2018 PENGAWASAN Nabire, Papua; 18 Juni Sentosa route to Nabire, and update all stored GPS flight plan TOPO. 2018 route in accordance with the revised route. KNKT recommends the FlyingSAS to ensure the route guidance for pilot contains same information.

The AirNav Indonesia had conducted location check to the actual location of the NBR VOR/DME and published NOTAM to disseminate the correct coordinate of the NBR VOR/DME. The AirNav Indonesia has planned to The AIP Volume IV of Nabire published by the DGCA contained different KNKT.18.06.24.04 - revise the AIP Volume IV of the NBR VOR/DME coordinate of the NBR VOR/DME location. FlyingSAS; Cessna 208B; coordinate. PK-FSL 18-Jun 2018 Preliminary Report 11-Jul 2018 AirNav Indonesia 04 A 2018 24 2 KNKT recommends the AirNav Indonesia to provide correct information of the CLOSED 7-Feb 2020 9-Oct-2018 PRASARANA 42 Nabire, Papua; 18 Juni NBR VOR/DME location to the DGCA and also review the possibility of other 2018 The AirNav Indonesia developed Standard Operating incorrect coordinate of navigation aid prior to publish in the AIP. Procedure (SOP) of Aeronautic Information Publication which included verification phase of the raw data provided by the source data provider.

KNKT.18.06.24.04 - Directorate General In 2017, KNKT issued safety recommendation number 04.R-2015-17.6 which PK-FSL 18-Jun 2018 Preliminary Report 11-Jul 2018 04 R 2018 24 3 OPEN 9-Oct-2018 ATURAN FlyingSAS; Cessna 208B; of Civil Aviation was recommend the Directorate General of Civil Aviation (DGCA) to publish

The AIP Volume IV of Nabire published by the DGCA contained different KNKT.18.06.24.04 - coordinate of the NBR VOR/DME location. FlyingSAS; Cessna 208B; Directorate General PK-FSL 18-Jun 2018 Preliminary Report 11-Jul 2018 04 R 2018 24 4 KNKT recommends the DGCA to determine the correct coordinate of NBR OPEN 9-Oct-2018 ATURAN Nabire, Papua; 18 Juni of Civil Aviation VOR/DME and also review the possibility of other incorrect coordinate of 2018 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 Wings Air published Notice to All Crews, NTA/001/VI/2018 Upstream Defenses to prevent landing or Attepted Landing on a KNKT.18.06.25.04; PT. Closed Runway or Taxi Way. The flight was the first flight for the PIC and SIC to Tebelian Airport and there Wings Abadi Airlines; was no briefing related to the operation of new airport, therefore KNKT ATR 72-212; Sintang, PK-WHF 19-Jun 2018 Preliminary Report 30-Jul 2018 Wings Air 04 O 2018 25 1 CLOSED 21-Aug 2018 28-Oct-2018 On June 22, 2018 – Flight Standard input AVG Tebelian, PENGAWASAN 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)

43 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE)

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 (OAM – Operation Administration Manual, Preamble KNKT.18.06.25.04; PT. including Airport Visual Guidance (AVG). The aircraft document library was page 4/18, Electronic (Soft Copy). Wings Abadi Airlines; updated on January 2018, while the AVG revision status was number 5 dated 43 ATR 72-212; Sintang, PK-WHF 19-Jun 2018 Preliminary Report 30-Jul 2018 Wings Air 04 O 2018 25 2 25 August 2017. The AVG of the Sintang Airport available on the aircraft library CLOSED 21-Aug 2018 28-Oct-2018 Short term : PENGAWASAN West Kalimantan; 19 and utilized by the pilot was published on 2 March 2018 and effective since 9 June 2018 March 2018, therefore KNKT recommends to ensure all the document The Flight Standard Departement already input AVG provided for the flight 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; Directorate General 1112713.13 E, this format is not clearly describe decimal degrees format or ATR 72-212; Sintang, PK-WHF 19-Jun 2018 Preliminary Report 30-Jul 2018 04 R 2018 25 3 OPEN 28-Oct-2018 PENGAWASAN of Civil Aviation 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; Directorate General which had been closed for operation. The information of the Tebelian Airport ATR 72-212; Sintang, PK-WHF 19-Jun 2018 Preliminary Report 30-Jul 2018 04 R 2018 25 4 OPEN 28-Oct-2018 PENGAWASAN of Civil Aviation available in the website on page link AIP Supplement, therefore KNKT West Kalimantan; 19 recommends to ensure only the current information available in the June 2018 publication 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; Directorate General been completed at that time of occurrence, therefore KNKT recommends to ATR 72-212; Sintang, PK-WHF 19-Jun 2018 Preliminary Report 30-Jul 2018 04 R 2018 25 5 OPEN 28-Oct-2018 PENGAWASAN of Civil Aviation ensure the process of airport certification are properly conducted before West Kalimantan; 19 release amendment of aerodrome certificate. June 2018

KNKT.18.08.32.04; PT. Marta Buana Abadi (Dimonim Air); PAC KNKT recommends the Dimonim Air to ensure all flights are conducted at or PK-HVQ 11-Aug 2018 Preliminary Report 5-Oct 2018 Dimonim Air 04 O 2018 32 1 OPEN 3-Jan-2019 PENGAWASAN 750XL; Menuk above the required weather minima. Mountain Oksibil Papua; 11 August 2018 44 KNKT.18.08.32.04; PT. Marta Buana Abadi KNKT recommends the DGCA to ensure that the safety recommendation (Dimonim Air); PAC Directorate General number 04.R-2015-17.6 which published in 2017 and 04.R-2018-24.3 in 2018 PK-HVQ 11-Aug 2018 Preliminary Report 5-Oct 2018 04 R 2018 32 2 OPEN 3-Jan-2019 ATURAN 750XL; Menuk of Civil Aviation to publish the visual route guidance for airport without instrument approach Mountain Oksibil procedure. Papua; 11 August 2018 1. Lion Air had emphasized the Operation Manual part A (OM-A) Chapter 1.4.2. Refer to the CASR Part 91.7 Civil Aircraft Airworthiness and the Operation 2. Lion Air had issued the Safety Notice Manual part A subchapter 1.4.2, the pilot in command shall discontinue the 16/SS/SN/XI/2018 Lion Emergency Flowchart-Revision KNKT.18.10.35.04 PT. flight when un-airworthy mechanical, electrical, or structural conditions occur. Nov 2018. Lion Mentari Airlines; The flight from Denpasar to Jakarta experienced stick shaker activation during 3. Lion Air had issued Temporary Revision (TR) on Boeing 737-8 MAX; PK-LQP 29-Oct 2018 Preliminary Report 28-Nov 2018 Lion Air 04 O 2018 35 1 the takeoff rotation and remained active throughout the flight. This condition CLOSED 4-Feb 2020 26-Feb-2019 Safety Management Manual (SMSM) Number PENGAWASAN Tanjung Karawang, is considered as un-airworthy condition and the flight shall not be continued. 01/ERM/XI/2018 on Lion Emergency Flowchart. West Java; 29 October KNKT recommend ensuring the implementation of the Operation Manual part 4. Short term: Flight Operation had published NTP 2018 A subchapter 1.4.2 in order to improve the safety culture and to enable the 30/NT/XI/2018 Flight Following OM-A 236 to all pilot pilot to make proper decision to continue the flight. regarding OM 2.3.6 (Flight Following). 5. Lion Air had issued LA-OT-02-PILOT-02-11 B737 Recurrent 5 Trainee Lesson Plan. 1. Lion Air had coordinated with Angkasa Aviation According to the weight and balance sheet, on board the aircraft were two KNKT.18.10.35.04 PT. Services (AAS) and they had issued Quality Assurance pilots, five flight attendants and 181 passengers consisted of 178 adult, one Lion Mentari Airlines; Notice 102/AQ-AAS/N/XII/2018 on Akurasi Konfigurasi child and two infants. The voyage report showed that the number of flight Boeing 737-8 MAX; Crew di Pesawat. PK-LQP 29-Oct 2018 Preliminary Report 28-Nov 2018 Lion Air 04 O 2018 35 2 attendant on board was six flight attendants. This indicated that the weight CLOSED 4-Feb 2020 26-Feb-2019 PENGAWASAN Tanjung Karawang, 2. Chief Pilot had published Notice to Pilot and balance sheet did not contain actual information. West Java; 29 October 010/NTP/II/2019 SAFETY and SERVICE IMPROVEMENT KNKT recommend ensuring all the operation documents are properly filled 2018 regarding cross check crew composition with Flight and documented. Attendant and Ramp officer.

3. To ensure the company manual are updated in KNKT.18.10.35.04 PT. timely manner: Lion Mentari Airlines; - Lion Air has been revised COM 6.4.6.1 regarding Boeing 737-8 MAX; KNKT recommends establishing system to ensure the company manuals are PK-LQP 29-Oct 2018 Final 25-Oct 2019 Lion Air 04 O 2018 35 3 CLOSED 4-Feb 2020 23-Jan-2020 Document Review ATURAN Tanjung Karawang, updated in timely manner. (TR 11/TR/COM-JT/XII/2019) West Java; 29 October - Lion Air has been publishing notice: QAN- 2018 05/DQ/XII/2019: Manual Synchronization

1. Lion Air has been revised SMS training syllabus: -Initial [LA-SS-03-01-54] Rev 2 2019 KNKT.18.10.35.04 PT. Recurrent [LA-SS-03-01-55] Rev 2 2019 Lion Mentari Airlines; Material: Boeing 737-8 MAX; KNKT recommends that Lion Air review the SMS training material and the -Initial [LA-SS-03-01-49] Rev 7 2019 PK-LQP 29-Oct 2018 Final 25-Oct 2019 Lion Air 04 O 2018 35 4 CLOSED 4-Feb 2020 23-Jan-2020 PENGAWASAN Tanjung Karawang, duration of training Recurrent [LA-SS-03-01-52] Rev 2 2019 West Java; 29 October Revision of SMSM related 7.4.2 General safety 2018 Management System Training (TR 1/SMSM/XII/2019). 2. Lion Air has been revised duration of SMS training. 3. Lion Air has been inserted Training case of JT43 and

45 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE) To improve Lion Ops Personnel knowledge regarding hazard identification: KNKT.18.10.35.04 PT. -Lion Air has been published Monthly Bulletin edition Lion Mentari Airlines; Nov 2019 vol 58, add content example of hazard report Boeing 737-8 MAX; recommends that Lion Air improve their hazard report management enabling from CORUSON (continue program to next edition) PK-LQP 29-Oct 2018 Final 25-Oct 2019 Lion Air 04 O 2018 35 5 CLOSED 4-Feb 2020 23-Jan-2020 PENGAWASAN Tanjung Karawang, identifying the hazard and provides proper mitigation. -Lion Air has been conducted safety campaign West Java; 29 October regarding hazard identification and hazard reporting: 2018 station SOC (24 July 2019), station JOG (25 July 2019), CGK (16 August 2019 FMM Management (11 July 2019), ME 121 (2 Dec 2019)

KNKT.18.10.35.04 PT. Lion Mentari Airlines; Boeing 737-8 MAX; KNKT recommends emphasizing engineers to record test values as required by All engineer LM has been brief again about LMPM PK-LQP 29-Oct 2018 Final 25-Oct 2019 Batam Aero Technic 04 MO 2018 35 6 CLOSED 28-Jan 2020 23-Jan-2020 PENGAWASAN Tanjung Karawang, the BAT LMPM chapter 4.2.2.3.2 maintenance defect rectification West Java; 29 October 2018

BAT quality assurance has a time frame to evaluate all KNKT.18.10.35.04 PT. BAT manual, refer to AMOQSM (Aircraft Maintenance Lion Mentari Airlines; Organization Quality System Manual) Batam Aero Boeing 737-8 MAX; KNKT recommends establishing system to ensure the company manuals are Technic chapter 1.1 and QPM (Quality Procedure PK-LQP 29-Oct 2018 Final 25-Oct 2019 Batam Aero Technic 04 MO 2018 35 7 CLOSED 28-Jan 2020 23-Jan-2020 ATURAN Tanjung Karawang, updated in timely manner. Manual) Batam Aero Technic chapter 3.2.3. This West Java; 29 October evaluation including synchronizing with current 2018 regulation, customer manual, and internal company policy

Procedure about handling OMF for 737 MAX has been KNKT.18.10.35.04 PT. added in LMPM (Line Maintenance Procedure Manual) Lion Mentari Airlines; Batam Boeing 737-8 MAX; KNKT recommends that Batam Aero Technic establish policy and procedure of PK-LQP 29-Oct 2018 Final 25-Oct 2019 Batam Aero Technic 04 MO 2018 35 8 CLOSED 28-Jan 2020 23-Jan-2020 Aero Technic chapter 4.4.3 and 4.4.4. This procedure ATURAN Tanjung Karawang, handling OMF also in line with PTSPM (Planning and Technical West Java; 29 October Procedure Manual) Lion Air chapter 3.2.29 2018

KNKT.18.10.35.04 PT. KNKT recommends providing information to the flight crew that the altitude AirNav Indonesia issued circular to all branch office PK-LQP 29-Oct 2018 Final 25-Oct 2019 AirNav Indonesia 04 A 2018 35 9 CLOSED 8-Jan 2020 23-Jan-2020 ATURAN Lion Mentari Airlines; indication on the ATC radar display was repeating data from the aircraft which contained instruction to review and amend the KNKT.18.10.35.04 PT. KNKT recommends emphasizing the implementation of a company manual On 24 October 2019 the company surrendered its PK-LQP 29-Oct 2018 Final 25-Oct 2019 Xtra Aerospace 04 MO 2018 35 10 TDTL 17-Jan 2020 23-Jan-2020 PENGAWASAN Lion Mentari Airlines; including equivalency assessment, training and written procedure, to ensure repair station certificate and no longer performs

KNKT.18.10.35.04 PT. KNKT recommends that the aircraft manufacture to consider the effect of all Lion Mentari Airlines; possible flight deck alerts and indications on flight crew recognition and Boeing 737-8 MAX; PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 11 response; and incorporate design, flight crew procedures, and/or training CLOSED 1-Dec 2020 23-Jan-2020 ATURAN Tanjung Karawang, requirements where needed to minimize the potential for flight crew actions West Java; 29 October that are inconsistent with manufacturer assumptions 2018

KNKT.18.10.35.04 PT. Lion Mentari Airlines; Boeing 737-8 MAX; KNKT recommends that Boeing include a larger tolerance in the design is PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 12 CLOSED 1-Dec 2020 23-Jan-2020 ATURAN Tanjung Karawang, required to allow operability by a larger population of flight-rated pilots West Java; 29 October 2018

KNKT.18.10.35.04 PT. Lion Mentari Airlines; KNKT recommends that Boeing and the FAA more closely scrutinize the Boeing 737-8 MAX; PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 13 development and certification process for systems whose malfunction has the CLOSED 1-Dec 2020 23-Jan-2020 ATURAN Tanjung Karawang, ability to lead to loss of control of the airplane. West Java; 29 October 2018

KNKT.18.10.35.04 PT. Lion Mentari Airlines; Boeing 737-8 MAX; KNKT recommends to Boeing to develop the guidance for the criteria of PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 14 CLOSED 1-Dec 2020 23-Jan-2020 ATURAN Tanjung Karawang, information which should be included in flight crew and engineer’s manuals West Java; 29 October 2018

45 KNKT.18.10.35.04 PT. Lion Mentari Airlines; Boeing 737-8 MAX; KNKT recommends to Boeing that they ensure that certified and delivered PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 15 CLOSED 1-Dec 2020 23-Jan-2020 PENGAWASAN Tanjung Karawang, airplanes have intended system functionality West Java; 29 October 2018 45 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE) On 15 November 2019, Boeing published a revision to the IFIM in which the repetitive step has been KNKT.18.10.35.04 PT. removed from the following tasks. Lion Mentari Airlines; ‐ IFIM Task 34‐10‐00‐810‐801 – Capt IAS Disagree Boeing 737-8 MAX; KNKT recommends the IFIM tasks sequence are reviewed to ensure they are ‐ IFIM Task 34‐10‐00‐810‐802 – FO IAS Disagree PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 16 CLOSED 28-Nov 2019 23-Jan-2020 ATURAN Tanjung Karawang, effective. ‐ IFIM Task 34‐20‐00‐810‐801 – Capt ALT Disagree West Java; 29 October ‐ IFIM Task 34‐20‐00‐810‐802 – FO ALT Disagree 2018 ‐ IFIM Task 34‐24‐00‐810‐812 – Integrated Standby Flight Display: Altitude display disagrees with primary display The following measures have been adopted to improve the operator's KNKT.18.10.35.04 PT. oversight: a. To establish a new training program for Lion Mentari Airlines; training of inspectors, adapted to the competency Boeing 737-8 MAX; Directorate General KNKT recommends improving oversight to ensure implementation of the based training recommended by ICAO. It is PK-LQP 29-Oct 2018 Final 25-Oct 2019 04 R 2018 35 17 OPEN 30-Dec 2020 23-Jan-2020 PENGAWASAN Tanjung Karawang, of Civil Aviation standard procedure. forecasted to be implemented along 2020; West Java; 29 October b. To incorporate periodic workshops and continuously 2018 coaching program commanded by external experts in PEL, AIR and OPS domains to share

KNKT.18.10.35.04 PT. DGCA conducted unscheduled Manuals evaluation for Lion Mentari Airlines; Lion Air, specially Boeing 737-8 MAX; Directorate General KNKT recommends improving the oversight of the manual to ensure the PK-LQP 29-Oct 2018 Final 25-Oct 2019 04 R 2018 35 18 OPEN 30-Dec 2020 23-Jan-2020 focused in the areas where inconsistencies have been PENGAWASAN Tanjung Karawang, of Civil Aviation manuals are conform to the standard and updated in timely manner founded. The lessons learned on that evaluation will West Java; 29 October be applied to the rest of operators. 2018

DGCA conducted SMS assessment to ensure the effectiveness of operator KNKT.18.10.35.04 PT. SMS implementation: Lion Mentari Airlines; c. In 2019, DGCA started the surveillance of SMS KNKT recommends that the Directorate General of Civil Aviation review Boeing 737-8 MAX; Directorate General implementation in PK-LQP 29-Oct 2018 Final 25-Oct 2019 04 R 2018 35 19 operators SMS training material and the duration of training to ensure OPEN 30-Dec 2020 23-Jan-2020 ATURAN Tanjung Karawang, of Civil Aviation operators. This should help improve the effectiveness adequacy of SMS implementation West Java; 29 October of SMS in 2018 operators, which in turn should impact the level of compliance with standard procedures;

KNKT.18.10.35.04 PT. Lion Mentari Airlines; United States Federal KNKT recommends to review the requirements of the applicable FARs to Boeing 737-8 MAX; PK-LQP 29-Oct 2018 Final 25-Oct 2019 Aviation 04 RL 2018 35 20 consider any issue that may be overlooked when the requirements are OPEN 23-Jan-2020 ATURAN Tanjung Karawang, Administration considered separately West Java; 29 October 2018

KNKT.18.10.35.04 PT. Lion Mentari Airlines; United States Federal KNKT recommends that the FAA review their processes for determining their Boeing 737-8 MAX; PK-LQP 29-Oct 2018 Final 25-Oct 2019 Aviation 04 RL 2018 35 21 level of involvement (degree of delegation) and how changes in the design are OPEN 23-Jan-2020 ATURAN Tanjung Karawang, Administration communicated to the FAA to ensure an appropriate level of review West Java; 29 October 2018

The FAA determined existing regulations and policy regarding oversight of repair stations is adequate and KNKT.18.10.35.04 PT. robust. The FAA developed a presentation and Lion Mentari Airlines; interactive sessions for its internal workforce to United States Federal KNKT recommends that the FAA improves the oversight to Approved Boeing 737-8 MAX; provide enhanced clarity regarding certain aspects of PK-LQP 29-Oct 2018 Final 25-Oct 2019 Aviation 04 RL 2018 35 22 Maintenance Organization (AMO) to ensure the processes within the AMO are CLOSED 24/05/2021 2021 23-Jan-2020 PENGAWASAN Tanjung Karawang, repair station oversight, to inlcude review and Administration conducted in accordance with the requirements West Java; 29 October acceptance of revisions to repair station's capability 2018 list. The title 14, Code of Federal Regulations Part 145, Repair Stations Webinar titled Rules and Misconceptions was provided to FAA Worlforce on

KNKT.18.10.35.04 PT. Lion Mentari Airlines; United States Federal KNKT recommends that Boeing and the FAA more closely scrutinize the Boeing 737-8 MAX; PK-LQP 29-Oct 2018 Final 25-Oct 2019 Aviation 04 RL 2018 35 23 development and certification process for systems whose malfunction has the OPEN 23-Jan-2020 ATURAN Tanjung Karawang, Administration ability to lead to loss of control of the airplane West Java; 29 October 2018

KNKT.18.10.35.04 PT. Lion Mentari Airlines; KNKT recommends that the FAA work with international regulatory authorities United States Federal Boeing 737-8 MAX; to review assumptions on flight crew behavior used during design and revise PK-LQP 29-Oct 2018 Final 25-Oct 2019 Aviation 04 RL 2018 35 24 OPEN 23-Jan-2020 ATURAN Tanjung Karawang, certification processes to ensure assumptions used during the design process Administration West Java; 29 October are validated. 2018

KNKT.18.10.35.04 PT. Lion Mentari Airlines; United States Federal KNKT recommends to the FAA work with international regulatory authorities Boeing 737-8 MAX; PK-LQP 29-Oct 2018 Final 25-Oct 2019 Aviation 04 RL 2018 35 25 to review the guidance for the criteria of information which should be OPEN 23-Jan-2020 ATURAN Tanjung Karawang, Administration included in flight crew and engineer’s manuals West Java; 29 October 2018 45

KNKT.18.10.35.04 PT. Lion Mentari Airlines; United States Federal Boeing 737-8 MAX; KNKT recommends to Boeing and the FAA that they ensure that certified and PK-LQP 29-Oct 2018 Final 25-Oct 2019 Aviation 04 RL 2018 35 26 OPEN 23-Jan-2020 PENGAWASAN Tanjung Karawang, delivered airplanes have intended system functionality Administration West Java; 29 October 2018

KNKT.18.10.35.04 PT. Lion Mentari Airlines; United States Federal KNKT recommends to the FAA work with international regulatory authorities Boeing 737-8 MAX; PK-LQP 29-Oct 2018 Final 25-Oct 2019 Aviation 04 RL 2018 35 27 to review the requirements for installation of Non-Rechargeable Lithium OPEN 23-Jan-2020 ATURAN Tanjung Karawang, Administration Battery certification requirements. West Java; 29 October 2018

KNKT.18.12.41.04 PT. Alfa Trans Dirgantara; The KNKT recommends the Alfa Aviation to ensure SD data card for data Follow up recommendation could not be confirmed. 46 Cessna 208; Kasonaweja PK-ASE 12-Dec 2018 Preliminary Report 29-Jan 2019 Alfa Trans Dirgantara 04 O 2019 41 1 TDTL 29-Apr-2019 PENGAWASAN logging is inserted in all aircraft that installed with Garmin G1000 for the The aircraft operator is no longer operation. Airstrip, Papua; 12 purpose of enhancing safety. Desember 2018

KNKT.19.03.08.04 - PT. Air Transport Services - Helikopter Bolkow BO Immediate Air Transport Meyakinkan management dan system perawatan dilaksanakan dengan benar PK-EAH 16-Mar 2019 29-Mar 2019 04 O 2019 8 1 OPEN 27-Jun-2019 PENGAWASAN 105 - Desa Jayaratu, Recommendation Services sesuai prosedur yang berlaku Tasikmalaya, Jawa Barat - 16 Maret 2019

KNKT.19.03.08.04 - PT. Air Transport Services - Helikopter Bolkow BO Immediate Air Transport Melaksanakan pemeriksaan ganda (double inspection atau required inspection PK-EAH 16-Mar 2019 29-Mar 2019 04 O 2019 8 2 OPEN 27-Jun-2019 PENGAWASAN 105 - Desa Jayaratu, Recommendation Services item) pada pekerjaan yang melibatkan flight control atau engine control. Tasikmalaya, Jawa Barat - 16 Maret 2019

KNKT.19.05.10.04 - PT. Batik Air amended the OM-part A subchapter 11.3.3 Batik Air Indonesia - with detail description of event that requires pilot to Airbus A320 - Sultan KNKT recommend the Batik Air to review and amend procedure to enable CVR secure the CVR. Hasanuddin PK-LZJ 25-May 2019 Preliminary Report 29-Aug 2019 Batik Air 04 O 2019 10 1 data can be preserved for investigation following accident and serious CLOSED 18-Oct 2019 27-Nov-2019 Batik Air issued safety notice for pilot, flight attendant, ATURAN International Airport - incident. engineer, line maintenance, flight operation officer Sulawesi Selatan - 25 which highlighted the requirement to secure CVR on Mei 2019 the new subchapter 11.3.3

KNKT.19.05.10.04 - PT. Batik Air Indonesia - Batik Air issued safety notice for engineer, line Airbus A320 - Sultan KNKT recommend the Batam Aero Technic to review and amend procedures maintenance, flight operation officer which highlighted Hasanuddin PK-LZJ 25-May 2019 Preliminary Report 29-Aug 2019 Batam Aero Technic 04 MO 2019 10 2 to enable accident or serious incident can be reported to the KNKT without CLOSED 18-Oct 2019 27-Nov-2019 ATURAN the event that need to be reported to KNKT as soon as International Airport - delay. possible. Sulawesi Selatan - 25 Mei 2019

KNKT.19.05.10.04 - PT. Batik Air Indonesia - Airbus A320 - Sultan KNKT recommend the Batam Aero Technic to ensure all personnel working in Batam Aero Technic issued safety notice to all personel 48 Hasanuddin PK-LZJ 25-May 2019 Preliminary Report 29-Aug 2019 Batam Aero Technic 04 MO 2019 10 3 the aircraft movement area is equipped with fluorescence strip uniform or CLOSED 18-Oct 2019 27-Nov-2019 to use personal protective equipment including the PENGAWASAN International Airport - high visibility vest, especially during night time or reduced visibility condition. high visibility vest during working in the field Sulawesi Selatan - 25 Mei 2019

Angkasa Aviasi Servis amended the Ground Support Equipment Operation SOP subchapter 5.1.1, 5.1.2 and KNKT.19.05.10.04 - PT. the Mini Briefing Form which includes requirement for Batik Air Indonesia - conduct briefing of pushback maneuver in every Airbus A320 - Sultan KNKT recommend the Angkasa Aviasi Servis to ensure towing tractor drivers pushback operation. Hasanuddin PK-LZJ 25-May 2019 Preliminary Report 29-Aug 2019 Angkasa Aviasi Servis 04 G 2019 10 4 follow the available guidance line and/or conduct briefing for any plan of CLOSED 18-Oct 2019 27-Nov-2019 PENGAWASAN Batam Aero Technic amended the Line Maintenance International Airport - deviation maneuver from the guidance line Procedure Manual to include requirement for Sulawesi Selatan - 25 engineer, headsetman or wingman to have Mei 2019 coordination with the pushback car driver prior pushback operation. 48

KNKT.19.05.10.04 - PT. Batik Air Indonesia - Airbus A320 - Sultan KNKT recommend the PT. Angkasa Pura I to improve the surveillance ensuring Hasanuddin PK-LZJ 25-May 2019 Preliminary Report 29-Aug 2019 Angkasa Pura I 04 B 2019 10 5 OPEN 27-Nov-2019 PENGAWASAN pushback operation follows the available guidance lines International Airport - Sulawesi Selatan - 25 Mei 2019

According to the Dinges et al., (1996), on 24-hour cycle, between 0200 and 0600 is estimation for window of circadian low, when human biological KNKT.19.05.10.04 - PT. functions and performance efficiency are at their lowest level. Maintaining Batik Air Indonesia wakefulness during the window of circadian low has a higher potential for Airbus A320; PK-LZJ fatigue and increased requirement for recovery. Sultan Hasanuddin The pushback operation was conducted during window of circadian low on 49 PK-LZJ 25-May 2019 Final Report 24-Aug 2020 Angkasa Aviasi Servis 04 G 2019 10 7 OPEN 22-Nov-2020 International Airport night time condition which might create fatigue that decreases human Republic of Indonesia alertness and increase requirement for recovery. 25 May 2019 The reduced alertness combined with the different assumption of pushback maneuver, focused attention to the aircraft maneuver, decreasing visual condition, resulted in the towing tractor driver did not aware of the headset- Flyingman position below the and minimum continued safe the altitude maneuver is contrary until the to accident the Indonesia happened. regulation and AAA procedure and hazardous especially if any obstacles surround the KNKT.19.07.14.04 - flight path. The Garmin G1000 data log of two AAA aircraft within period of Angkasa Aviation four months prior the PK-WUG accident recorded 17 training flights flying Academy below the minimum safe altitude. These low flying were not detected as the Cessna 172S; PK-WUG Angkasa Aviation AAA had not established systems to monitor the movement of aircraft or to Cimanuk River, PK-WUG 22-Jul 2019 Final Report 9-Apr 2020 04 O 2019 14 1 OPEN 8-Jul-2020 Academy review and analyze the available data, such as Garmin G1000 data log. Indramayu, West Java After the accident, the AAA installed ADS-B receiver in the Cirebon flight Republic of Indonesia operation office to enhance the capability to retrieve ADS-B data in order to 22 July 2019 monitor the movement of aircraft in real time. The AAA had developed Standard Operation Procedure (SOP) of flight following activities which requires dedicated personnel to monitor flight activities using ADS-B-based

50 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE)

KNKT.19.07.14.04 - Angkasa Aviation The AAA aircraft engineer that had suspected the aircraft had flown on low Academy altitude. However, the investigation did not find any air safety/hazard report Cessna 172S; PK-WUG regarding this finding. The hazard that is not reported makes the absence of Angkasa Aviation Cimanuk River, PK-WUG 22-Jul 2019 Final Report 9-Apr 2020 04 O 2019 14 2 risk assessment and the mitigation that may resulted in accident or incident. OPEN 8-Jul-2020 Academy Indramayu, West Java KNKT recommends the AAA to improve the safety management system Republic of Indonesia implementation including hazard report by all company employees. 22 July 2019

50 The DAAO inspector used DGCA form 141-04 which comprised of several checklist questions to check the conformity of requirement standard in the CASR part 141. Different interpretation of the checklist guidance by DAAO inspectors had made the requirement of the flight following did not oversight thoroughly. The DAAO inspectors explained that if PSC or Provisional Pilot School a. DGCA ensure that the AAA have a system to monitor Certificate holder able show the ability to monitor the aircraft in real time the training activity using available means; KNKT.19.07.14.04 - during audit or surveillance, it considered complied with the flight following b. DGCA ensure that the AAA already improved the Angkasa Aviation requirement in the subchapter 141.27. There was no requirement to provide SMS report system for all company employee; Academy evidence that the training flight was systematically monitored. Showing the c. Based on the statement “other student pilot Cessna 172S; PK-WUG flight tracking application that able to monitor aircraft without any procedure suggests to fly over a river”, DGCA ensure that the AAA Directorate General Cimanuk River, PK-WUG 22-Jul 2019 Final Report 9-Apr 2020 04 R 2019 14 3 to conduct the flight following activities was insufficient to ensure that the OPEN 30-Dec 2020 8-Jul-2020 has duty and responsibility for other student pilot in of Civil Aviation Indramayu, West Java flight following had been conducted systematically. This also supported the mutual flight clearly stated in operator manual; Republic of Indonesia fact that the AAA that had established a method without procedure had made d. DGCA implemented program Resolution of Safety 22 July 2019 the method did not implement and resulted in 17 flights that were flying Issue including law enforcement to improve aircraft below the AAA minimum safe altitude requirement undetected. personnel/operator safety awareness and compliance The lack of checklist guidance resulted in different interpretation of the with applicable CASR. checklist and the quality of the oversight. Therefore, the KNKT recommend to review the DGCA form 141-04 to ensure all inspectors have same interpretation and able to conduct oversight all requirement standard of the CASR Part 141 thoroughly including the flight following requirement. KNKT.19.12.30.04 - PT. In the case of Indonesia civil aircraft experienced serious incident, the CASR ASI Pudjiastuti Aviation Part 830 subpart 830.06 requires person, organization or enterprise engaged in (Susi Air) or offering to engage in an aircraft operation, with minimum delay and by the Cessna C208B, PK-BVN most suitable and quickest means available, must report to the KNKT. The About 32 Nm North of Appendix B of the CASR Part 830 described that flight crew incapacitation in Dili flight is included in the list examples of serious incident. 51 PK-BVN 5-Dec 2019 Preliminary Report 22-Jan 2020 Susi Air 04 O 2020 30 1 OPEN 21-Apr-2020 On coordinate The Susi Air Safety Management System Manual (SMSM) described the 8°5'5.71"S; definition of serious incident, however the list of examples of serious incident 125°30'47.91"E, has not included. The KNKT received the report of the PK-BVN pilot Republic of Indonesia incapacitation from Indonesia Ministry of Foreign Affair five days after the 5 December 2019 occurrence. The delay of serious incident could affect the availability of information • Smart Aviation revised the generic weight and balance form to several forms based on the aircraft KNKT.20.01.02.04 - PT. type. Smart Cakrawala • Smart Aviation issued Operation Notice for FOO and Aviation KNKT recommends to review the calculation of weight and balance ensuring Pilot which advised that the generic weight and PK-SNP, Cessna 208B the calculation is conducted appropriately includes the right aircraft empty PK-SNP 21-Jan 2020 Preliminary Report 13-Mar 2020 Smart Aviation 04 O 2020 2 1 CLOSED 15-Jun 2021 11-Jun-2020 balance form had been revised to several forms based ATURAN (EX) weight and the conversion value. on the aircraft type. Kenyam Airstrip, Papua • Smart Aviation issued Operation Notice to FOO and Republic of Indonesia Pilot which reminded to use conversion value as 21 January 2020 described in the OM Part B. 52

KNKT.20.01.02.04 - PT. Smart Cakrawala • Smart Aviation revised the weight and balance form Aviation using the same weight unit. KNKT recommends to review the weight and balance form ensuring the PK-SNP, Cessna 208B • Smart Aviation issued Operation Notice for FOO and PK-SNP 21-Jan 2020 Preliminary Report 13-Mar 2020 Smart Aviation 04 O 2020 2 2 calculation is used the same weight unit CLOSED 13-Apr 2020 11-Jun-2020 ATURAN (EX) Pilot which advised that the weight and balance form Kenyam Airstrip, Papua had been revised using the same weight unit. Republic of Indonesia 21 January 2020

Trigana had issued the Engineering Instruction (EI) identified by number B737- KNKT.20.02.03.04 - PT. EI/32/083R1 with the title DVI Main Landing Gear Shimmy Damper Bolt. Trigana Air Service However, the EI did not reflect the content of Service Letter (SL) 737-SL-32- Boeing B737-300; PK- 057-E issued by the Boeing such as the inspection of the apex bolt, regularly YSG bleed the hydraulic manifold of the shimmy damper and define the Sentani International PK-YSG 25-Feb 2020 Preliminary Report 9-Apr 2020 Trigana Air Services 04 O 2020 3 1 OPEN 8-Jul-2020 maintenance interval. The absence of inspection requirement to the shimmy Airport, Jayapura damper assembly might lead to the similar accident. Republic of Indonesia Therefore, KNKT recommend to implement the Boeing SL 737-SL-32-057-E (or 25 February 2020 the latest revision) requirement.

KNKT.20.02.03.04 - PT. The height variation on the runway resulted in the bumpy to the aircraft Trigana Air Service during takeoff and landing that led to increasing the vertical acceleration Boeing B737-300; PK- during takeoff as reported by some operators. Since the height variation was YSG Directorate General not resolve yet, the height variation on the runway might contribute to the Sentani International PK-YSG 25-Feb 2020 Preliminary Report 9-Apr 2020 04 R 2020 3 2 OPEN 8-Jul-2020 of Civil Aviation fatigue to the landing gear system including the torsion link and shimmy Airport, Jayapura damper. Republic of Indonesia Therefore, KNKT recommend to resolve the height variation on the runway. 25 February 2020 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE)

The PIC last flight was on 16 August 2020 and last flight from right hand seat was on 13 March 2020 while the SIC last flight was conducted on 1 February 2020. This condition was not meet the requirement for pilot recent experience KNKT.20.09.19.04 - PT. based on CASR 121.439 and Lion Air Operation Manual chapter 5.2.3. Lion Mentari Airlines Despite of the DGCA issued letter Number AU.402/2/22/DRJU.DKPPU-2020 Airbus A330; PK-LEG related to exemption to pilot proficiency check and recent experience and The Directorate General of Civil Aviation has issued Kualanamu Directorate General Safety Circular number SE.36 of 2020, the aircraft operator did not have any Safety Circular No. SE 46 Year 2020 concerning International Airport, PK-LEG 15-Sep 2020 Preliminary Report 18-Nov 2020 04 R 2020 19 1 CLOSED 12-Oct 2020 16-Feb-2021 of Civil Aviation guidance to manage this issue in their operational level. The absence of Procedures for Application for Safety Risk Mitigation Medan guidance may place two pilot were not recent in a set of flight crew that may Programs in Emergencies and I or Standards. Republic of Indonesia become hazard for the flight safety. 15 September 2020 KNKT recommend the DGCA to develop a guidance for implementing the alleviation or required the aircraft operator to adopt the existing guidance 54 issued by ICAO.

The Angkasa Pura II had a monthly routine lawn mowing program. The mowing area divided into several sectors. The mowing program for the sector KNKT.20.09.19.04 - PT. near the touchdown zone runway 23 was scheduled to be conducted on 24 Lion Mentari Airlines 1. Menyusun jadwal pemotongan rumput dan until 30 September 2020, while the last mowing was conducted at 25 until 30 Airbus A330; PK-LEG menentukan area kegiatan pemotongan rumput; Angkasa Pura II August 2020. Meanwhile, the grass on area near the runway 23 found about Kualanamu Branch Office 50 centimeters height above the runway. This condition might increase the International Airport, PK-LEG 15-Sep 2020 Preliminary Report 18-Nov 2020 04 B 2020 19 2 CLOSED 21-Dec 2020 16-Feb-2021 2. Melaksanakan pengawasan pelaksanaan kegiatan Kualanamu possibility of water ponding and increase the hazard of runway slippery and Medan pemotongan rumput secara berkala sesuai dengan International Airport hydroplaning. Republic of Indonesia jadwal dan area yang telah ditentukan. KNKT recommend the Angkasa Pura II to ensure the grass on the runway strip 15 September 2020 area was maintained properly and observed/monitored in the daily routine inspection.

KNKT.20.10.22.04 Aircraft Accident Investigation Report Yayasan Pelayanan Penerbangan Tariku the KNKT recommends the Tariku Aviation to obtain accurate runway PK-RWR 15-Oct 2020 Preliminary Report 20-Jan 2021 Tariku Aviation 04 O 2020 22 1 OPEN 20-Apr-2021 PAC 750 XL; PK-RWR condition information to support pilot decision making. Bayabiru Airstrip, Paniai, Papua Republic of Indonesia 15 October 2020

KNKT.20.10.22.04 Aircraft Accident Investigation Report Yayasan Pelayanan Penerbangan Tariku the KNKT recommends the Tariku Aviation to ensure the calculation 55 PK-RWR 15-Oct 2020 Preliminary Report 20-Jan 2021 Tariku Aviation 04 O 2020 22 2 OPEN 20-Apr-2021 PAC 750 XL; PK-RWR of weight and balance is conducted based on the actual aircraft configuration. Bayabiru Airstrip, Paniai, Papua Republic of Indonesia 15 October 2020

KNKT.20.10.22.04 Aircraft Accident Investigation Report Yayasan Pelayanan the KNKT recommends the AirNav Indonesia branch Nabire to review Penerbangan Tariku Airnav Indonesia the use of radio communication frequency on uncontrolled area to ensure PK-RWR 15-Oct 2020 Preliminary Report 20-Jan 2021 04 A 2020 22 3 OPEN 20-Apr-2021 PAC 750 XL; PK-RWR Branch Office Nabire pilots on Bayabiru Airstrip, Paniai, the same area communicates on the same frequency. Papua Republic of Indonesia 15 October 2020

KNKT.21.01.01.04 Aircraft Accident Investigation Report PT. Sriwijaya Air Directorate General KNKT recommends the DGCA to include a requirement of UPRT in the CASR Boeing 737-500; PK-CLC PK-CLC 9-Jan 2021 Preliminary Report 9-Feb 2021 04 R 2021 1 1 OPEN 10-May-2021 of Civil Aviation and to develop guidance to increase the effectiveness of UPRT. Near Kepulauan Seribu, Jakarta Republic of Indonesia 9 January 2021 56

KNKT.21.01.01.04 Aircraft Accident Investigation Report PT. Sriwijaya Air KNKT recommends the DGCA to review the requirements of notification of Directorate General Boeing 737-500; PK-CLC PK-CLC 9-Jan 2021 Preliminary Report 9-Feb 2021 04 R 2021 1 2 rescue coordination center in the CASR 170 to ensure that the requirement is OPEN 10-May-2021 of Civil Aviation Near Kepulauan Seribu, in accordance with the standards in ICAO Annex 11. Jakarta Republic of Indonesia 9 January 2021

KNKT.20.12.27.04 Aircraft Serious Incident Investigation Report PT. Smart Cakrawala Directorate General KNKT recommends the DGCA to review the aerodrome information provided 57 Aviation PK-SNR 26-Dec 2021 Preliminary Report 24-Feb 2021 04 R 2021 27 1 OPEN 25-May-2021 of Civil Aviation in the AIP Volume IV to ensure the information is correct and accurate. PK-SNR, Cessna 208B Sela Airstrip, Papua Republic of Indonesia 26 December 2020 STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE) KNKT.18.06.24.04 Aircraft Serious Incident Investigation Report PT. Spirit Avia Sentosa (FlyingSAS) Cessna 208B, PK-FSL PT. Spirit Avia KNKT recommends the FlyingSAS to ensure all pilot taking into account the PK-FSL 18-Jun 2018 Final Report 19-Apr 2021 04 O 2021 24 5 OPEN 18-Jul-2021 About 3.6 Nm from NBR Sentosa GPS information as additional reference for the decision making. VOR/DME on bearing of 105°, Nabire, Papua Republic of Indonesia 18 June 2018 KNKT.18.06.24.04 Aircraft Serious Incident Investigation Report PT. Spirit Avia Sentosa (FlyingSAS) the KNKT recommends the FlyingSAS to ensure the current publication of VFR Cessna 208B, PK-FSL PT. Spirit Avia 58 PK-FSL 18-Jun 2018 Final Report 19-Apr 2021 04 O 2021 24 6 routes in the AIP includes the altitude restriction were adopted in the OPEN 18-Jul-2021 About 3.6 Nm from NBR Sentosa FlyingSAS flight guidance. VOR/DME on bearing of 105°, Nabire, Papua Republic of Indonesia 18 June 2018 KNKT.18.06.24.04 Aircraft Serious Incident Investigation Report PT. Spirit Avia Sentosa (FlyingSAS) the KNKT recommends the FlyingSAS to review the operational control system Cessna 208B, PK-FSL PT. Spirit Avia to improve the operational control and supervision for ensuring the flight PK-FSL 18-Jun 2018 Final Report 19-Apr 2021 04 O 2021 24 7 OPEN 18-Jul-2021 About 3.6 Nm from NBR Sentosa operation is conducted in safe and efficient manner. VOR/DME on bearing of 105°, Nabire, Papua Republic of Indonesia 18 June 2018

KNKT.18.08.32.04 Aircraft Accident Investigation Report PT. Marta Buana Abadi Until the issuance of this report, the KNKT had not received any respond from (Dimonim Air) the Dimonim Air responding to the aforesaid safety recommendation. PAC 750XL; PK-HVQ PK-HVQ 11-Aug 2018 Final Report 19-Apr 2021 Dimonim Air 04 O 2021 32 1 Therefore, the KNKT encourage the Dimonim Air to conduct the safety OPEN 18-Jul-2021 Menuk Mountain, recommendation number 04.O-2018-32.01 that had been issued in the Oksibil, Papua Preliminary Report. Republic of Indonesia 11 August 2018

KNKT.18.08.32.04 Aircraft Accident Investigation Report PT. Marta Buana Abadi the KNKT recommends the Dimonim Air to review the operational control (Dimonim Air) system to improve the operational control and supervision within the PAC 750XL; PK-HVQ PK-HVQ 11-Aug 2018 Final Report 19-Apr 2021 Dimonim Air 04 O 2021 32 3 OPEN 18-Jul-2021 company for ensuring the flight operation is conducted in safe and efficient Menuk Mountain, manner. Oksibil, Papua Republic of Indonesia 11 August 2018

KNKT.18.08.32.04 Aircraft Accident Investigation Report PT. Marta Buana Abadi (Dimonim Air) the KNKT recommends the DGCA to provide inspector with sufficient Directorate General PAC 750XL; PK-HVQ PK-HVQ 11-Aug 2018 Final Report 19-Apr 2021 04 R 2021 32 4 knowledge of TAWS requirement standard as required in the CASR Part 135 for OPEN 18-Jul-2021 of Civil Aviation Menuk Mountain, ensuring the inspection of the TAWS can be performed appropriately Oksibil, Papua Republic of Indonesia 11 August 2018

KNKT.18.08.32.04 Aircraft Accident Investigation Report PT. Marta Buana Abadi the KNKT recommends the DGCA to review the manual inspection process for (Dimonim Air) Directorate General ensuring that the inspection of the operation manuals is able to identify the 59 PAC 750XL; PK-HVQ PK-HVQ 11-Aug 2018 Final Report 19-Apr 2021 04 R 2021 32 5 OPEN 18-Jul-2021 of Civil Aviation absence of procedure to use of TAWS and the response to audio and/or visual Menuk Mountain, warnings. Oksibil, Papua Republic of Indonesia 11 August 2018

KNKT.18.08.32.04 Aircraft Accident Investigation Report PT. Marta Buana Abadi (Dimonim Air) KNKT recommends the DGCA to review the standard requirement of TAWS in Directorate General PAC 750XL; PK-HVQ PK-HVQ 11-Aug 2018 Final Report 19-Apr 2021 04 R 2021 32 6 the CASR Part 135 or another requirement standard published by the DGCA to OPEN 18-Jul-2021 of Civil Aviation Menuk Mountain, include the detail requirement of the TAWS. Oksibil, Papua Republic of Indonesia 11 August 2018

KNKT.18.08.32.04 Aircraft Accident Investigation Report PT. Marta Buana Abadi (Dimonim Air) the KNKT recommends the DGCA the finding of non-compliance standard Directorate General PAC 750XL; PK-HVQ PK-HVQ 11-Aug 2018 Final Report 19-Apr 2021 04 R 2021 32 7 requirement to provide meteorology information to be followed up as soon as OPEN 18-Jul-2021 of Civil Aviation Menuk Mountain, possible to improve the safety of aircraft operation. Oksibil, Papua Republic of Indonesia 11 August 2018 59

KNKT.21.03.04.04 Aircraft Accident Investigation Report Yayasan Mission On 17 June 2021, the MAF Indonesia issued notice to Aviation Fellowship all pilot which reminded the implementation of landing Yayasan Mission Indonesia KNKT recommends the MAF Indonesia to emphasize all pilots to implement requirements as described in the OM-B. The 60 PK-MAD 10-Mar 2021 Preliminary Report 27-Apr 2021 Aviation Fellowship 04 O 2021 4 1 CLOSED 24-Jul 2021 26-Jul-2021 PK-MAD, Cessna 208B the landing requirements as described in the OM-B. implementation of the landing requirement would be (MAF) Angguruk Airstrip, checked frequently every six months during the Papua proficiency check. Republic of Indonesia 10 March 2021

KNKT.21.03.05.04 Aircraft Accident Investigation Report PT. Trigana Air Service B737-400F; PK-YSF the KNKT recommends the Trigana Air Service to ensure pilot execute QRH PK-YSF 20-Apr 2021 Preliminary Report 30-Apr 2021 Trigana Air Services 04 O 2021 5 1 OPEN 29-Jul-2021 Halim Perdanakusuma procedure properly. Airport, Jakarta Republic of Indonesia 20 March 2021

61 KNKT.21.03.05.04 Aircraft Accident Investigation Report PT. Trigana Air Service the KNKT recommends the Trigana Air Service to ensure pilot conduct B737-400F; PK-YSF approach briefing as required in the OM-A. PK-YSF 20-Apr 2021 Preliminary Report 30-Apr 2021 Trigana Air Services 04 O 2021 5 2 OPEN 29-Jul-2021 Halim Perdanakusuma Airport, Jakarta Republic of Indonesia 20 March 2021

KNKT.21.03.05.04 the KNKT recommends the Trigana Air Service to ensure pilot response the PK-YSF 20-Apr 2021 Preliminary Report 30-Apr 2021 Trigana Air Services 04 O 2021 5 3 OPEN 29-Jul-2021 Aircraft Accident GPWS as required in the QRH. Aircraft Serious Incident the KNKT recommend the Garuda Indonesia to review the implementation of Garuda Indonesia issued Safety Advisory which PK-GAF 19-Oct 2015 Final Report 25-Jun 2021 Garuda Indonesia 04 O 2015 23 1 CLOSED 13-Jul 2021 23-Sep-2021 Investigation Report PT. serious incident handling to ensure the serious incident is reported as soon as included a reminder to safety personnel to report Aircraft Serious Incident the KNKT recommend the Garuda Indonesia to review the Visual Maneuvering Garuda Indonesia advised that the flight operation PK-GAF 19-Oct 2015 Final Report 25-Jun 2021 Garuda Indonesia 04 O 2015 23 2 CLOSED 13-Jul 2021 23-Sep-2021 Investigation Report PT. Chart of runway 27 Ende to prevent pilot improvisation that may deviate from from and to Ende had been closed until further notice. Aircraft Serious Incident the KNKT recommend the Garuda Indonesia to review the training method to Garuda Indonesia included the runway excursion at PK-GAF 19-Oct 2015 Final Report 25-Jun 2021 Garuda Indonesia 04 O 2015 23 3 CLOSED 13-Jul 2021 23-Sep-2021 Investigation Report PT. ensure the Crew Resource Management is implemented in accordance with Ende as CRM syllabus which highlighted the issue of STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2021 (Data s.d Agustus 2021) REGISTRASI PESAWAT TANGGAL KEJADIAN TANGGAL NOMOR REKOMENDASI BATAS INVESTIGASI INSTANSI PENERIMA TANGGAL DITERIMA KATEGORI NO (AIRCRAFT (DATE OF SUMBER (SOURCE) DIKELUARKAN (DATE OF (RECOMMENDATION NUMBER) REKOMENDASI (RECOMMENDATION) STATUS WAKTU (DUE TANGGAPAN (RESPONSE) (INVESTIGATION) (ADDRESS TO) (RESPONSE DATE) (CLASSIFICATION) REGISTRATION) OCCURRENCE) ISSUED) DATE)

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